The Most Confusing Spine Condition Explained

What Is Spondylosis?

You may have heard your doctor talk about the term spondylosis, which is a confusing condition to understand because the word is used in many different ways. On top of its assortment of meanings, the terms are often associated with words like spondylitis. The term “spondyl” is the Greek word for vertebrae. Because of this, in medicine, many different conditions relating to the spine begin with the word “spondyl” causing confusion. To begin addressing the meaning of spondylosis, it is a term that refers to degenerative changes in the spine by aging. This can be from a variety of problems ranging from bone spurs, degenerative disc, facet joint syndrome, and osteoarthritis. In essence, spondylosis is a general term describing any type of spinal degeneration. Words you hear associated with spondylosis are more direct conditions or clinical diagnosis occurring to the spine.  

Spondylosis Umbrella of Conditions:

To fully understand spondylosis (or the specific conditions falling under the umbrella of spondylosis), you must understand the anatomy of your spine. Your spine is made up of 24 individual bones that are stacked one on top of the other. To visualize the anatomy of your spine, separate it into three parts. The cervical spine is the neck portion, the thoracic spine covers the majority of your upper to mid back, and the lowest portion of your spine is referred to as the lumbar spine. This portion of your body is vital to your health as it supports the rest of your body. This means, without your spine, you wouldn’t be able to stand upright, bend, or twist.

Ankylosing Spondylosis? Not so Fast!

Many people have the misunderstanding that a condition of spondylosis ankylosing exists. However, as we touched on earlier, this confusion comes from the similarity in the words spondylosis and spondylitis. The actual name of the condition is spondylitis ankylosing. Unlike spondylosis, the catch-all term for spinal degeneration, spondylitis refers to the clinical diagnosis of inflammatory arthritis to the spine. This condition can affect the spine and any larger joints. In fact, overtime this inflammation can become so severe that eventually, your vertebrae could fuse together. Unfortunately for males, this condition is two to three times more likely to affect you. This condition is also known to be genetically inherited, so if you’re a man with family history of ankylosing spondylitis we highly recommend you take precautions. In fact, the HLA-B27 gene can be detected in the blood of most patients with the condition.

Ankylosing spondylitis is a form of chronic inflammation of the spine and sacroiliac joints. These joints are located at the base of the low back where the sacrum meets the iliac bones. You can see the inflammation that develops in the graphic comparing a normal spine and ankylosing spine below. Thankfully, if you catch and treat this condition early on you can likely relieve the pain and not cause permanent spinal deformities. However, people who have severe ankylosing spondylitis can over time grow a permanent spinal deformation. For example, into severe conditions like kyphosis.

Symptoms of Ankylosing Spondylitis:

The early symptoms of ankylosing spondylitis include pain and stiffness in your lower back, specifically hips. You will likely experience this more in the morning and after any extended periods of inactivity. It’s not uncommon to experience things like neck pain and fatigue, which over time these symptoms will likely worsen. This condition will most likely be experienced in your joints between the base of the spine and your pelvis, as well as vertebrae in your lower back.

How do I Treat My Ankylosing Spondylitis?

There is no absolute cure for ankylosing spondylitis. However, there are many things you can do to reduce symptoms and help manage your pain. Often times people will be prescribed some form of anti-inflammatory medication to assist with the pain. Beyond medication, therapy is often used to treat and help with strength and flexibility. Using a range of motion exercises can help maintain flexibility in your joints and encourage good posture. In rare cases your doctor may talk to you about potential surgical options, however, this is fairly uncommon.

Cervical, Thoracic, Lumbar, and Multilevel Degenerative Spondylosis:

Spondylosis of the spine can occur in any portion of the spine, including the cervical, lumbar, and thoracic. As touched on earlier, cervical is the beginning portion of the spine at the neck, thoracic in the upper to middle back, and lumbar in the lower back. So depending on the location of the disc and joint degeneration, the name of your specific spondylosis will change. Most of these conditions are also referred to as cervical osteoarthritis, thoracic osteoarthritis, and lumbar osteoarthritis. However, just because we often refer to spondylosis in terms of cervical, thoracic, and lumbar, this doesn’t mean it can’t affect more than one. This type of spondylosis is known as multilevel degenerative spondylosis, meaning it’s affecting more than one of the areas. This type of spondylosis is often more degenerative and advanced than the other forms. You may have your doctor refer to your condition as mild spondylosis. Essentially, this means your spondylosis is in the beginning stages of degeneration, rather than advanced spondylosis.

In the medical world, the terms bilateral and unilateral are often used. Unilateral means that the condition is happening on one side, while bilateral means that both sides are being affected. The terms unilateral and bilateral apply to spondylosis and are often used to describe the location of the spondylosis on the spine.

Cervical Spondylosis:

This form of spondylosis is also known as cervical osteoarthritis or neck arthritis. This is an age-related condition that affects the joints and discs in the neck. According to Mayo Clinic, the condition is present in more than 85 percent of people over the age of 60. Unfortunately, it’s common to experience side effects like dizziness and vertigo with cervical spondylosis.

Cervical Spondylosis With or Without Myelopathy:

Cervical spondylosis with myelopathy is also referred to as CSM. This condition refers to the impaired function of your spinal cord by degeneration. Because what happens to your spinal cord is caused by degeneration, it’s considered a type of spondylosis.

To understand myelopathy you must understand what your spinal cord is. Your spinal cord is the inner portion of your spine that is made up of bundles of fibers; it’s the main pathway of information from your brain to the rest of your body. Your brain and spinal cord together make up your central nervous system.

But it’s important to understand that your spine and your spinal cord are different. The spinal cord runs down from your brain, through a canal in the middle of the bones that make up your spine. Your spinal cord runs through your C1 vertebrae (your neck, or the top of your spine), all the way down through your T12 vertebrae (the end of your thoracic spine, or the top of your lower back).

So, you have cervical spondylosis with myelopathy if the degeneration of your upper spine (C1-C8 vertebrae) has become so severe that it is impairing your spinal cord. But there are many people who experience degeneration of the cervical spine without it affecting their spinal cords; these people have cervical spondylosis without myelopathy. This type of spondylosis with and without myelopathy can occur in more than just the cervical region. This includes your thoracic spine, in which the condition is called thoracic spondylosis with myelopathy. Unlike the cervical and thoracic spine, lumbar (L1 to S1) spondylosis cannot be affected with myelopathy. This condition is often thought to be referred to as lumbosacral spondylosis with or without myelopathy. However, because the spinal cord ends with the thoracic region, lumbar spondylosis exists only without myelopathy.

Spondylosis with Radiculopathy:

You may be wondering, what is radiculopathy? Well, it’s similar to the term spondylosis in the sense that it’s a catch-all term, but radiculopathy is in reference to a pinched nerve. Radiculopathy occurs when a nerve in the spine is compressed or irritated at the point where it branches to the spinal cord. Any type of spinal degeneration can cause radiculopathy, hence why it’s associated with spondylosis. The case of radiculopathy is the same as myelopathy. This condition can only occur in cervical and thoracic spondylosis as these are the locations of the spine where the spinal cord exists.

Spondylosis Causes:

The spine is a part of the human body that is very susceptible to problems, specifically as we age. A variety of things may have directly caused your specific spondylosis condition. However, it’s often related to general wear and tear from our daily lives.

What Happens to our Spines as we Age?

Over time through wear and tear on the body, our spines can begin to degenerate. This is especially true for women who are undergoing menopause. For example, the flexibility our spine provides us while we’re young will naturally dry up throughout time. Losing the flexibility of your spine can become a major issue because those cushions act as shock absorbers for our spinal bones. This type of problem can lead to conditions such as bone spurs or weakened facet joints. Essentially, with time people begin to lose bone or vertebrae mass or density, meaning the bone has less calcium and other minerals. It’s this type of spinal change that is collectively called spondylosis.

Spondylosis Symptoms:

Spondylosis symptoms can vary greatly from person to person. In fact, many people won’t experience much for symptoms at all. However, it generally depends on what form of spondylosis condition you specifically have.

Cervical Spondylosis: Stiffness and pain in the neck

Osteoarthritis: Pain and stiffness throughout the spine, specifically in the morning

Bone Spurs: Dull neck, headaches, and numbness or tingling throughout the body

Degenerative Disc Disease: Lower back and neck pain, activity flare pain

Spinal Stenosis: Leg and lower back pain

Facet Joint Syndrome: Pain and numbness depending on location

Spondylosis Treatment:

There is no true cure to reverse the process of spondylosis. This is true because the condition is a degenerative process, meaning it irreversible and occurs mostly with age. However, there are many treatment options for pain relief when spondylosis is experienced in the neck, back, and spine.

Acupuncture: You may have heard of acupuncture in recent years as it’s become a nonsurgical way to treat a multitude of body pains. In acupuncture, tiny needles are inserted into specific and targeted parts of the body. The location of these needles depends on the pain in which you are having treated. In the case of spondylosis, needles will most likely range between the cervical and the lumbar spine. Each of these individual needles may be twirled, electrically stimulated, or warmed. The theory behind acupuncture is that the tiny needles encourage the body to release chemicals that help with pain reduction.

Bed Rest: If you’re experiencing a very severe case of spondylosis your doctor may recommend some level of bed rest. Most often, bed rest is encouraged no longer than 3 days. Unfortunately, if bed rest is done for too long it may have reverse effects on the progress of your spondylosis.

Brace Use: Bracing can be a very useful tool in helping to relieve pain caused by spondylosis. However, it’s important similar to bed rest, braces aren’t worn for too long. Braces will help to target and isolate areas of pain to offer you some level of relief.

Physical Therapy: Physical therapy is a form of treatment that focuses on healing through massages, heat treatments, and exercises. This combination of treatment can be extremely helpful in pain relief for spondylosis. For example, a joint effort of heat and ultrasound treatment and exercises for strength and increased flexibility will commonly take away the chronic pain of back and neck problems.

Spinal Injections: If you’re experiencing a more severe case of spondylosis spinal injections may be your best option to find relief. However, we strongly recommend more mild attempts at relief before considering things such as injections and surgery. Most commonly injections will combine a local anesthetic and steroid medication to reduce inflamed nerve tissues, this will in return relieve pain.

Spondylosis Exercises: Performing exercises for your spondylosis can be very helpful in pain relief. Exercises can help to strengthen and stretch the affected areas which are important in the process of relief. Medical professionals recommend keeping your spine mobile in order to achieve a healthier spine.

Spondylosis Surgery: Surgery on spondylosis is extremely uncommon, but not unheard of. Thankfully, most cases of spondylosis never become severe enough for surgical options, or people experience enough relief through treatments like what is talked about above. In the case that surgery may be an option for you, the surgical procedure performed will be at your doctor’s discretion. In some cases, the removal of bone spurs may be best for your specific case, or your physician may recommend a spinal fusion.

Spondylosis: The general term pertaining to degeneration of the spine including cervical, thoracic, and lumbar. This term is an umbrella term often pertaining to conditions like osteoarthritis, bone spurs, and degenerative disc disorder.

Spondylitis: The term referring to the form of arthritis that commonly occurs in the back. Ankylosing spondylitis refers to the inflammation of the joint in the spine, otherwise known as the sacroiliac joints (SI joints).

Spondylolisthesis: A specific condition in which the bones within your vertebra slide forward or backward over the bone next to it. This typically occurs at the fifth or fourth vertebra of the lower back.

Spondylolysis: A condition in which a defect or stress fractures occurs in the pars interarticularis of the vertebral arch. The most common form of this condition is the L5 spondylolysis, followed by spondylolysis of the fourth vertebrae.

Lumbar spondylosis without myelopathy – PM&R KnowledgeNow

History

As mentioned previously, LS is a radiographic finding that does not rely on clinical symptoms for diagnosis.   However, in some patients with acute or gradual onset of LBP, LS is present and could potentially be a cause of the pain.  Pain may refer unilaterally or bilaterally to the buttock, hip, groin, and thigh regions; although, typically, it does not extend past the knee.^6,10 The pain tends to worsen with extension, rotation, and standing; it is better with lying and L-spine flexion.¹⁰ By definition, lumbar spondylosis exhibits no neurologic deficits; however, because of its association with conditions that can affect the neurologic function of the lower limbs, it is imperative to ask about weakness, balance, gait, and bowel/bladder function.

There are several validated outcome measures for grading functional limitations, including the following: McGill Low Back Pain Scale, Oswestry Disability Index, and the Medical Outcomes Study 36-Item Short-Form Health Survey.¹¹  These should typically be administered at every office visit for following the patient’s progression.

