Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

axial neck pain

1st line – physiotherapy

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ACUTE
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axial neck pain
1st line – 

physiotherapy

Physiotherapy is the first-line treatment for axial neck pain, which is a mechanical or musculoskeletal form of pain.[22] Advice on posture, sleeping position, daily activities, work and hobbies, stretching exercises, mobility exercises, and head, neck, and shoulder exercises may benefit individual patients.[47][48]

Additional treatment modalities include transcutaneous electrical nerve stimulator chiropractic treatment, acupuncture, and other, less orthodox approaches, particularly electrotherapy, laser therapy, and cervical spine manipulation therapy.​[34][47][50][54]​​[57][58][59][60][61][62][63]​ Although these approaches may be beneficial for symptomatic relief in some patients,high-quality evidence supporting their use in this setting is lacking.[3][12][59][60][64] In addition, some of these therapies may entail additional risks; for example, cervical manipulation can be associated with serious neurological complications.[50][60]

Consider – analgesia

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ACUTE
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axial neck pain
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Depending on the severity of pain, the use of non-steroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, diclofenac, meloxicam) may be beneficial in individual patients.[46] Cyclo-oxygenase-2 (COX-2) inhibitors (e.g., celecoxib) may be preferred in patients with a history of gastro-oesophageal reflux disease (GORD) or peptic ulcers. 

There is no clinical efficacy difference between various NSAIDs, but many patients tolerate one better than others or may have individual-based treatment preferences.

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

Paracetamol may be used in patients who have a contraindication to NSAIDs. Caution is required in patients with hepatic disease.

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

OR

meloxicam: 5-10 mg orally (capsule) once daily when required; 7.5 to 15 mg orally (tablet or suspension) once daily when required

OR

celecoxib: 200 mg orally twice daily when required

OR

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – muscle relaxant

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ACUTE
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axial neck pain
Consider – 

muscle relaxant

Additional treatment recommended for SOME patients in selected patient group

Because cervical muscle spasm is a critical component of cervical spondylosis, drugs may alleviate some of the secondary pain effects in combination with physical measures to relax muscles (including heat, massage, and cervical pillows).[54] There is no clinical efficacy difference between various muscle relaxants. All drugs may cause drowsiness sufficient to interfere with driving or critical activities.[3][22]​​[24]​​

Primary options

tizanidine: 4 mg orally every 6-8 hours when required initially, increase by 2-4 mg/dose increments according to response, maximum 18 mg/day

OR

methocarbamol: 1500 mg orally four times daily for 2-3 days initially, then decrease dose according to response, usual dose 4000-4500 mg/day given in 3-6 divided doses

OR

diazepam: 5-10 mg orally every 8 hours when required

Consider – trigger-point and/or facet joint injection

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ACUTE
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axial neck pain
Consider – 

trigger-point and/or facet joint injection

Additional treatment recommended for SOME patients in selected patient group

These injections are usually performed by either a radiologist (under CT or fluoroscopy control) or a pain management anaesthesiologist (under fluoroscopic control) as needed.[55]

A long-acting corticosteroid preparation is usually added to a long-acting local anaesthetic.[3][24][56]

In practice trigger-point injections to local muscle, fascia, and/or ligaments (using local anaesthetic) may be considered medically necessary if trigger points have been identified by palpation. If this option does not improve the patient's condition and cervical facet-mediated pain sources are suspected based on both physical examination and imaging, then image-guided cervical facet joint injections (intra-articular injections to the joint(s) using a mixture of local anaesthetic and a corticosteroid, or alternatively, diagnostic medial branch nerve blocks, followed by therapeutic radiofrequency ablation/denervation) may be considered if medical management consisting of at least activity modification, physiotherapy, analgesia, and muscle relaxants have not succeeded in alleviating the patient's pain.

Primary options

dexamethasone: 4 mg intra-articularly/intrasynovially/into tendon sheath as a single dose

More

cervical spondylotic radiculopathy (CSR)

1st line – analgesia

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ACUTE
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cervical spondylotic radiculopathy (CSR)
1st line – 

analgesia

Radiating arm pain can be severe and is initially managed with oral analgesia combined with physiotherapy and cervical traction.[12][22]​​

Non-steroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, diclofenac, meloxicam) are typically used first-line with escalation to an opioid (e.g., hydrocodone, oxycodone) or gabapentin if the patient’s pain remains uncontrolled.

NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.

The addictive potential and harm from overdose of opioids should always be considered. Escalation to an opioid (e.g., hydrocodone or oxycodone) should only be considered if pain is not adequately controlled with the non-opioid analgesics, muscle relaxants, physiotherapy, and image-guided interventional spine injections to decrease reliance of this drug class.

Gabapentin may be used as a second-line option for neuropathic pain. Patients should be cautioned regarding potential sedation or cognitive adverse effects at the beginning of treatment. Once the patient's symptoms have improved, the dose may be tapered.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

OR

meloxicam: 5-10 mg orally (capsule) once daily when required; 7.5 to 15 mg orally (tablet or suspension) once daily when required

Secondary options

paracetamol/hydrocodone: 5 mg orally every 4-6 hours when required, maximum 60 mg/day

More

OR

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours

OR

gabapentin: 300 mg orally once daily for 1 day, followed by 300 mg twice daily for 1 day, then 300 mg three times daily, increase gradually according to response, maximum 3600 mg/day

Consider – physiotherapy and traction

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ACUTE
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cervical spondylotic radiculopathy (CSR)
Consider – 

physiotherapy and traction

Additional treatment recommended for SOME patients in selected patient group

All patients with cervical radicular pain who have physical difficulty with daily activities should be offered physiotherapy, including posture correction, stretching exercises, and active range-of-movement exercises.[22]

Physiotherapy and particularly cervical traction can help to enlarge foramina narrowed by cervical spondylosis. It may provide further room for nerve roots and subsequently decrease the severity of the nerve tightness (hence partially alleviating the radicular pain).[3][24] Traction regimen of 5-8 kg (12-18 pounds) for 30-45 minutes several times a day is recommended.

