and Uwe Spetzger1
Department of Neurosurgery, Klinikum Karlsruhe, Karlsruhe, Baden-Württemberg, Germany
Conservative treatment in cases of degenerative diseases of the cervical spine primarily addresses pain relief. For this nonsteroidal anti-inflammatory drugs (NSAID) and, where required, additional central analgesics are applied. Physiotherapy focuses on passive procedures in the acute phase. In the subacute and rehab phase (after surgery or also for conservative cases), active exercises are added. Physical therapeutical methods are massages, application of warmth or cold and electrotherapy. Psychotherapy can be indicated in cases of chronic complaints with the absence of morphological findings in imaging.
5.1 General Considerations
If a patient is suffering from short-term neck-shoulder-arm pain without or slight neurological deficits, a conservative treatment for 6–8 weeks is indicated. Furthermore, conservative treatment is indicated for patients with chronic complaints but without pathological findings in the MR imaging. During conservative therapy the patient must be informed about the possibility of progressive motor deficits and the necessity of urgent readmission to the hospital and the indication for surgery in this case.
Conservative treatment includes multimodal analgetic therapy and physiotherapy as well as psychotherapy in selected cases with psychosomatic or chronified complaints. The primary goal of conservative treatment is pain relief, especially in the acute phase. Therefore, during physiotherapy the focus is on procedures with pain relief potential such as massage, traction, manual therapeutical procedures, application of warmth or cold and electrotherapy (Sect. 5.3). In the subacute and rehab phase, treatment is more focused on active physiotherapy to achieve muscular stabilisation of the spine.
The best prognosis for a success of conservative treatment can be expected in cases of soft disc herniation since pain causing nerve root compression can regress because of the morphological finding.
5.2 Pain Management
5.2.1 Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are the medication of first choice for the symptomatic treatment of pain due to degenerative diseases of the spine. Their principle of operation is an inhibition of cyclooxygenase (prostaglandin-endoperoxide synthase) in the prostaglandin metabolism (Kellner 2005). The mainly used classical NSAIDs are diclofenac and ibuprofen.
Diclofenac is a derivate of aryl acetic acid and has anti-inflammatory, analgetic and antipyretic effects. The plasma half-life is 1–2 h. The elimination is mainly renal (Offermanns 2012).
Ibuprofen is a derivate of aryl propionic acid and has similar effects as diclofenac. The plasma half-life is about 2 h (Offermanns 2012).
In cases of longer application, it is indicated to combine the NSAIDs with a proton-pump inhibitor (e.g. pantoprazole) to avoid gastrointestinal side effects.
Besides the systemic application, it might be useful to applicate NSAIDs locally for the treatment of neck pain.
The WHO suggests a three-step analgesic ladder for medicamentous pain management, whereas step 1 (mild pain) includes the application of NSAIDs only (Diener 2005). For moderate pain (step 2), the application of an NSAID and/or paracetamol in combination with a weak opioid such as tramadol is recommended. Severe pain (step 3) requires the combination of an NSAID and/or paracetamol with a strong opioid (Table. 5.1).
Stepwise scheme of pain management as recommended by the WHO (Diener 2005)
NSAID, Metamizole, Paracetamol
Non-opioid analgetics and weak opioids
Non opioid analgetics and strong opioids
Morphine, Oxycodone, Fentanyl
5.2.2 Central Analgetics
If the application of an NSAID only is not effective for pain management, then the addition of a central analgetic should be considered. According to the WHO analgesic ladder, the mainly used drug in clinical practice is the opioid tramadol. For the treatment of spinal caused pain, it can be combined with metamizole and dexamethasone (optional) and applied intravenously. With this medication it is usually possible to manage even severe neck and arm pain due to cervical disc herniation.
Patients with chronic pain and without a surgical option can be treated with a transdermal opioid patch. A multimodal pain management in chronified cases should be initiated by a specialised pain therapist.
5.3.1 Aim of Treatment and Instruction of the Patient
A main principle of physiotherapy is instructing the patient how motional behaviour in the daily life can be improved to avoid inappropriate biomechanical stresses. Besides instructions there should be controls and corrections on a regular basis. By doing so the patient learns self-help strategies to avoid pain and increase his or her effectiveness. Another step is the instruction of the patient for independent exercising at home. The number and complexity of the exercises should be moderate to achieve an adequate compliance.