Physical examination

A systematic review revealed that most physical exam maneuvers have limited or no diagnostic validity for spondylosis.⁶ Paraspinal tenderness is the only physical exam maneuver that seems to correlate with z-joint arthropathy, but not with high diagnostic confidence. Although classically felt to diagnose z-joint pain, joint loading with pain on extension and ipsilateral rotation has not been shown to consistently correlate with spondylosis.^12,13  Because the pain distribution may overlap with other clinical entities, a comprehensive exam including radiculopathy, hip, and sacroiliac joint provocative maneuvers should be performed routinely. Associated neurologic conditions should be ruled out through thorough strength, sensation, reflexes, gait, and balance testing.

Laboratory studies

Although no laboratory studies are routinely indicated, some, such as C-reactive protein, sedimentation rate, and complete blood count, may be ordered if there is clinical suspicion for a more serious condition, such as malignancy, infection, or rheumatologic disease.

Imaging

Lumbar spondylosis is visible on multiple imaging modalities, including plain radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) studies.  However, as spondylosis on imaging does not constitute a cause for LBP, imaging is typically ordered to rule out other disorders.^13,14,15

Plain radiographs are not sensitive for detecting early z-joint OA or spondylosis, but are highly accessible, and often used. Lateral views are important to study sagittal alignment and the presence of spondylolisthesis. If present, patients should undergo flexion and extension radiographs to rule out instability of the spine.

MRI is generally not needed for diagnosis of spondylosis, but it is useful for evaluating the soft tissues and neural elements within the spine, especially to rule out neuroforaminal stenosis in patients with concomitant leg pain. Large amounts of fluid within the z-joints may represent instability and/or infection, which would warrant further work up and/or treatment, but is beyond the scope of this article.

CT is typically utilized when an MRI is unobtainable or if fracture is suspected.  It can also be helpful in identifying synovial cyst borders with implications for surgical vs percutaneous treatment.

Supplemental assessment tools

Diagnostic Injections

Given the low correlation of radiographic spondylosis with axial low back pain, the only means for an accurate diagnosis of symptomatic lumbar spondylosis secondary to facet arthropathy is to perform controlled diagnostic blocks of the medial branch nerves that innervate the z-joints.¹⁶  This assumes that the patient’s pain generator(s) is/are the z-joints and not another spondylotic spine component, such as the disc. Each z-joint has dual innervation from the medial branch of the dorsal ramus of the nerve at the corresponding level and the level above. In order to treat the pain associated with a specific z-joint, both nerves must be targeted.

Several key principles exist for diagnostic medial branch blocks:

1. Because of the inaccuracy of landmark guidance, all blocks should be performed utilizing image guidance.   Both fluoroscopic and ultrasound guidance have been described in the literature.
2. False positive blocks occur at a high rate of 17% to 41% in the lumbar spine, thus necessitating a second control block for confirmation of the diagnosis. Ideally, the two injections should be performed with anesthetics of differing duration.  Concordant pain relief (>1h with lidocaine and >3h with bupivacaine hydrochloride), greatly enhances the sensitivity and specificity of the injections.¹³
3. The greater the percentage of pain relief a patient obtains with a given injection, the more likely that injection correctly targeted the pain generator. Some clinicians accept 50% pain relief as a diagnostic criterion. An 80% pain relief threshold with comparative medial branch blocks results in more successful outcomes with radiofrequency ablation, a denervation procedure which uses radiofrequency to thermally ablate the medial branch nerves (13, 16).  For more details, please see the lumbar zygapophyseal arthropathy section of Knowledge NOW.

Cervical spondylosis and neck pain

BMJ. 2007 Mar 10; 334(7592): 527–531.

, consultant rheumatologist

Allan I Binder

Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB

Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB

This article has been cited by other articles in PMC.

Supplementary Materials

[extra: References]

GUID: 296DB0F5-23DB-41EB-8E6B-9E9869CA5064

GUID: 9338E631-BE64-4AE3-9DB2-BDCCCDD41F8B

Most patients who present with neck pain have “non-specific (simple) neck pain,” where symptoms have a postural or mechanical basis. Aetiological factors are poorly understood^w1 and are usually multifactorial, including poor posture, anxiety, depression, neck strain, and sporting or occupational activities.^w2 Neck pain after whiplash injury also fits into this category, provided no bony injury or neurological deficit is present. ^w3 When mechanical factors are prominent, the condition is often referred to as “cervical spondylosis,” although the term is often applied to all non-specific neck pain. Mechanical and degenerative factors are more likely to be present in chronic neck pain.

In cervical spondylosis, degenerative changes start in the intervertebral discs with osteophyte formation and involvement of adjacent soft tissue structures. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, however, so the boundary between normal ageing and disease is difficult to define.^w4 Even severe degenerative changes are often asymptomatic, but can lead to neck pain, stiffness, or neurological complications.

I will concentrate on the diagnosis of cervical spondylosis and the evidence available for the different treatments. I will also mention some practical measures that are thought to be important but have not yet been studied. Specific conditions like fibromyalgia, disc prolapse, and whiplash will not be considered, although some patients with these conditions may have been included in therapeutic studies.

Summary points

• The diagnosis of cervical spondylosis is usually based on clinical symptoms

• Patients need detailed neurological assessment of upper and lower limbs as cervical degeneration is often asymptomatic, but can lead to pain, myelopathy, or radiculopathy

• “Red flag” symptoms identify the small number of patients who need magnetic resonance imaging, blood tests, and other investigations

• The best treatments are exercise, manipulation, and mobilisation, or combinations thereof

• Radiculopathy has a good prognosis and may respond to conservative measures

• Results of neck surgery for myelopathy or intractable pain are often disappointing

Data sources and selection criteria

I searched Chirolars (now called Mantis), Bioethicsline, Cinahl, Current Contents, and Medline for therapeutic options to treat mechanical neck pain when preparing and updating an article for Clinical Evidence. ¹ This review is based on that article.

Who gets neck pain?

About two thirds of the population have neck pain at some time in their lives,^w5w6 and prevalence is highest in middle age. In a general practice survey of adults in the United Kingdom, 25% of women and 20% of men reported current neck pain.^w7 In a Norwegian survey of 10 000 adults, 34% of responders had experienced neck pain in the previous year.^w8 After back pain, neck pain is the most frequent musculoskeletal cause of consultation in primary care worldwide. In the UK about 15% of hospital based physiotherapy and in Canada 30% of chiropractic referrals are for neck pain.^w9w10 Epidemiological studies of neck pain are mostly based on questionnaire or population surveys and may overestimate the frequency of the condition. Despite these methodological difficulties, they do provide evidence that neck pain places a heavy burden on individuals, employers, and healthcare services.

What is the natural history of neck pain?

The outcome of neck pain depends on the underlying cause, but acute neck pain usually resolves within days or weeks, although it can recur or become chronic (more than three months’ duration). A UK survey of 7669 adults found that 18% had neck pain at the time of the survey, and half of those (58% of the symptomatic patients responded) still had pain when asked one year later.^w11 Outcome is unpredictable once pain becomes chronic, and prognosis and the factors that influence it vary greatly.^w1 Reports on the importance of factors like age, sex, occupation, psychological factors, and radiological findings are conflicting,^w1w2 but the quality of most studies is poor. Three recent studies (1535 patients)^w11–w13 found that the best predictors of an unfavourable outcome one year after presentation with neck pain were severity of the initial pain and concomitant back pain. At least 10% of affected people develop chronic neck pain,^w5 although this figure is much higher in some studies. ^w11w13 In some industries, neck related disorders account for as much time off work as low back pain.^w14 Neck pain causes severe disability in 5% of affected people.^w6

How is cervical spondylosis diagnosed?

Cervical spondylosis is usually diagnosed on clinical grounds alone (box 1). Although pain is predominantly in the cervical region, it can be referred to a wide area, and is characteristically exacerbated by neck movement. Neurological change should always be sought in the upper and lower limbs, but objective changes occur only when spondylosis is complicated by myelopathy or radiculopathy, or when unrelated causes like disc prolapse, thoracic outlet obstruction, brachial plexus disease, malignancy, or primary neurological disease are present.

Box 1 Presenting features of cervical spondylosis

Symptoms

• Cervical pain aggravated by movement

• Referred pain (occiput, between the shoulder blades, upper limbs)

• Retro-orbital or temporal pain (from C1 to C2)

• Cervical stiffness—reversible or irreversible

• Vague numbness, tingling, or weakness in upper limbs

• Dizziness or vertigo

• Poor balance

• Rarely, syncope, triggers migraine, “pseudo-angina”^w15

Signs

• Poorly localised tenderness

• Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides)

• Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy)

Box 2 Differential diagnosis of cervical spondylosis

• Other non-specific neck pain lesions—acute neck strain, postural neck ache, or whiplash

• Fibromyalgia and psychogenic neck pain

• Mechanical lesions—disc prolapse or diffuse idiopathic skeletal hyperostosis

• Inflammatory disease—rheumatoid arthritis, ankylosing spondylitis, or polymyalgia rheumatica

• Metabolic diseases—Paget’s disease, osteoporosis, gout, or pseudo-gout

• Infections—osteomyelitis or tuberculosis

• Malignancy—primary tumours, secondary deposits, or myeloma

What conditions need to be differentiated from cervical spondylosis?

Box 2 shows the most important differential diagnoses. Other non-specific neck pain syndromes are not easy to distinguish from cervical spondylosis, but conditions like whiplash have different dynamics, which may greatly influence outcome. Fibromyalgia and related conditions cause more diverse symptoms, with prominent tender “trigger” points around the joints, sleep disturbance, and psychological abnormalities. The other differential diagnoses are usually suggested by “Red flag” symptoms (box 3), which indicate the need for further investigation. Inflammatory changes associated with rheumatoid arthritis affect the atlanto-axial joint and upper cervical spine, where degenerative change is unusual, and in patients with arthritis it may be necessary to determine whether neck pain is due to arthritis or concomitant cervical spondylosis. Disc prolapse, other mechanical lesions, or primary neurological disease are likely to cause objective neurological abnormalities and trigger further investigation.

Box 3 “Red flag” features and the conditions they may suggest

Malignancy, infection, or inflammation

• Fever, night sweats

• Unexpected weight loss

• History of inflammatory arthritis, malignancy, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression

• Excruciating pain

• Intractable night pain

• Cervical lymphadenopathy

• Exquisite tenderness over a vertebral body

Myelopathy

• Gait disturbance or clumsy hands, or both

• Objective neurological deficit—upper motor neurone signs in the legs and lower motor neurone signs in the arms

• Sudden onset in a young patient suggests disc prolapse

Other

• History of severe osteoporosis

• History of neck surgery

• Drop attacks, especially when moving the neck, suggest vascular disease

• Intractable or increasing pain

How do I investigate patients with suspected cervical spondylosis?

Most patients do not need further investigation, and the diagnosis is made on clinical grounds alone. Plain radiographs of the cervical spine may show a loss of normal cervical lordosis, suggesting muscle spasm, but most other features of degenerative disease (fig 1) are found in asymptomatic people^w4 and correlate poorly with clinical symptoms. Magnetic resonance imaging of the cervical spine is the investigation of choice if more serious pathology is suspected, as it gives detailed information about the spinal cord, bones, discs, and soft tissue structures (fig 2). However, normal people can show important pathological abnormalities on imaging,^w16 so scans need to be interpreted with care. Patients who are systemically ill or have symptoms suggesting more serious pathology (box 3) may need additional investigations such as full blood count, erythrocyte sedimentation rate, C reactive protein, protein electrophoresis, and occasionally electrodiagnostic studies to exclude other pathologies. In patients with rheumatoid arthritis, flexion and extension radiographs of the neck will show whether severe atlanto-axial subluxation is present, but magnetic resonance imaging may be needed to define the severity of inflammatory and degenerative changes.

Fig 1 Oblique radiograph of the cervical spine in a patient with cervical spondylosis showing loss of disc height, anterior osteophytosis, and narrowing of the foramina

Fig 2 Magnetic resonance imaging scan of the cervical spine showing the loss of disc height and signal from several discs with multisegmental spondylotic bars. Protrusion of the C5/6 disc results in compression of the cervical cord, which shows associated myelopathic changes

What are the complications?

Cervical spondylosis can be complicated by myelopathy or radiculopathy, although cervical disc prolapse, plexopathy, motor neurone disease, or other diseases can cause similar symptoms²; magnetic resonance imaging, electrodiagnostic tests, and other investigations may be needed to exclude other diagnoses. Neurological complications can occur in established cervical spondylosis or can be the presenting feature of the disease.