Consider – oral corticosteroid

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ACUTE
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cervical spondylotic radiculopathy (CSR)
Consider – 

oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Usually limited to 8-10 days total due to systemic toxicity, but can be helpful as an adjunctive initial treatment to decrease nerve irritation and radicular pain.​[22][26][56]

Primary options

prednisolone: 60-80 mg orally once daily for 2-3 days, then taper dose gradually over 10-14 days

2nd line – epidural anaesthesia or cervical nerve root block

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ACUTE
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cervical spondylotic radiculopathy (CSR)
2nd line – 

epidural anaesthesia or cervical nerve root block

Depending on the timing and outcome of initial treatments, subsequent more invasive treatments may consist of epidural corticosteroids or cervical nerve root block at the suspected level to maintain a positive effect from the oral corticosteroids.[25][34][61][64]

Epidural anaesthesia or cervical nerve root block should be administered by a fellowship-trained or board-certified interventional spine consultant, who may be an interventional radiologist, pain management physician (generally anaesthesia trained), physiatrist (physical drug & rehabilitation), and/or neurologist.

3rd line – surgical nerve decompression

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ACUTE
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cervical spondylotic radiculopathy (CSR)
3rd line – 

surgical nerve decompression

If the pain does not resolve and if all symptoms, signs, and diagnostic studies indicate pressure on a single nerve root, then surgical nerve decompression may be a helpful treatment in some patients.[13][25]

Either anterior cervical discectomy with fusion (ACDF) or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, the number of levels of involvement, and the specific anatomy from the cervical MRI scan.

A minimum of 2 to 3 months of conservative therapy is usually required. Because there is rarely any significant weakness or neurological change associated with radiculopathy, the primary decision for considering surgical decompression is the patient's subjective degree of pain and the significance of the discomfort.

Another approach is cervical arthroplasty, where an artificial disc is placed instead of a bone graft and plate to avoid a fusion and retain motion; multiple randomised studies have been carried out, but these procedures are not yet routinely performed everywhere.[69][70] Despite these multiple randomised studies, there is not yet any clear evidence regarding improved relief of radicular arm pain with arthroplasty compared with ACDF. However, although there are no clear data yet on the prevention of adjacent segment stenosis over time, arthroplasty may provide a lower rate of re-operation compared with ACDF.[69][70][71]

Anterior cervical discectomy is less painful, but swallowing problems may occur.[13][28][72]

Posterior cervical discectomy may be associated with increased neck pain, but does not typically involve a fusion, resulting in preservation of motion.

degenerative cervical myelopathy (DCM)

1st line – surgical decompression

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ACUTE
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degenerative cervical myelopathy (DCM)
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moderate to severe symptoms: good surgical candidate
1st line – 

surgical decompression

Surgical decompression is the preferred treatment in patients with moderate and severe symptoms and who are good surgical candidates, although two randomised controlled trials do not show any short-term benefit for mild to moderate myelopathy.[26][27][28][33][37]​​​​​​ 

Adequate treatment of the severe underlying degenerative joint disease (DJD) usually requires fusion or immobilisation of the segments, leading to loss of range of motion of the cervical spine.[26][28]​​​ Surgery is, therefore, typically considered to stabilise function rather than necessarily improve it. This surgery has higher risks than surgery for radiculopathy, particularly of neurological worsening.

With anterior approaches, adjacent segments often develop DJD over time, leading to adjacent segment stenosis. With posterior approaches there can be either instability (following laminectomy alone) or near complete loss of cervical range of motion, with the typical extensive posterior fusion needed. Furthermore, decompression surgery typically only stabilises spinal cord function (with only mild improvement in symptoms) because there is usually existing permanent damage to the spinal cord at the time of surgery. The trend is consequently towards earlier surgery, while the patient has more of a chance of returning to normal function, or surgery while the patient is asymptomatic.[26]​​[27][28][33][35]​​​[36]​​

There are no long-term drug treatments that are helpful in management of DCM; corticosteroids may be used short-term, such as a bridge prior to possible surgical decompression, but for less than a 2-week period due to severe side effects over time.

1st line – conservative treatment with immobilisation in a hard cervical collar

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ACUTE
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degenerative cervical myelopathy (DCM)
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mild symptoms or poor surgical candidate
1st line – 

conservative treatment with immobilisation in a hard cervical collar

Conservative treatment is the preferred approach for patients who are poor surgical candidates. In some countries, although not all, it is also used for those who have mild, chronic symptoms.

Conservative measures implemented in randomised trials primarily consist of immobilisation in a hard cervical collar.[35]​ This conservative treatment has been shown to be equivalent (over 1-3 years) to surgical decompression in patients with mild to moderate myelopathy.[33]

There are no long-term drug treatments that are helpful in management of DCM; corticosteroids may be used short-term, such as a bridge prior to possible surgical decompression, but for less than a 2-week period due to severe side effects over time.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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