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stretching, and muscle strengthening are also recommended. Heating pads or
blankets may provide local relief. In general, evidence for these measures is not
based on controlled trials.
Pain management often includes the use of medications. Acetaminophen and
nonsteroidal anti-in
fl
ammatory drugs (NSAIDs) such as ibuprofen or naproxen are
the
ciently
with these treatments, opioids can be considered. Muscle relaxants may provide
relief in acute pain episodes. However, they are often associated with side effects
such as dizziness, so long term use is not recommended. Local injections with
corticosteroids or anesthetics are sometimes used, with variable results.
Surgery is indicated for patients with progressive nerve symptoms and com-
pression of the spinal cord or the spinal nerve roots. For neck pain or back pain
without nerve compression, surgery is not recommended due to lack of effectiveness.
first line treatments. In patients with severe pain who do not improve suf
2.1.4 Imaging
Plain radiographs of the cervical spine and lumbar spine are typically adequate to
reveal spondylosis. Because the correlation between symptoms and radiographic
changes is poor, radiographs have limited usefulness in the evaluation of neck pain
or back pain. In the absence of systemic symptoms such as fever or weight loss,
history of trauma, or progressive nerve symptoms, radiographs are typically not
obtained until after 6
8 weeks of conservative management.
However, radiographs may still provide valuable information. Osteophytes,
narrowing of the intervertebral disk spaces, narrowing of the facet joints, sclerosis
(increased radiographic density) of the facet joints and the endplates of the vertebral
bodies, and narrowing of the neural foramen are common
-
findings in spondylosis
(Figs.
1
and
2
). Radiographs are also useful to assess the alignment of the spine and
to exclude other diagnoses. The Kellgren/Lawrence system was developed to
classify the degree of osteoarthritic change in the spine, including the facet joints.
Lateral views of cervical spine and lumbar spine are obtained for grading. Five
features are considered in the Kellgren/Lawrence system: osteophytes, ossicles near
the joints, narrowing of joint spaces with subchondral sclerosis, pseudocysts, and
altered bone shape (Table
1
). Radiographic changes are classi
ed into
ve grades
(0
4), with a grade of 2 or higher as the conventional standard of diagnosis [
9
].
In patients with progressive neurologic symptoms, or in patients with persistent
pain and severe radiographic spondylosis, MRI is the imaging test of choice. It
provides a better resolution for structural changes, and is ideal for visualization of
the spinal cord, the intervertebral disk, and the soft tissues.
CT is superior for detection of bony changes, especially small osteophytes or
erosions arising from the lateral edge of the vertebral body and the facet joints
(Fig.
3
). However, because of the exposure to radiation, it is only used in patients
-