Myelopathy causes clumsiness of the hands or gait disturbance, or both, as a result of sensory ataxia or spastic paraparesis of the lower limbs, with bladder dysfunction being a late symptom. Examination of the upper limbs may show an increase in tone, with a pronator “catch” (C6/C7) or increased tone in finger flexors (C8). Wasting and fasciculation of biceps (C5/C6) or triceps (C7) are occasional findings. The lower limbs usually show an increase in tone with spasticity, but little true weakness. Tendon reflexes are characteristic, with reduced or even inverted biceps or supinator jerks (finger flexion instead of the normal biceps or supinator jerk), and an increase in triceps jerks, finger jerks, and all lower limb reflexes, with upgoing plantar responses. A positive Hoffman’s sign (flexion of the terminal phalanx of the thumb and second and third phalanges of the other fingers when one of the middle fingertips is flicked) and ankle clonus are also common findings. Sensory changes vary, but tend to affect vibration and joint position sense in the hands more than the feet.

Radiculopathy (nerve root compression) due to cervical spondylosis usually occurs at the C5 to C7 levels, although higher levels can also be affected. Neurological features follow a segmental distribution in the upper limb, with sensory symptoms (shooting pains, numbness, hyperaesthesia) being more common than weakness. Reflexes are usually diminished at the appropriate level (biceps (C5/6), supinator (C5/6), or triceps (C7)). Figure 3 shows the dermatomal distribution of the cervical and upper thoracic nerves.

Fig 3 Dermatomal distribution of cervical and upper thoracic nerves

How do I treat cervical spondylosis?

Most mechanical neck pain will respond to conservative measures, but the optimal treatment for uncomplicated neck pain has yet to be established. Few treatments have been assessed in high quality randomised studies, but I will present the best available evidence for the most commonly used ones.

Pragmatic (unstudied) measures

Currently, a balanced view of the management of neck pain cannot be given by discussing evidence based treatments only. Stress management and postural advice on daily activities, work, and hobbies may be useful in some patients. Patients should be advised to use only one pillow at night. When pain is severe, analgesics and anti-inflammatory agents are widely used, despite the lack of evidence that they work. Low dose tricyclic antidepressants, like amitriptyline 10-30 mg per night, might be more effective. Yoga, pilates, and the Alexander technique all improve neck posture, but their value in treating neck pain is uncertain.

How do I treat acute neck pain to prevent chronic disability?

Most studies of early treatment of acute neck pain are on patients with whiplash injury, and it is unclear whether the data can be generalised to non-traumatic causes. Two systematic reviews of small poor quality studies considered acute neck pain not due to whiplash and found limited evidence of benefit for manipulation or mobilisation therapy.^3,4 No evidence exists for the efficacy of non-steroidal anti-inflammatory agents or analgesics. The evidence that muscle relaxants relieve pain more than placebo is weak, and the incidence of side effects like drowsiness is high. Studies of the early treatment of whiplash provide moderate evidence that early mobilisation physiotherapy^w17-w20 and advice to “act as usual”^w21 are more effective than immobilisation and less active treatments in speeding up recovery and reducing chronic disability. Less evidence exists for the benefit of home exercise regimens,^w22 pulsed electromagnetic field therapy,^w23 and multimodal therapy.^w24

How do I treat chronic cervical spondylosis?

Randomised controlled trials identified by systematic reviews^1,5,6,7,8 provide moderate evidence that various exercise regimens—using proprioceptive, strengthening, endurance, or coordination exercises—are more effective than usual care (analgesics, non-steroidal anti-inflammatory drugs, or muscle relaxants)^9w25 or stress management,^10,11 although not all studies have found exercise beneficial. ¹² One randomised controlled trial found exercise plus infrared heat no more effective than transcutaneous electrical nerve stimulation plus heat at relieving pain at six weeks and six months, although both were better than heat alone.^w26

Randomised controlled trials included in systematic reviews of manual treatments (mobilisation physiotherapy or manipulation)^{1,4,5,13,14,15,16} provide limited evidence that mobilisation physiotherapy^17,18 and manipulation¹⁷ are more effective for chronic neck pain than less active treatments (drug treatment, education, counselling). However, manipulation has occasionally been associated with serious neurological complications (around 5-10 per 10 million manipulations).^w27

Mobilisation, manipulation, and exercise seem to be equally effective.^19,20w28 A study comparing combined exercise and manipulation with either modality alone found the combination to be more effective at three months,²¹ but no difference was seen compared with exercise alone at one and two years. ²² However, another pragmatic study found no advantage at six weeks or six months of adding manual therapy (63% of patients had mobilisation physiotherapy) or heat (shortwave diathermy) to exercise and advice.²³

Systematic reviews of weak randomised controlled trials provided no conclusive evidence about the effectiveness of acupuncture²⁴ or traction²⁵ compared with a range of other treatments in patients with chronic neck pain. The addition of psychotherapy techniques like cognitive behavioural therapy also added little to physical or mechanical treatment alone.²⁶

How do I treat cervical spondylosis complicated by neurological abnormality?

Most patients with neurological abnormality will need magnetic resonance imaging of the cervical spine at an early stage, particularly if they have progressive myelopathy, radiculopathy, or intractable pain. Neurosurgical intervention also needs to be considered, but the outcome of decompressive surgery is often disappointing, especially for myelopathy complicating cervical spondylosis. While progression of the neurological deficit may be slowed by surgery, lost function may not recover or symptoms may progress at a later date. Poor outcome after surgery may reflect irreversible damage to the cervical cord (see fig 2) or compromise to the vascular supply to the cord.

Radiculopathy usually has a favourable outcome, so conservative treatments are gaining popularity, especially for patients with comorbidities or those who are unsuitable for general anaesthesia but are neurologically stable. Only a few small poor quality randomised controlled trials have assessed cervical epidural injection²⁷ and other conservative measures²⁸ to treat this condition. Two small studies that compared epidural injection with placebo found epidural injections slightly more effective,^w29w30 but the difference was not significant. Epidural injection in the cervical region is more invasive than in the lumbar region, and it should be considered in patients with severe intractable pain or radiculopathy only if surgical intervention is not an option. ²⁷ One randomised controlled trial in patients with cervical radiculopathy compared surgical intervention with physiotherapy or immobilisation. While the surgical group had less pain at three to four months, no difference was seen between the three treatment groups at one year.²⁹

What has changed and what needs to be done?

Recently, better quality randomised controlled trials have suggested that exercise, mobilisation physiotherapy, and manipulation are more effective than less active treatments, although their relative cost effectiveness has not been studied.^10,19,21 One high quality study^21,22 suggested further advantages to combining exercise with mobilisation or manipulation; this approach has been advocated by a Cochrane review group^8,15 and warrants further study.

Many commonly used treatments including analgesics, anti-inflammatory agents, tricyclic antidepressants, strategies to improve posture, and stress management are widely used but have not been studied. Other modalities like acupuncture, traction, electrotherapy, and psychotherapy are of uncertain value and need further study.

The lack of consistency in study design, populations studied, outcome measures, and lengths of follow-up make comparisons across studies difficult. Use of multiple interventions in the same study also complicates these analyses. Large well designed randomised studies using standardised study protocols are needed to clarify the efficacy and cost effectiveness of individual treatments.

Notes

Competing interests: None declared.

References

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ICD-10-CM/PCS MS-DRG v37.0 Definitions Manual

Cervical spondylotic myelopathy | MedLink Neurology

Presentation and course

Patients with cervical spondylosis usually present with neck pain with or without radiculopathy or myelopathy. Even painless progression of sensorimotor deficit is seen in patients with more centrally located compression, as the roots are relatively spared. Myelopathy develops in approximately 5% to 10% of patients with clinically symptomatic spondylosis (95), but cervical spondylosis is the most common cause of myelopathy in middle-aged and elderly patients (24; 66). It is rarely seen before the age of 40, and often no injury is elicited or the patient reports only a series of minor or repetitive strains.

Because cervical spondylotic myelopathy may involve compression of the descending lateral corticospinal upper motor neuron tracts and ascending dorsal column sensory tracts, as well as compression of the lower motor neuron in the central gray of the spinal cord, patients present with a variety of symptoms. Emphasis should be placed on obtaining a history of numbness and clumsiness in the hands, decreased fine motor movements, and subtle gait disorders. Suspicion of the clinical entity remains the single greatest element in early identification of cervical spondylotic myelopathy.

The clinical features, duration, and natural history of this condition vary considerably because of their relationship to the inconstant combination of mechanical, dynamic forces and periods of vascular ischemia (63). Consequently, various patterns of myelopathy have been described. Crandall and Batzdorf classified patients into five groups based on their dominant syndromes (24):

Many patients also present with neck pain due to the degenerative components associated with spondylosis. Though patients may present with a radiculopathy secondary to extensive compression of various roots, it must be noted that cervical radiculopathy is not the main component of the disorder; long track dysfunction is the prerequisite of cervical spondylotic myelopathy. Similarly, a significant morbidity arising from cervical spondylosis is due to positional vertebral artery compression rather than spinal cord compression. A dramatic example of posterior circulation compromise due to cervical spondylosis can occur with therapeutic neck manipulation, or even with rotation-extension positions of the neck that may occur during sleep. An elderly patient awakening with acute nausea, vomiting, dysarthria, gait instability, and other signs of brainstem or cerebellar dysfunction should be studied urgently for cerebellar infarction due to cervical spondylotic vertebral artery compression (69).

An additional presentation of cervical spondylotic myelopathy is posttraumatic central cord syndrome. In these patients, relatively minor trauma can precipitate a neurologically devastating injury. The pathophysiology is thought to involve vascular injury to the relatively poorly perfused medial regions of the cord from buckling of the hypertrophic ligament both anteriorly and posteriorly. Consequently, medial damage leads to preferential damage to the upper extremities. Early stages of spondylotic myelopathy with milder compression often present with hand numbness and complaints of impaired fine motor coordination in such tasks as buttoning a shirt or managing pills in a bottle. One group studying transcortical motor potentials and spinal cord sensory-evoked potentials during surgery found electrophysiologic evidence for this clinical progression, noting that the lateral part of the posterior funiculus mediating upper limb sensory function was more vulnerable to compression than was the lateral corticospinal tract (47).

The physical findings associated with cervical spondylotic myelopathy vary depending on the exact level of compression, the degree of compression modified by aggravating factors, and the span of segments comprised in the cervical spinal cord. Symptoms may be characterized by lower motor neuron involvement at the level of the clinical lesion and upper neuron involvement at the levels below the site of compression. Thus, lower extremity involvement will present with upper motor neuron symptoms, whereas the upper extremities may present with both upper and lower motor neuron involvement depending on the level and the nature of the compression. Clark proposed that the sensory findings in myelopathy usually include the loss of pain and temperature, proprioception, and vibrations below the level of the lesion, with the relative sparing of touch (19). These factors are clearly influenced by the multiplicity of levels and degrees of compression. The most common presentation is spastic weakness of the hands and forearms before involvement of the proximal upper extremity muscles and hand numbness with paresthesias, which may be painful. Wasting of hand musculature is a late finding and is often symmetric because of the central nature of osteophytic compression in the canal. Likely related to the compressive effect on lower motor neurons within the cord, mid-cervical spondylotic myelopathy may present with unilateral or bilateral hand weakness mimicking a C8-T1 radiculopathy (78). It is common for some patients to present with leg weakness, emphasizing the effect of long tract compression on lower extremity motor function. Typically, the proximal musculature is affected early, making it difficult for the patient to get up out of a chair, get out of a car, or climb stairs.

Reflexes are generally hyperreflexic below the level of compression and hyporeflexic at the level of the anatomic lesion because of impaired lower motor neuron function in the anterior horn. Pathologic reflexes, such as the presence of the Babinski reflex in the lower extremities and Hoffmann reflex in the upper extremities, characterize upper motor neuron involvement in the cervical spine. Furthermore, clonus may be present in the lower extremities. Lhermitte sign may be present when the patient flexes and extends the neck, producing a feeling of electrical shock. Lunsford and colleagues reported that although a significant number of patients manifest hyperreflexia (87%), only about 50% have the Babinski reflex and about 20% have the Hoffmann reflex (59). To further complicate the evaluation, it should be remembered that at least 10% to 20% of patients with cervical spondylosis have some degree of symptomatic lumbar stenosis as well, blunting the increased tone and hyperreflexia of the lower extremities produced by the upper spinal compression and adding radicular leg pain to the history (82).

