How should I approach the management of chronic neck pain in a patient with cervical spondylosis who has not responded to conservative treatment?

Management of chronic neck pain in cervical spondylosis unresponsive to conservative treatment:

• Ensure no red flag features are present that require urgent referral or investigation.
• Continue to provide reassurance and education about the condition, encouraging activity and return to normal lifestyle as tolerated.
• Consider referral to a multidisciplinary pain clinic for a comprehensive pain management programme if symptoms persist beyond 12 weeks despite conservative measures.
• Evaluate for psychological risk factors and consider referral for psychological therapies to address chronic pain and associated distress.
• Review analgesic use carefully; avoid long-term opioids, gabapentinoids, NSAIDs, and paracetamol for chronic primary pain due to lack of evidence and potential harms.
• Consider use of antidepressants (e.g., amitriptyline, duloxetine) for chronic primary pain management after discussing benefits and harms with the patient.
• Referral to physiotherapy for multimodal treatment including supervised strengthening, stretching, and manual therapy remains important.
• Address occupational factors with referral to occupational health if relevant.

This approach aligns with NICE and CKS guidance emphasizing multimodal, multidisciplinary management and cautious pharmacological use in chronic neck pain related to cervical spondylosis.

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