Bladder and bowel symptoms tend to occur infrequently and late in cervical spondylotic myelopathy. Bladder dysfunction was demonstrated in 15% and bowel dysfunction in 18% of the patients in a clinical series of 269 patients with myelopathy (46). In a separate clinical study, Epstein and colleagues found that 20% of patients exhibited bladder dysfunction with various degrees of urinary retention (31). The most common urinary symptoms in early spondylotic myelopathy are urinary urgency and frequency, particularly in women. Impotence in males may occur with more chronic and severe cord compression but may have other causes in the older population.

Myelopathy hand, introduced by Ono and colleagues in 1987, is a loss of power of adduction and extension of the two ulnar fingers and an inability to rapidly grab and release these fingers (73). “Burning hand syndrome” from chronic vascular injury to the medial sensory tracts tends to be bilateral and symmetric, provoked by light touch that produces sustained burning. This is generally an indication of a late permanent hyperpathic sensory derangement that may respond little or not at all to surgical decompression.

Gait abnormalities are noticeable in patients with cervical spondylotic myelopathy. Gorter noted that cervical myelopathy usually presents initially as subtle gait disturbances with gradual deterioration (39). He stated that spasticity and paretic dysfunction occur first and are followed by numbness and a loss of fine motor movements in the upper extremities. A myelopathic gait with a hesitant, jerking motion may appear. In addition to the gait abnormalities, some patients present with lower extremity complaints that are more of a lower motor neuron involvement. This is not surprising because it is estimated that 5% of patients with cervical stenosis have concomitant lumbar stenosis (32). Treatment should first be directed toward the cervical component, which often improves or alleviates the lumbar component.

Prognosis and complications

Though it has been several decades since the first clinical history of myelopathy was published, no definable natural history is available. Lees and Turner concluded clinical exacerbation added to neurologic deficits in patients with more than 10 years of myelopathy but emphasized that long periods of a neurologic stabilization occur between episodes of deterioration (56). Nurick supported this concept and concluded that the amount of disability in cervical myelopathy was established early in the disease process and generally did not progress significantly afterwards (72). Epstein’s clinical review of 1355 patients with cervical spondylotic myelopathy determined in a conservative treatment evaluation that 36% showed improvement, whereas 64% showed no improvement (30). In the group that did not improve, 26% deteriorated neurologically with the remainders remaining stable. Sixty-seven percent of Symon and Lavender’s patients displayed a linear relentless progression of neurologic deterioration rather than stabilization (85). A study classified patients who were “pre-symptomatic” with cervical spinal stenosis, followed them for a year, and determined that 19% had symptomatic progression; in 90% of these, an electrophysiologic data-based model was predictive (11).

Typically, patients with myelopathy have symptoms and signs for several years before seeking medical attention. Although the progression is usually slow, the course often involves a progressive decline if the disease is left untreated. A small percentage of patients exhibit a more rapid onset of progression of symptoms and signs.

Cervical spondylotic myelopathy is an intermittently progressive disease process without significant chance of reversal when no treatment is administered. Conservative therapy rarely solves the myelopathy. Once patients have presented with the signs and symptoms of cervical spondylotic myelopathy, most have some degree of permanent disability. Little chance of symptom resolution is possible with conservative treatment; therefore, patients with moderate or severe myelopathy are candidates for surgery. The two most important factors for successful outcome in patients treated for cervical spondylotic myelopathy are (1) the patient’s age and (2) the duration of symptoms. Young patients tend to do better than elderly patients. With respect to duration of disease, patients whose disease has been present for fewer than six months have a more favorable outcome than patients whose symptoms have been present for one year.

Chiles and colleagues examined a group of 76 individuals after anterior decompressive surgery. Interestingly, improvement occurred in the lower extremities in 47% of patients compared to a 75% improvement in the upper extremities. Approximately 2% per year developed symptomatic restenosis at adjacent levels to the original decompression (18). A prospective multicenter study with independent clinical review was performed by Sampath and colleagues to analyze the outcome of patients treated for cervical myelopathy. The study, sponsored by the Cervical Spine Research Society, indicated that surgically treated patients had a significant improvement in functional status and overall pain, with improvement also observed in neurologic symptoms (79). Several radiological studies have shown that favorable prognosis following decompressive surgery of any type may be predicted by the severity of preoperative spasticity, weakness, and atrophy coupled with critical MRI spinal cord findings; patients with normal cord appearance or presence of intramedullary high-signal change on T2WI fare better than those patients with hypointense (low signal) change on T1WI, which may indicate permanent injury (02; 60).

Clinical vignette

A 56-year-old right-handed man presented with three-year history of progressively severe radiating neck, right shoulder, and arm pain with intermittent paresthesias in both hands, right worse than left. Over the preceding four months, he had noticed impairment in fine motor coordination in his hands, with deterioration in his signature, difficulty with buttoning his shirt, and discriminating coins in his pocket. He also complained of fatigue and feeling of heaviness in his legs but without leg pain. He denied bladder or sexual difficulties. Physical exam revealed some loss of mechanical range of neck motion, particularly in rotation and in extension; Spurling maneuver provoked radiation of pain down the right arm from the shoulder with paresthesias in the entire right hand. Lhermitte sign was not elicited. Hoffman sign was present bilaterally. Mild weakness was noted in right biceps in forearm supination, right triceps, and finger extensors; grips were slightly weak, but abduction and adduction of both hands were moderately weak, right worse than left, with noticeable atrophy in right first dorsal interossei. Reflexes were diminished bilaterally in the upper extremities but brisk in the lower extremities. Gait appeared normal but with some difficulty with tight-roping. Lateral C-spine x-ray revealed a normally aligned but straightened spine with loss of normal lordotic curve, moderately severe spondylotic changes at the C5-6 disc space, narrowing with anterior and posterior spurring, and a chronically collapsed C6-7 disc space with more severe posterior spurring compromising the spinal canal.

Spondylosis

Definition (MSH)	A degenerative spinal disease that can involve any part of the VERTEBRA, the INTERVERTEBRAL DISK, and the surrounding soft tissue.
Definition (CHV)	degeneration of the spinal bone where spinal columns are fused and immobilized
Definition (CHV)	degeneration of the spinal bone where spinal columns are fused and immobilized
Concepts	Disease or Syndrome (T047)
MSH	D055009 , D013128
ICD9	721. 9
ICD10	M47 , M47.9
SnomedCT	202701004, 202704007, 156622007, 267973008, 268075001, 268074002, 156628006, 8847002
English	Spondylosis, Spondylosis, unspecified, spondylosis, spondylosis (diagnosis), Spondylosis [Disease/Finding], Unspecified spondylosis, spondyloses, Spondyloses, Spondylosis NOS (disorder), Spondylosis (disorder), Spondylosis, NOS, Spondylosis of unspecified site, Spondylosis NOS
Dutch	spondylose, spondylose met plaats niet-gespecificeerd, spondylose NAO, Spondylose, niet gespecificeerd, Spondylose
French	Spondylose SAI, Spondylose de site non précisé, Spondylose, Arthrose de la colonne vertébrale, Arthrose spinale, Arthrose vertébrale, Spondylarthrose, Spondylose rachidienne, Arthrose rachidienne
German	Spondylose NNB, Spondylose an unspezifischer Stelle, Spondylose, nicht naeher bezeichnet, Spondylose
Italian	Spondilosi in sede non specificata, Spondilosi NAS, Spondilosi
Portuguese	Espondilose NE, Espondilose de localização NE, Espondilose
Spanish	Espondilosis NEOM, Espondilosis de localización no especificada, Espondilosis, espondilosis, SAI (trastorno), Spondylosis NOS, espondilosis, SAI, espondilosis (trastorno), espondilosis
Japanese	部位不明の脊椎症, 脊椎症ＮＯＳ, 脊椎症, ﾌﾞｲﾌﾒｲﾉｾｷﾂｲｼｮｳ, ｾｷﾂｲｼｮｳ, ｾｷﾂｲｼｮｳNOS
Czech	Spondylóza NOS, Spondylóza blíže neurčené lokalizace, Spondylóza, spondylóza
Korean	상세불명의 척추증, 척추증
Russian	ШЕЙНЫЙ СПОНДИЛЕЗ, POIASNICHNO-KRESTTSOVYI SPONDILEZ, SHEINYI SPONDILEZ, SPONDILEZ DEFORMIRUIUSHCHII, СПОНДИЛЕЗ ДЕФОРМИРУЮЩИЙ, СПОНДИЛЕЗ, ПОЯСНИЧНО-КРЕСТЦОВЫЙ СПОНДИЛЕЗ, SPONDILEZ, ГРУДНОЙ (ТОРАКАЛЬНЫЙ) СПОНДИЛЕЗ, GRUDNOI (TORAKAL’NYI) SPONDILEZ
Swedish	Spondylos
Croatian	Not Translated[Spondylosis]
Polish	Spondyloza lędźwiowo-krzyżowa, Spondyloza piersiowa, Spondyloza szyjna, Spondyloza
Hungarian	Spondylosis, Spondylosis nem meghatározott helyen, Spondylosis k. m.n.
Norwegian	Spondylose, Ryggvirveldegenerasjon

Cervical spondylosis – Illnesses & conditions

Treatment for cervical spondylosis aims to relieve symptoms of pain and prevent permanent damage to your nerves.

Pain relief

Over-the-counter painkillers

Non-steroidal anti-inflammatory drugs (NSAIDs) are thought to be the most effective painkillers for symptoms of cervical spondylosis. Some commonly used NSAIDs include:

• diclofenac
• ibuprofen
• naproxen

If one NSAID fails to help with pain, you should try an alternative.

However, NSAIDs may not be suitable if you have asthma, high blood pressure, liver disease, heart disease or a history of stomach ulcers. In these circumstances, paracetamol is usually more suitable. Your pharmacist or GP can advise you.

Codeine

If your pain is more severe, your GP may prescribe a mild opiate painkiller called codeine. This is often taken in combination with NSAIDs or paracetamol.

A common side effect of taking codeine is constipation. To prevent constipation, drink plenty of water and eat foods high in fibre, such as wholegrain bread, brown rice, pasta, oats, beans, peas, lentils, grains, seeds, fruit and vegetables.

Codeine may be unsuitable for a number of people, especially if taken for long periods of time. Your GP can advise on whether it is safe for you to take codeine.

It is generally not recommended for people who have breathing problems (such as asthma) or head injuries, particularly those that increase pressure in the skull.

Muscle relaxants

If you experience spasms, when your neck muscles suddenly tighten uncontrollably, your GP may prescribe a short course of a muscle relaxant such as diazepam.

Muscle relaxants are sedatives that can make you feel dizzy and drowsy. If you have been prescribed diazepam, make sure you do not drive. You should also not drink alcohol, as the medication can exaggerate its effects.

Muscle relaxants should not be taken continuously for longer than a week to 10 days at a time.

Amitriptyline

If pain persists for more than a month and has not responded to the above painkillers, your GP may prescribe a medicine called amitriptyline.

Amitriptyline was originally designed to treat depression, but doctors have found that a small dose is also useful in treating nerve pain. You may experience some side effects when taking amitriptyline, including:

• drowsiness
• dry mouth
• blurred vision
• constipation
• difficulty urinating

Do not drive if amitriptyline makes you drowsy. Amitriptyline should not be taken by people with a history of heart disease.

Gabapentin

Gabapentin (or a similar medication called pregabalin) may also be prescribed by your GP for helping radiating arm pain or pins and needles caused by nerve root irritation.

Some people may experience side effects that disappear when they stop the medication, such as a skin rash or unsteadiness. Gabapentin needs to be taken regularly for at least two weeks before any benefit is judged.

Injection of a painkiller

If your radiating arm pain is particularly severe and not settling, there may be an option of a “transforaminal nerve root injection”, where steroid medication is injected into the neck where the nerves exit the spine. This may temporarily decrease inflammation of the nerve root and reduce pain.

Side effects include headache, temporary numbness in the area and, in rare cases, spinal cord injury (limb paralysis).

Your GP would have to refer you to a pain clinic if you wished to explore this option.

Exercise and lifestyle changes

You could consider:

• doing low-impact aerobic exercises such as swimming or walking
• using one firm pillow at night to reduce strain on your neck
• correcting your posture when standing and sitting

The long-term use of a neck brace or collar is not recommended, as it can make your symptoms worse. Do not wear a brace for more than a week, unless your GP specifically advises you to.

Surgery

Surgery is usually only recommended in the treatment of cervical spondylosis if:

• there is clear evidence that a nerve is being pinched by a slipped disk or bone (cervical radiculopathy), or your spinal cord is being compressed (cervical myelopathy)
• there is underlying damage to your nervous system that is likely to worsen if surgery is not performed

Surgery may also be recommended if you have persistent pain that fails to respond to other treatments.

It’s important to stress that surgery often doesn’t lead to a complete cure of symptoms. It may only be able to prevent symptoms from getting worse.

The type of surgery used will depend on the underlying cause of your pain or nerve damage. Surgical techniques that may be used include:

• Anterior cervical discectomy – This is used when a slipped disc or osteophyte (lump of extra bone) is pressing on a nerve. The surgeon will make an incision in the front of your neck and remove the problem disc or piece of bone. This procedure results in a fusion across the disc joint. Some surgeons will insert a bone substitute to encourage fusion, and occasionally put a metal plate across the disc if there is slippage of one vertebra on the one beneath.
• Cervical laminectomy – The surgeon will make a small incision in the back of your neck and remove pieces of bone that are pressing on your spinal cord. A similar approach is known as a laminoplasty, where bones are spread open to widen the space, but not removed.
• Prosthetic intervertebral disc replacement – This relatively new surgical technique involves removing a worn disc in the spine and replacing it with an artificial disc. The results of this technique have been promising, but as it is still new, there is no evidence about how well it works in the long term, or whether there will be any complications.

Most people can leave hospital within three to four days, but it can take up to eight weeks before you can resume normal activities. This may have an impact on your employment, depending on the type of work you do.

Many people are recommended to return to work on a part-time basis at first, although you should discuss this with your employer before surgery.

Complications of surgery

Like all surgical procedures, surgery on the cervical spine carries some risk of complications, including:

• rare complications associated with general anaesthetic – such as heart attack, blood clot in the lung (pulmonary embolism) or a severe allergic reaction (anaphylaxis)
• some mild difficulties with swallowing (dysphagia) – this usually passes within a few months
• hoarse voice – this is a rare complication, but when it does occur it can be permanent
• paralysis (inability to move one or more parts of the body) – which could occur if there is bleeding into the spinal canal after surgery, or the blood supply to spinal nerves is damaged
• infection of the wound after surgery – which is not usually serious and can be treated with antibiotics (deeper spinal infection is more serious but very rare)
• damage to nerves, which occurs in rare cases – this can result in persistent feelings of numbness and “pins and needles”

If it’s decided that you could benefit from surgery, your consultant will discuss the risks and benefits with you.

90,000 Spondylosis – treatment, symptoms, causes, diagnosis

Spondylosis literally means compaction or fixation of the vertebrae as a result of pathological changes in the spine. Spondylosis is caused by degenerative changes in the spine, such as the formation of osteophytes (bone spines) and degenerative-dystrophic changes in the intervertebral discs. Changes in the spine with spondylosis are referred to as osteoarthritis. For example, the phrase “spondylosis of the lumbar spine” means the presence of degenerative changes such as osteoarthritis in the intervertebral joints and the presence of degenerative changes in the intervertebral discs in the lumbar spine.

Spondylosis can affect all parts of the spine (cervical thoracic lumbar), but the most common spondylosis is cervical and lumbar spine. Thoracic spondylosis often causes no symptoms. With lumbar-sacral spondylosis, changes occur not only in the lumbar spine, but also in the sacral spine. There are several medical terms that are similar in name to spondylosis and are therefore often confused. These are terms such as:

• spondylitis: an inflammation of one or more vertebrae of an infectious (including specific genesis) or non-infectious genesis (in inflammatory diseases such as ankylosing spondylitis).Spondylitis is a completely different disease, because degenerative processes take place in spondylosis, while spondylitis is an inflammatory disease
• spondylolysis: incomplete development and formation of the articular part of the vertebra (pars interarticularis). This defect predisposes to spondylolisthesis due to the development of instability of the motor segments
• spondylolisthesis: displacement forward or backward of the vertebral body in relation to the underlying vertebra. For example, anterior spondylolisthesis L4 to L5 means that the fourth lumbar vertebra is displaced forward in relation to the fifth vertebra.As a result, the geometry of the spine changes.
• spondylosis deformans : occurs due to the growth of osteophytes or bone bridges around the degrading intervertebral disc (this term is almost synonymous with the term spondylosis).
• stenosis: narrowing of the spinal canal. It is a narrowing of the spinal canal that limits the space needed for the spinal cord and nerves. Pressure on the spinal cord and nerves due to the narrowing of the spinal canal can cause symptoms such as pain, numbness, and tingling.

Causes and risk factors

Spondylosis is an age-related change in the spine. With age, the bones and ligaments in the spine wear out, which leads to the formation of bony growths. In addition, the intervertebral discs degenerate, weaken, which can lead to the formation of protrusions or disc herniation. The cause of early spondylosis can be heavy physical activity of a professional nature. Spondylosis is common. The first symptoms may appear between the ages of 20 and 50.More than 80% of people over 40 have radiological signs of spondylosis. The rate of development of spondylosis depends on both genetic factors and the presence of injuries or excessive stress on the spine.

Symptoms

Many people with spondylosis on radiographs have no symptoms. According to statistics, lumbar spondylosis is present in 27% -37% of people without any symptoms.

In some people, spondylosis causes lower back and neck pain due to compression of the nerves.Nerve compression is caused by herniated discs or osteophytes in the facet joints, which narrow the space where the nerves pass and cause spinal or foraminal stenosis. Even with small herniated discs, when they do not cause compression of the root, local inflammation and irritation of nerve fibers are possible. In addition, herniated discs can put pressure on the spinal ligaments and thus cause pain. Compression creates conditions for stimulating the growth of blood vessels and nerves, and this leads to chronic pain syndrome.In pain syndrome, individual parts of the spine try to compensate for the pain, and as a result, areas of soreness, muscle spasm and trigger points appear.

Symptoms of spondylosis include localized pain in the area of ​​the spondylosis, usually in the lower back or neck. If a herniated disc causes compression of the nerve, then the pain may radiate to the limb. For example, a large disc herniation in the lumbar spine can compress a nerve and cause pain that occurs in the lower back and then travels down one leg and foot.This condition is commonly referred to as sciatica. Back pain due to a herniated disc usually worsens with prolonged standing, sitting, and bending forward, and often decreases with changes in body position and walking. Back pain due to arthrosis of the facet joints, as a rule, increases with walking and standing, and decreases with straightening of the trunk. Numbness and tingling may occur when the nerve is compressed. With severe compression of the nerves, muscle weakness in the limb may appear.If a herniated disc puts pressure on the spinal cord, it can damage the spinal cord (myelopathy). Myelopathy symptoms include numbness, tingling, and muscle weakness. For example, a large herniated disc in the cervical spine can lead to cervical myelopathy, resulting in symptoms such as numbness, tingling, and weakness in the arms and possibly legs. As a rule, patients with spondylosis have already been in contact with doctors, since CT or MRI radiography well visualize changes in the spine characteristic of this disease.The reason for the obligatory visit to the doctor is the following reasons:

• Lack of effect from the prescribed treatment
• Signs of acute nerve dysfunction (eg, weakness in one or more limbs)
• Disorders of the bladder or intestines, against the background of acute pain in the lower back or neck, indicate serious nerve dysfunctions and require hospitalization
• Numbness in the groin or in the sciatic area may indicate severe dysfunction of the nerve structures and also requires immediate hospitalization.

Diagnostics

Spondylosis is diagnosed using radiological methods such as plain radiography, MRI or CT. Radiography allows visualization of osteophytes, joint thickening and a decrease in the distance between the vertebrae. A CT scan of the spine is able to visualize the spine in more detail and can diagnose narrowing of the spinal canal (stenosis) if present. MRI research is the most informative and allows you to visualize soft tissues (discs, ligaments, nerves) and diagnose the presence of compression of nerve structures, which often allows you to find out the true cause of pain in spondylosis.
If nerve damage is suspected, ENMG may be prescribed to determine the extent of nerve damage and conduction disturbances. Sometimes, to clarify the diagnosis, a radioisotope scan may be prescribed, based on a different degree of absorption of radioactive material by tissues with different metabolism (for example, with inflammation or a tumor, more radioisotope will selectively abnormally accumulate in the bone tissue).

Treatment

There is currently no treatment that can reverse spondylosis because it is a degenerative process. Treatment of spondylosis consists of treating symptoms such as lower back or neck pain and similarly to those of osteochondrosis.

Drug treatment. Medicines that reliably stop the degenerative process in the spine do not yet exist. In pain syndrome, as a rule, drugs of the NSAID group and muscle relaxants are widely used. Nonsteroidal anti-inflammatory drugs can be very effective in relieving low back and neck pain associated with spondylosis (ibuprofen, movalis, naproxen).Muscle relaxants such as cyclobenzaprine (Flexeril) and tizanidine (Zanaflex) can reliably reduce muscle spasm associated with spondylosis. For severe pain, analgesics such as tramatodol or drugs of the narcotic group can be used.
Antidepressants may be used for chronic pain. Medicines called tricyclic antidepressants, including amitriptyline (Elavil) and doxepin (Sinevkan), have been used for years in small doses to treat chronic back pain.Recently, an antidepressant such as duloxetine (Simbalta) has been used, and its effectiveness in chronic back pain has been reliably proven. A good effect is the use of ointments containing capsaicin.

Physiotherapy allows you to reduce pain, improve microcirculation in the tissues of the spine.

LFK . A carefully selected program of exercises, both with weights (on simulators) and in the form of gymnastics (qigong or yoga), can also reduce both pain manifestations and improve the functionality of the spine.

Manual therapy Gentle manual therapy techniques allow to achieve mobilization of motor segments and reduce pain. However, some patients should not undergo manual manipulation, especially when spondylosis is combined with a disease such as ankylosing spondylitis.

Acupuncture allows you to reduce pain and improve the conduction of nerve fibers.

Minimally invasive procedures such as injections of steroids into the epidural space or joints, or injection into trigger points can also reduce pain.

Surgical treatment

Recommended for patients with severe neurological symptoms and no effect of conservative treatment. Usually, surgical methods of treatment are used in the presence of severe spinal stenosis, in cauda equina syndrome, or in the presence of severe compression of the root by a herniated disc (osteophyte).

Forecast

Spondylosis is a degenerative process, and currently there are no methods of treatment that reliably stop degenerative pathological processes.But with systematic observation and treatment, it is possible to achieve stabilization of pain manifestations and preservation of the functionality of the spine.

90,000 Myelopathy of the cervical spine, symptoms, types and treatment

3 January 2021 15979

Certain diseases of the spine, vascular disorders and even endocrine pathologies can provoke the emergence of such an unpleasant and very reducing the quality of life condition as cervical myelopathy. It is accompanied by impaired sensitivity and mobility, and can also lead to severe complications. Therefore, it is important to diagnose it in the early stages of development, to establish the cause of its occurrence and to effectively influence it in order to avoid aggravating the condition.

What is cervical myelopathy and the causes of its occurrence

Cervical myelopathy is a well-studied clinical syndrome, the occurrence of which is caused by damage to the spinal cord as a result of various factors, including trauma, degenerative changes in the cervical spine, the formation of tumors, the development of infectious, neurological and vascular diseases.In other words, cervical myelopathy and the accompanying complex of symptoms is not an independent disease, but is only a consequence of a narrowing of the spinal canal, malnutrition of the spinal cord, an inflammatory process in it, due to one reason or another.

The spinal cord, surrounded by its own membranes, with its nerve roots and blood vessels, passes through the spinal canal. Therefore, its narrowing, especially progressive, will sooner or later affect the state of this nervous structure, which is responsible for the proper functioning of almost all organs and tissues of the human body, which will lead to corresponding neurological disorders, and in case of damage to blood vessels, ischemia (acute malnutrition) and other undesirable consequences. Therefore, the development of symptoms of cervical myelopathy requires an early visit to a neurologist, comprehensive diagnosis and treatment, which may include decompression surgery.

The main causes of cervical myelopathy are:

• inflammatory diseases of the spine, which include rheumatoid arthritis, spondyloarthritis, tuberculosis of the spine;
• injuries of the spine and spinal cord, in particular comminuted fractures of the vertebrae and direct injuries of the spinal cord;
• vascular disorders, which can be atherosclerosis, thrombosis and aneurysms of the spinal arteries, leading to spinal cord infarction;
• compression of the spinal cord by tumors, large intervertebral hernias, osteophytes of the vertebral bodies, displaced vertebrae, hematomas, etc.

The most common cause of cervical myelopathy is complications of osteochondrosis of the cervical spine.

The disorder can occur at any age, although it is most common in older people with severe degenerative changes in the spine. But if we consider each age group separately, then in children most often the pathology becomes a consequence of the transfer of enterovirus infection, in young people – injuries of the back and spine in particular.In the middle age category, cervical myelopathy is caused by neoplasms and injuries.

In general, 2 types of cervical myelopathy can be distinguished:

• progressive – accompanied by a rapid increase in the severity of symptoms and most often it becomes a consequence of trauma;
• chronic – the manifestations of pathology intensify gradually.

Myelopathy can affect any part of the spine, including the thoracic and lumbar, although the cervical spine is most often affected by anatomical features.In each case, stenosis of the spinal cord or its vessels leads to its development. But the manifestations of pathology directly depend on the localization of the affected area and can be radically different.

Congenital narrowness of the spinal canal significantly increases the risk of cervical myelopathy. Thus, if its diameter is less than 12 mm, the probability of this disorder is extremely high.

The prerequisites for the development of pathology may be:

• obesity, since this leads to an increase in the load on the cervical and other parts of the spine;
• sedentary lifestyle, in particular prolonged static loads on the spine, arising from prolonged sitting at the computer, gadgets;
• malnutrition that does not meet the body’s needs for nutrients;
• smoking, since this bad habit negatively affects the condition of the blood vessels;
• alcohol abuse;
• excessive physical activity provoking increased stress on the cervical spine;
• Long-term wearing of high-heeled shoes, provoking an incorrect distribution of the load on the spine.

In some cases, cervical myelopathy develops after surgical interventions on the cervical spine. In such situations, tissue degeneration is sometimes observed with the formation of areas devoid of functional activity. As a result, they interfere with the free flow of oxygen and nutrients to the spinal cord. But in the overwhelming majority of cases, cervical myelopathy becomes a consequence of the natural aging of the body.

Types

Depending on the causes of development, there are quite a few types of cervical myelopathy.Determination of a specific one allows you to develop the most effective treatment tactics and achieve the best outcome.

Vertebrogenic

It is this form of cervical myelopathy, which is also called spondylogenous, that is diagnosed in the vast majority of cases. It develops as a result of disorders in the condition of the spine against the background of congenital features, for example, congenital narrowness of the spinal canal, or diseases acquired during life.

Osteochondrosis is the main cause of the development of vertebral cervical myelopathy.With this disease, degenerative-dystrophic changes gradually occur in the intervertebral discs, which eventually leads to the formation of protrusion, and then an intervertebral hernia. In such cases, the affected disc bulges and, as a rule, this occurs in the direction of the spinal canal. In the absence of treatment, the hernia tends to gradually increase in size and thereby lead to compression of the anatomical structures passing near it: spinal roots, vertebral arteries, and spinal cord.This becomes a consequence of the development of the so-called discogenic myelopathy.

Also, the consequence of osteochondrosis can be the growth of bone tissue of the vertebral bodies with the formation of bone protrusions on their surface, which are called osteophytes. They can also compress nerve roots, blood vessels and affect the quality of the spinal cord.

Another consequence of degenerative changes in the spine is thickening of the yellow ligaments, hypertrophy of the facets, ie complications of osteoarthritis, which can also provoke the development of cervical myelopathy.

Vertebrogenic cervical myelopathy is most often diagnosed in people over 50 years of age.

Cervical myelopathy can also result from curvature of the spinal column, in particular kyphosis or scoliosis, or ankylosing spondylitis, which gradually affects all joints of the body.

Pathology is characterized by a chronic course with a gradual increase in the severity of symptoms and moments of exacerbation. Most often, patients complain of a decrease in the strength of the muscles of the neck, shoulders and arms, soreness in the neck, impaired sensitivity, tremors in the hands.

Vascular

Vascular or discirculatory myelopathy is caused by the occurrence of circulatory disorders and damage to blood vessels, which can be caused by atherosclerosis, thrombosis, venous congestion and other changes. Damage to the arteries responsible for feeding the cervical spinal cord provokes atrophy of nerve fibers. At the same time, the severity of the manifestations of the disorder largely depends on what caused their development and the age of the patient.

It is in the cervical region that the risk of developing vascular myelopathy is highest. Its main manifestation is the occurrence of the so-called Lermitte phenomenon, accompanied by a tremor in the neck, which can spread to the wrist and feet, during tilting the head or pulling it back. After the end of the tremor, weakness is observed. Occasionally, vascular cervical myelopathy causes encephalopathy.

Post-traumatic

This type of cervical myelopathy is a consequence of trauma resulting in damage to the spinal cord.These can be fractures, including compression fractures, dislocations, blows that provoked displacement, compression, injury to nerves, blood vessels or spinal cord. This can be accompanied by paralysis, a decrease in sensitivity in areas of the body corresponding to the level of damage, and a violation of the functioning of internal organs.

Carcinomatous

As the name suggests, this type of cervical myelopathy results from the formation of benign or malignant neoplasms, metastases in the spine, spinal cord or surrounding tissues.When a certain size is reached, they can mechanically squeeze the spinal cord, lead to a violation of its nutrition and thereby provoke the development of a symptom complex characteristic of cervical myelopathy.

The most common cause of carcinomatous myelopathy is lymphoma, leukemia, spinal hemangiomas and some other tumors.

Infectious

As already mentioned, infectious diseases can also cause the development of cervical myelopathy.It can occur in connection with the transfer of enterovirus infections, tuberculosis, herpes infection, osteomyelitis of the spine, Lyme disease and some other diseases.

As a rule, initially patients are disturbed by symptoms characteristic of an infectious disease, including fever, weakness, etc. Subsequently, they are replaced by signs of myelopathy, among which shortness of breath is especially common.

In severe viral and fungal lesions of the spinal cord, the consequences can be irreversible.

Toxic

This type of disorder occurs when the body is exposed to organic and inorganic neurotoxins that can adversely affect nerve cells. Toxic cervical myelopathy is characterized by rapid development, as well as the appearance of signs of impaired sensitivity and mobility. But damage to the spinal cord in the cervical region is not as common as in the chest.

Radiation

The reason for the development of radiation cervical myelopathy is the action of ionizing radiation, for example, during radiation therapy for laryngeal cancer or suppression of neoplasms localized in the mediastinal region.

Symptoms of myelopathy may not appear until 6 to 36 months after the end of radiation therapy. Initially, they are weak and tend to disappear periodically, but their intensity is constantly increasing. Often, radiation myelopathy is accompanied by additional ulceration, decreased bone density, etc.

Metabolic

Metabolic disorders can also lead to the development of cervical myelopathy. In particular, it can be a complication of diabetes mellitus and other endocrine pathologies.

Demyelinating

Cervical myelopathy is a frequent consequence of demyelinating diseases, including multiple sclerosis, Balo’s disease, Canavan’s disease. In such situations, the destruction of the membrane surrounding the nerve fibers occurs, which makes them vulnerable and sensitive. This is accompanied by a malfunction of the organs corresponding to the affected nerve, for example, impaired vision, swallowing, etc.

Hereditary

Some hereditary diseases can cause the development of cervical myelopathy.One of them is Strummel’s spastic paraplegia. In such cases, there is an increase over time in the hands, visual impairment, coordination of movements, the development of epilepsy, mental retardation or dementia.

Symptoms of cervical myelopathy

The nature of manifestations of cervical myelopathy largely depends on the causes of its development and the degree of damage to the structures of the spinal cord. Thus, the patient may have one or a number of symptoms of the following nature:

• pain in the neck, which can radiate to the head, shoulder blades, shoulders and arms;
• movement disorders, which may consist in excessive relaxation or, on the contrary, muscle spasm, impaired coordination, fine motor skills, the appearance of seizures, trembling, twitching, involuntary movements, less often paralysis, spastic gait with legs wide apart;
• violations of sensitivity in areas of the body corresponding to the level of the lesion, which may consist in a decrease or absence of sensations when touching, pain or temperature exposure, the development of numbness, a feeling of running creeps, a burning sensation, as well as a sensation of current flow in the limbs with rapid flexion or extension of the neck;
• Disruption of the sensory organs, swallowing, speech, sleep, etc.;
• violations of hand reflexes;
• mental disorders, mood swings, irritability, causeless anxiety, less often a decrease in the acuity of intelligence, memory;
• signs of infectious diseases, including fever, general weakness, chills, headaches, etc.

But such disorders are typical for advanced, severe cases. Initially, the disease manifests itself with only minor discomfort, which people usually mistake for typical fatigue after a long day at work.

Diagnostics

If signs of cervical myelopathy occur, consult a neurologist. In some cases, in the presence of several symptoms, already during the questioning of the patient, the doctor may suspect the development of this disorder, especially if the patient mentions receiving blows to the neck in the recent past, transferring specific infectious diseases, the presence of certain chronic diseases. In other situations, it is extremely difficult to differentiate cervical myelopathy from other pathologies, since its characteristic sensory disturbances, movement disorders, pain accompany a number of other common diseases of the spine.

Nevertheless, in both cases, patients are assigned a comprehensive examination to assess the condition of the spine, spinal cord, its roots and blood vessels. These data will make it possible not only to diagnose cervical myelopathy, but also to establish the causes of its development, and therefore, to find the most effective way to eliminate them.

At the appointment, the doctor will not only conduct a thorough interview of the patient to collect an anamnesis, but also perform a physical examination, that is, an examination. During it, the strength of reflexes, muscle tone, the severity of motor and sensory disorders, etc., are assessed.

Further, a number of instrumental examinations are necessarily assigned:

• X-ray – allows you to assess the position and condition of the vertebrae, the distance between them, the formation of osteophytes, but if possible, preference is given to CT;
• CT or computed tomography is an informative method for examining the state of bone tissue, which makes it possible to assess the state of the spine in the smallest detail;
• MRI or magnetic resonance imaging is the most informative diagnostic method today, providing comprehensive data on the state of soft tissue structures, including the spinal cord, intervertebral discs, tumors;
• myelography – an auxiliary research method, with the help of which it is possible to establish the causes of the appearance of signs of neurological disorders, if other studies have not provided the necessary information;
• electromyography – a diagnostic procedure that allows you to assess the quality of nerve impulses to various parts of the hands;
• angiography is a method used to assess the state of blood vessels in order to determine the degree of their patency and the quality of blood supply to tissues.

To obtain more complete data on the patient’s health status and the reasons for the development of cervical myelopathy, a general blood and urine test, a biochemical blood test, an analysis of cerebrospinal fluid and some other laboratory tests can be prescribed. When tumors are found, a biopsy is performed to determine the exact nature of their origin.

After establishing the cause of cervical myelopathy, the neurologist may recommend that the patient additionally consult an endocrinologist, cardiologist, orthopedist, infectious disease specialist, phthisiatrician.

Treatment of cervical myelopathy

Since cervical myelopathy is only a consequence of the development of a particular disease, efforts are primarily directed towards eliminating the cause of its occurrence. Therefore, the nature of the treatment directly depends on what caused the compression of the spinal structures. It can consist in the use of conservative therapy or surgery. Also, patients are usually prescribed symptomatic therapy aimed at reducing the severity of the manifestations of cervical myelopathy and improving the quality of life until the main treatment gives results.

Thus, conservative therapy is usually indicated for infectious, vascular, toxic and metabolic cervical myelopathy. It may include:

• drug therapy, which consists in prescribing antibiotics, antimicrobials, antiviral agents, NSAIDs, corticosteroids, glucocorticosteroids, muscle relaxants, metabolic enhancers, neuroprotectors, statins, heparin preparations, antihypoxants, nootropes, and tropics. etc .;
• physiotherapy, within which courses of electrophoresis, UHF, electrostimulation, magnetotherapy, paraffin therapy are conducted;
• manual therapy aimed at normalizing the state of the spine and releasing compressed vessels and spinal roots, improving tissue trophism and normalizing muscle tone;
• Exercise therapy, which aims to strengthen the muscle corset, increase blood circulation in the neck, and improve the course of metabolic processes.

In case of vertebrogenic, post-traumatic myelopathy, as well as the absence of the effect of conservative therapy, patients may be recommended surgical treatment. Good reasons for its implementation are:

• progression of muscle weakness;
• gait disturbances;
• urinary disorders and the development of urinary incontinence;
• complete loss of hand coordination and fine motor skills.

The goal of surgical treatment is to decompress the spinal cord, i.e.e. elimination of the factor that squeezes it. Therefore, depending on the situation, operations can be performed to correct the deformity of the spine caused by vertebral fractures, as well as discectomy and laminectomy. If necessary, drainage of the formed post-traumatic cyst affecting the spinal cord, replacement of the removed intervertebral disc with an endoprosthesis, etc. , provoking the occurrence of neurological disorders.The operation can be performed by methods with varying degrees of invasiveness, but the choice of a specific one is carried out by a neurosurgeon based on the individual characteristics of the patient. These are:

• Classical discectomy is a rather traumatic operation that requires a large incision to gain access to the damaged disc. During it, either only the hernia itself is removed, or the entire disc is completely removed, which eliminates pressure on the spinal cord, blood vessels or nerve roots and leads to a solution to the problem of cervical myelopathy.
• Microdiscectomy is a less invasive alternative to classical discectomy, as it requires a much smaller incision, but has the same capabilities. The operation also allows you to remove a disc or just a hernia, achieving decompression of nerve structures and blood vessels. It involves the use of special microsurgical instruments, the dimensions of which are much smaller than traditional ones.
• Endoscopic surgery is the least invasive type of decompression surgery, as it requires puncture incisions with a diameter of less than 1 cm.It has the same capabilities, but due to the peculiarities of the technique, it cannot always be applied.

If it is necessary to remove the intervertebral disc completely, during the operation it is replaced with an artificial implant, of which there are many types today. Less commonly, a bone graft taken from the patient’s own bone is used. The operated and adjacent segments of the spine can also be fixed with special metal structures, eliminating the risk of displacement of the vertebrae and re-development of cervical myelopathy, possibly with more serious consequences.In such situations, screws with holes in the heads are mounted at the junction points of the processes of adjacent vertebrae. They pass special rods that securely fix the spine. This technique is called transpedicular fixation.

In case of comminuted fractures and a number of other situations when it is required to gain open access to the spinal structures, laminectomy is used to eliminate compression. The essence of the operation is to remove the spinous process, possibly the arch, and in some cases the entire vertebra.This allows you to create a sufficiently large space for the spinal cord, eliminate the compression of blood vessels and spinal roots, get the opportunity to remove the tumor, etc. As a result, the symptoms of cervical myelopathy disappear, and the patient’s quality of life increases. If necessary, the vertebrae are also fixed by means of transpedicular fixation or other methods.

If it is necessary to perform a surgical intervention on the cervical spine, the size of the incision is of great importance, since the access to the lesion is not always carried out through the back of the neck.Often the surgeon needs to “enter” from the front using the antero-lateral approach.

Thus, everyone can face cervical myelopathy and effective preventive measures to reduce the risk of its development have not been developed. Therefore, in order to avoid its occurrence, it is possible to recommend leading a healthy lifestyle, and if a violation has already formed, you should seek medical help as soon as possible. In 60% of cases, with timely treatment, including surgery, it is possible to achieve complete or significant regression of neurological disorders.In 20% of patients, in this case, the condition does not change, but does not worsen, and the progression of myelopathy is observed in 10% of patients who have undergone treatment. But in the absence of such, the disease will necessarily progress and can cause paralysis, disability and more severe complications.

Cervical spondylosis – causes, symptoms, diagnosis and treatment

Cervical spondylosis is a degenerative disease of the cervical spine, accompanied by changes in the intervertebral discs, ossification of the anterior longitudinal ligament, the appearance of bone growths on the anterior and lateral surfaces of the vertebrae.Usually occurs in old age. It can be asymptomatic for a long time. With a decrease in the height of the discs and the addition of spondyloarthrosis, it is manifested by a limitation of the mobility of the neck, pain in the neck and back of the head. To clarify the diagnosis, X-ray, MRI, CT, myelography, electromyography and other studies are used. Treatment is usually conservative: exercise therapy, massage, manual therapy, physiotherapy.

General information

Cervical spondylosis is a degenerative-dystrophic lesion of the cervical spine (CS).Usually it is a consequence of involutive processes, occurs in the elderly. The initial signs of spondylosis are often seen on radiographs of elderly and middle-aged patients. According to statistics, after 40 years, pathology is detected in 30-40%, after 65 years – in 90% of the population. Less commonly, the disease develops in young people.

Cervical spondylosis is the most common type of spondylosis. This is due to the anatomical and physiological characteristics of the cervical spine. According to the observations of specialists in the field of vertebrology, traumatology and orthopedics, in most cases, clinically manifested cervical spondylosis is combined with other involutive lesions of the spinal column – osteochondrosis and arthrosis of the joints of the spine.

Cervical spondylosis

Causes

As a rule, age-related changes in metabolism, natural aging of cells and tissues of the human body become the main cause of cervical spondylosis. The early development of spondylosis is facilitated by:

• large single traumatic injuries, for example, a fracture of the cervical vertebrae;
• multiple minor spinal injuries in the cervical spine;
• congenital malformations of the spinal column;
• posture disorders, scoliosis and increased cervical lordosis;
• metabolic disorders, due to which calcium salts are intensively deposited in the spinal column;
• hormonal disorders, hypothermia and chronic infections.

Risk factors

A separate group of reasons should include the circumstances in which there is a prolonged non-physiological load on the cervical spine. Most often, pathology develops in knowledge workers, people performing professional duties in one static position, and people leading an inactive lifestyle. A combination of these factors is often observed in patients with cervical spondylosis.

The forced position of the head when working on a computer, at a microscope or a typewriter creates an excessive load on certain parts of the SHOP.The neck is very mobile, while the muscle corset in this area is less developed than in other parts of the spinal column. The muscles cannot cope with maintaining a non-physiological posture, there is an overload of the intervertebral discs, muscles and the ligamentous apparatus of the spine.

Pathogenesis

The cervical region is the most mobile region of the spinal column. It consists of seven vertebrae. Between all cervical vertebrae, except for the first and second, there are elastic intervertebral discs that act as shock absorbers.The discs consist of a soft nucleus pulposus and a rigid annulus fibrosus, which holds the nucleus in place, preventing it from protruding.

The spine is strengthened with ligaments and muscles. One of the large ligaments (the anterior longitudinal ligament) is located on the anterior surface of the vertebral bodies. With the development of cervical spondylosis, the annulus fibrosus partially loses its rigidity, and the nucleus pulposus under pressure bulges towards the anterior longitudinal ligament. In the area of ​​the ligament, areas of ossification appear.Over time, bone growths form on the anterior and lateral surfaces of the vertebrae.

While maintaining the height of the intervertebral disc, cervical spondylosis can be asymptomatic for a long time. Pain syndrome is caused by an increase in the tone of nearby muscles, joint blockages, inflammation in the area of ​​ligaments and fascia. Over time, gross anatomical disorders are formed: a decrease in the height of the intervertebral discs, limited mobility and ankylosis of small joints. Compression of the nerve roots and stenosis of the spinal canal with the development of neurological symptoms are possible.

Symptoms of cervical spondylosis

Patients with an isolated form of the disease, not accompanied by a decrease in the height of the intervertebral discs, may not present any complaints for a long time. With the addition of other diseases of the spine and the progression of anatomical disorders, local dull aching or pulling pains occur, which intensify after exertion and weaken or disappear after prolonged rest. The patient begins to spare the neck when moving, tries to turn not only the head, but also the body.

Pain occurs in the neck area, gives to the hands. Sometimes patients only complain of pain in the arms, which are localized along the outer surface of the limb from the shoulder to the elbow joint. Sometimes the pain radiates to the area of ​​the scapula. Possible cardialgia, pain in the area of ​​the sternum and upper ribs.

As the pathology progresses, the pain syndrome becomes longer and more intense. Subsequently, the pain becomes permanent and does not disappear even after sleep. Due to pain and disruption of the normal anatomical relationships between the individual elements of the spine, the neck muscles are in constant tension.The spasm of the cervical muscles limits the movement of the cervical spine and, over time, itself becomes the cause of neck pain.

Complications

Some patients develop periarthritis of the shoulder scapula, active abduction and rotation of the shoulder is limited due to pain. Due to the compression of the vertebral arteries by osteophytes, dizziness and headaches appear over time, due to a deterioration in the blood supply to the brain. The combined compression of nerves and blood vessels can cause visual and hearing impairment.Patients are worried about the inability to concentrate their gaze, flashing flies, tinnitus and hearing impairment.

Sometimes the syndrome of the scalene muscle is detected, caused by compression of blood vessels and nerves in the shoulder girdle area. Pathology is accompanied by pain in the arm and a weakening of the pulse. With further aggravation of pathological changes, neurological symptoms may occur due to compression of the nerve roots (radiculitis) and stenosis of the spinal canal (compression myelopathy). Muscle weakness, sensory disturbances in the upper and lower extremities are possible.

Diagnostics

Examination of a patient with cervical spondylosis is carried out by a vertebrologist or orthopedist with the participation of a neurologist, includes objective studies and imaging techniques. To clarify the diagnosis are carried out:

• Interview, visual inspection . The doctor specifies the time of occurrence and the dynamics of the development of manifestations of the disease, signs of complications. The specialist determines the mobility of the neck, identifies the characteristic symptoms (limitation of the head tilt to the side in a standing position and an increase in the prone position).
• Neurological examination . Includes testing of reflexes, sensitivity and movement. When the roots are compressed, reflexes from the biceps, triceps and brachioradialis muscle may disappear. When the spinal cord is compressed, an increase in muscle tone and an increase in reflexes are noted, a pathological Babinsky reflex appears.
• X-ray of the spine . The height of the intervertebral discs is reduced. The pictures show common degenerative changes, osteophytes protruding towards the spinal canal are determined.
• CT of the spine . Allows you to clarify the X-ray data. Indicates a narrowing of the intervertebral foramen, degenerative changes in the small joints of the spine. At a later stage, it confirms the compression of the spinal cord by altered discs and osteophytes.
• MRI spine . It is used for a detailed assessment of the state of soft tissue structures. Reveals stenosis or occlusion of the subarachnoid space, thickening of the ligaments, compression of areas of the spinal cord, areas of edema, demyelination, contusion or myelomalacia of nerve tissues.
• Electromyography . The study of nerve conduction is carried out when signs of radiculitis or compression myelopathy are detected. It makes it possible to clarify the severity and prevalence of damage to nerve fibers and muscles innervated by them.

CT of the cervical spine. Multiple deforming bone growths of the cervical vertebrae

Previously, myelography, an X-ray contrast study in which contrast fluid or air was injected into the spinal canal through a lumbar puncture, was commonly used to detect spinal stenosis, and then a series of x-rays were taken.Currently, this technique is gradually losing its importance due to the emergence of CT and MRI. These methods provide the same data, but have no side effects and are much more easily tolerated by patients.

Treatment of cervical spondylosis

Treatment is usually conservative. The main goals are the elimination of pain, improvement of local blood circulation, preservation of the mobility of the SHOP, restoration of normal relationships between the individual structures of the spinal column and slowing down of degenerative-dystrophic processes in the tissue of the intervertebral discs.

Conservative therapy

It is carried out on an outpatient basis, includes a special regimen, medicines and physiotherapy procedures. The following therapeutic measures are carried out.

• Safety mode . It involves limiting loads (especially static) on the neck area. Patients who have to be in a forced position for a long time are recommended to use an elastic collar.
• Drug therapy .Patients are prescribed chondroprotectors, angioprotectors and anti-inflammatory drugs. With intense pain syndrome, analgesics are used, with severe spasms of the cervical muscles, muscle relaxants.
• Physiotherapy . In cervical spondylosis, ultrasound, diadynamic currents, drug electrophoresis with novocaine are effective. To strengthen muscles and maintain mobility, regular exercise therapy is required without overextension and overstrain of the neck.

In the absence of contraindications, manual therapy and gentle massage are prescribed.Rough massage techniques and independent massage performed by a non-specialist are categorically contraindicated. In case of severe pain caused by compression of the nerve roots, blockade of the affected area is performed (paravertebral blockade and blockade of the facet joints).

Surgical treatment

Surgical interventions are rarely required. Patients are referred for surgery if several pathological processes are combined (for example, spondylosis and severe spondyloarthrosis), ineffectiveness of conservative treatment, as well as in the presence of progressive neurological symptoms, indicating spinal stenosis and compression of the spinal roots.Performed:

• Laminectomy . Removal of the arches and spinous processes of the vertebrae to eliminate root compression.
• Foraminotomy . Expansion of the opening through which the root and the vessels that feed the spinal cord pass.
• Microdiscectomy . It is indicated for complications of spondylosis by hernia of the cervical spine. Provides for partial excision of the disc using microsurgical techniques.

Operations are carried out in a neurosurgical or vertebrological department.In the postoperative period, anesthesia is carried out, physiotherapy, massage, physiotherapy exercises are prescribed.

Forecast

The forecast is usually good. Pathology is not life threatening. It is impossible to eliminate the degenerative changes in the spine that have already arisen, however, with the timely initiation of treatment, in most patients it is possible to eliminate pain syndrome, maintain neck mobility and prevent the development of neurological complications. In the later stages, the prognosis worsens somewhat due to the prevalence of pathological processes, concomitant changes in nerves, muscles and other structures.

Prevention

The list of preventive measures includes maintaining the physiological position of the neck during work that requires prolonged immobility, regular breaks to warm up the neck muscles, maintaining a sufficient level of physical activity, preventing injuries and diseases of the spine.

90,000 CT of the cervical spine – Computed Tomography Center “Premium”

In accordance with the Law of Ukraine “On the exterminator of the population from infectious diseases”, taking into account the official recommendations of the WHO and the Ministry of Health, the center of the computer tomography “Premium” , like, in the middle of the day, transfer the offensive, come in that intercourse and provide medical services:

1.To transfer to the territory of the medical center, patients / patients can be transferred to the medical masks and bahilahs (CCT “Premium” will not provide for the purpose of capturing the skin patient / patient on the basis of free of charge).

2. Before the entrance to the medical center, patients / patients are diagnosed with disinfectants, disinfected, disinfected hands with alcohol and disinfected disinfectants

3.If there is a sign of ailment (undead, cough, chhannya, tearing too much) at the patient / vidviduvach, the staff of the medical center can receive the right to check the temperature of the patient with non-contact infrared thermometers.

4. Patient’s support without medication to the medical center is healthy.

5. Staff medichnogo center Got right in vіdmoviti dostupі to primіschen center that away from vedennі patsієnta vipadkah, if at vimogu spіvrobіtnika medichnogo center patsієnt / vіdvіduvach vіdmovlyaєtsya dotrimuvatis zahodіv, peredbachenih Rules vnutrіshnogo rozporyadku that / abo have razі viyavlennya pіdvischenoї temperature tіla patsієnta / when driving more than 37 degrees.

6. It is easily recommended for patients to pass the diagnostic procedure to cleanse the hospital outside the boundaries of the medical center, so that the results can be discarded from the electronic service “MedOffice” (medoffice.zp.ua).

Failure to declare the provisions of the Rules to obstruct the life and health of the population, as well as the reason for seeing the patient from the art. Art. 11, 29 of the Law of Ukraine “About the destruction of the population from infectious diseases” that Art. 34 of the Law of Ukraine “Fundamentals of Ukrainian Legislation on Health Protection”.

Information on spinal cord disease, useful articles of the medical clinic Neuro-Med

Signs and symptoms

The main clinical signs of diseases of the spinal cord are: loss of sensitivity below a certain level (“level of sensitivity disorders”), accompanied by muscle weakness and spasticity of the limbs.

Sensitivity disorders. Paresthesias are frequent; they can develop in one or both feet and extend upward. The level of pain or vibration sensitivity disorders often coincides with the localization of the level of the transverse lesion of the spinal cord.

Movement disorders. Rupture of the corticospinal tract causes quadriplegia or paraplegia with increased muscle tone, increased deep tendon reflexes, and a positive Babinski symptom.

Segmental characteristics. There are indicative indicators of the level of damage, for example, a band of hyperalgesia or hyperpathy, a decrease in tone and atrophy of individual muscles with a loss of tendon reflexes.

Vegetative dysfunctions. First, urinary retention, which should raise the suspicion of a spinal cord disease when combined with spasticity and (or) sensitivity disorders at a certain level.

Pain. Back pain in the midline is of diagnostic value for localizing the level of the lesion; pain between the shoulder blades may be the first sign of compression of the spinal cord at the level of the middle part of the thoracic spine; radicular pain may indicate a more laterally located lesion; pain that occurs when the lower spinal cord (medullary cone) is affected may radiate to the lower back.

Lesions at or below the L4 vertebra. The defeat of the cauda equina causes the development of flaccid asymmetric paraparesis with the absence of reflexes, dysfunction of the bladder and rectum, loss of sensitivity from the L level; usually there are pains radiating to the perineum or thighs. The defeat of the medullary cone does not cause pain, but entails an earlier manifestation of symptoms of dysfunction of the bladder and rectum. Compression injuries of the cone and cauda equina at the same time can cause the combined development of signs of damage to peripheral motor neurons and hyperreflexia or positive Babinsky reflex.(This combination of symptoms is usually observed when not only the cauda equina and the cone are affected, but also the spinal cord at the level of the lumbar enlargement. Ed.).

Lesions at the level of the foramen magnum. In typical cases, muscle weakness in the shoulder and arm is accompanied by ipsilateral and then contralateral damage to the leg and, finally, to the contralateral arm; the presence of Horner’s syndrome suggests a lesion of the cervical spine.

Extramedullary lesions.They are accompanied by radicular pain, Brown-Séquard syndrome, signs of asymmetric segmental lesions of the lower motor neurons, early corticospinal signs, sacral sensory loss, early manifestations of CSF pathology.

Intramedullary lesions. They are accompanied by burning pains, the localization of which is difficult to determine, loss of pain sensitivity with a preserved sense of the position of the joint, with preservation of perineal and sacral sensations, less pronounced corticospinal signs; CSF is normal or slightly abnormal.

Etiology

Spinal cord compression

1. Tumors of the spinal cord: primary or metastatic, extra- or intra-radial; most of them are epidural metastases from the adjacent vertebrae; the most common malignant tumors affect the prostate gland, chest, lungs, lymphomas, plasmacytic dyscrasias; the first symptom is usually back pain that worsens when lying down, with pain points, this symptom precedes other symptoms for many weeks.

2. Epidural abscess: initially, fever of unknown etiology with aching spinal pain and painful points, then radicular pain develops; shortly after the development of neurological symptoms, spinal cord compression rapidly increases.

3. Spinal epidural hemorrhage and hematomyelia: manifests as acute transverse myelopathy, developing within minutes or hours against the background of severe pain. Causes: minor trauma, lumbar puncture, anticoagulant therapy, hematological disorders, arteriovenous anomalies, tumor hemorrhage.The etiology of most of these disorders is not clear.

4. Acute protrusion of the intervertebral disc: the formation of a herniated disc in the cervical and thoracic regions is less common than in the lumbar (see Chapter 5).

5. Acute trauma with spinal fracture or confusion: May not manifest as myelopathy until mechanical pressure causes further displacement of the destabilized spine.

6. Chronic compression myelopathies: a) cervical spondylosis; b) narrowing of the spinal canal at the lumbar level: intermittent and chronic compression of the cauda equina, associated with congenital narrowing of the lumbar canal and provoked by disc protrusion or spondylitis.

Non-compression neoplastic myelopathy. Intramedullary metastases, paracarcinomatous myelopathy, complications after radiation therapy.

Inflammatory myelopathy

1. Acute myelitis, transverse myelitis, necrotizing myelopathy: the disease develops over several days with sensory and motor symptoms, often involving the bladder. May be the first sign of multiple sclerosis.

2. Infectious myelopathy: herpes zoster with preceding radicular symptoms and rash, most often of a viral nature; also occurs with infection with lymphotropic retrovirus, HIV, with poliomyelitis.

Vascular myelopathies. Spinal cord infarction, vascular anomalies.

Chronic myelopathy. Spondylosis, degenerative and hereditary myelopathies, subacute combined degeneration (vitamin B12 deficiency), syringo-myelia, tabes dorsal.

Instrumental research

Plain X-ray, CT scan of the spine to detect fractures and curvature of the spinal column, as well as to identify possible metastases in the spine. MRI serves as a high-resolution accelerated assessment, especially for the diagnosis of intramedullary lesions, and is preferred over conventional myelography. CSF analysis for the presence of an infectious process, multiple sclerosis, carcinoma.Somatosensory evoked responses can be pathological.

Treatment

Tumor-induced compression. For epidural metastases, high doses of glucocorticoids (to reduce edema) and local irradiation of metastases, with or without chemotherapy; surgery is used if the tumor is insensitive to radiation therapy or does not respond to maximum radiation doses. Surgical removal of the tumor is indicated for neurofibromas, meningiomas, or other extramedullary tumors.

Epidural abscess. Usually requires urgent surgical intervention for drainage of the abscess and bacteriological examination, followed by the appointment of a course of intravenous antibiotics.

Epidural hemorrhage, or hematomyelia. If access is available, the clot is urgently removed. The causes of dyscrasia leading to hemorrhage should be established and, if possible, eliminated or corrected. Arteriovenous developmental abnormalities can be diagnosed using MRI, myelography, or segmental spinal arteriography.

Acute disc protrusion, spinal fracture or displacement. Requires surgical intervention.

Complications

Injury of the urinary tract associated with urinary retention due to distension of the bladder and damage to the detrusor muscle of the bladder; paroxysmal hypertension or hypotension with volume disturbances; ileus and gastritis; with high cervical injuries of the spinal cord – mechanical respiratory failure; severe hypertension and bradycardia in response to irritation or distension of the bladder and bowel; urinary tract infections; bedsores; TELA.

See also:

Medical Center “Brigid” – MSCT of the cervical spine

What is the research for?

Multispiral tomography of the cervical spine is prescribed in the following cases:
• the need to clarify the diagnosis made after radiography or other diagnostic methods;
• severe and frequent headaches of unexplained origin;
• previous injuries of the cervical spine;
• recurrent fainting for no apparent reason;
• systematic convulsions;
• suspicion of inflammatory or degenerative processes in the cervical spine;
• preparation for the operation.
The procedure also makes it possible to assess the condition and identify pathologies in the vessels and soft tissues of this zone. For this, the patient is additionally injected with a contrast agent.

What does MSCT of the cervical spine show?

The examination helps to reveal the following pathologies:
• osteoporosis;
• stenosis of the spinal canal;
• spondylosis;
• osteochondrosis;
• hernias and other disorders in the vertebral discs;
• cracks and fractures in the cervical spine;
• neoplasms and their growth into adjacent tissues;
• hemorrhage in the spinal cord;
• congenital pathologies;
• myelopathy and other pathologies of the spinal cord.

How is the study going?

There is no special preparation for the procedure. But the patient is advised to exclude eating for 2-4 hours before the start of the session.
The patient should remove all jewelry and other items that contain metal. When conducting an examination using a contrast agent, you must first pass an analysis for creatinine and urea. If you have previously performed other procedures (CT, MRI, X-ray), you need to take their results with you.
The patient lies down on a mobile table, which is moved to the annular part of the tomograph, where scanning will be performed. It is important to lie still, otherwise the quality of the images will turn out to be unsatisfactory. Therefore, the doctor can fix the head with special bolsters, pillows or straps.
The procedure without the introduction of contrast medium takes about 5 minutes. MSCT of the cervical spine with contrast takes up to 15 minutes.

Degenerative cervical myelopathy: methods of clinical assessment and an algorithm for choosing a treatment

Sigaleva T.V., Dmukhovsky D.V., Gushcha A.O., Bakulin I.S., Poydasheva A.G., Suponeva N.A., Piradov M.A.
M .: Nervous diseases. №4, 2020
Abstract: Degenerative cervical myelopathy (DSM) is the most common cause of spinal cord dysfunction in developed countries, the prevalence of which is growing due to trends towards an increase in population life expectancy. The cause of its development can be various degenerative changes in the cervical spine, which affect one or more anatomical structures, including the vertebrae, intervertebral discs and spinal ligaments.Neurological deficit resulting from chronic compression of the spinal cord in SCD can lead to significant disability. Permanent disability can be prevented through early diagnosis and intervention at the early stages of the disease. Over the past decade, advances in fundamental science have made it possible to study in more depth the pathophysiology of DSM and use new diagnostic methods in clinical practice. The latest methods of neuroimaging and neurophysiological studies open up prospects for quantitative assessment of spinal cord tissue damage and predicting the outcome of treatment.Currently, surgical decompression is recommended for moderate to severe cases, but the best management strategy for mild myelopathy has not yet been determined. This review presents current data on the definition, clinical presentation, diagnosis and treatment of DSM.