Cervical Spondylosis

Original Editors - Gertjan Peeters

Top Contributors - Bruno Luca, Rachael Lowe, Jolien Wauters, Scott Cornish, Gertjan Peeters, Deborah Huart, Abdelrahman Sameh Abdelkarim Attia, Garima Gedamkar, Kim Jackson, Admin, Lucinda hampton, Tony Lowe, Simisola Ajeyalemi, Deepmala Jadwani, Aline Tréfois, Rucha Gadgil, Jess Bell and Olajumoke Ogunleye

Definition/Description

Cervical spondylosis is a term that encompasses a wide range of progressive degenerative changes that affect all the components of the cervical spine (i.e., intervertebral discs, facet joints, joints of Luschka, ligamenta flava, and laminae). It is a natural process of aging and presents in the majority of people after the fifth decade of life.

In the cervical spine this chronic degenerative process affects the intervertebral discs and facet joints, and may progress to disk herniation, osteophyte formation, vertebral body degeneration, compression of the spinal cord, or cervical spondylotic myelopathy.

Symptoms of cervical spondylosis manifest as neck pain and neck stiffness and can be accompanied by radicular symptoms when there is compression of neural structures.

Neck pain is a widespread condition, and the second most common complaint after low back pain. This condition is associated with a significant burden of disease with substantial disability and economic cost, 

Although ageing is the primary cause, the location and rate of degeneration as well as degree of symptoms and functional disturbance varies and is unique to the individual.

Clinically Relevant Anatomy

See Cervical Anatomy for a comprehensive coverage of the Anatomy.

Epidemiology

Evidence of spondylotic change is frequently found in many asymptomatic adults, with evidence of some disc degeneration in:

• 25% of adults under the age of 40,
• 50% of adults over the age of 40, and
• 85% of adults over the age of 60

Asymptomatic adults showed significant degenerative changes at 1 or more levels

• 70% of women and 95% of men at age 65 and 60 were affected
• The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5".

Risk factors

• Age, gender and occupation .
• The prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males.
• Repeated occupational trauma may contribute to the development of cervical spondylosis.
• Increased incidence in patients who carried heavy loads on their heads or shoulders and in dancers and gymnasts.
• In about 10% of patients, cervical spondylosis is due to congenital bony anomalies, blocked vertebrae, malformed laminae that place undue stress on adjacent intervertebral discs.

Etiology

• The primary risk factor and contributor to the incidence of cervical spondylosis is age-related degeneration of the intervertebral disc and cervical spinal elements.
• Degenerative changes in surrounding structures, including the uncovertebral joints, facet joints, posterior longitudinal ligament (PLL), and ligamentum flavum all combine to cause narrowing of the spinal canal and intervertebral foramina. Consequently, the spinal cord, spinal vasculature, and nerve roots can be compressed, resulting in the three clinical syndromes in which cervical spondylosis presents: axial neck pain, cervical myelopathy, and cervical radiculopathy.
• Factors that can contribute to an accelerated disease process and early-onset cervical spondylosis include exposure to significant spinal trauma, a congenitally narrow vertebral canal, dystonic cerebral palsy affecting cervical musculature, and specific athletic activities such as rugby, soccer, and horse riding.

Pathophysiology

The development of cervical spondylosis involves a degenerative process that leads to biomechanical changes in the cervical spine, resulting in the compression of neural and vascular structures. An increase in the keratin-chondroitin ratio causes alterations to the proteoglycan matrix, leading to the loss of water, protein, and mucopolysaccharides within the intervertebral disc. Consequently, the desiccation of the disc causes the nucleus pulposus to lose elasticity, shrink, and become more fibrous. This loss of elasticity weakens the nucleus pulposus's ability to bear weight effectively, leading to herniation through the fibers of the annulus fibrosus. This process contributes to the loss of disc height, ligamentous laxity, and compression of the cervical spine. With continued disc desiccation, the annular fibers become more susceptible to mechanical compromise under compressive loads, resulting in significant alterations in load distribution along the cervical spine and leading to a reversal of the normal cervical lordosis.

Furthermore, the progression of kyphosis causes the annular and Sharpey fibers to detach from the vertebral body edges, prompting reactive bone formation. These bone spurs or osteophytes can form along the ventral or dorsal margins of the cervical spine and project into the spinal canal and intervertebral foramina. Moreover, the imbalance in load distribution along the spinal column imposes greater axial loads onto the uncovertebral and facet joints, leading to hypertrophy or enlargement of the joints and accelerating bony spur formation in the surrounding neural foramen. These degenerative changes result in the loss of cervical lordosis and movement, as well as a reduction in the spinal canal diameter.

Pathophysiological and Biomechanical pathway of cervical spondylosis

Histopathology

Disc herniation may serve as an early precursor to spondylosis development. While spondylotic and herniated discs undergo similar degenerative changes, there are immunohistological distinctions between the two conditions.

In a 2008 study by Kokubo et al, 500 cervical intervertebral discs from 198 patients with disc herniation and 166 patients with spondylosis were analyzed. Histological examination and immunohistochemical staining revealed CD68-positive macrophages, tumor necrosis factor-alpha (TNF-alpha), matrix metalloproteinase (MMP)-3, basic fibroblast factor (bFGF), and vascular endothelial growth factor (VEGF) in chondrocytes from both groups. However, the study found that herniated discs displayed more prominent inflammatory reactions, with CD68-positive macrophage infiltration into the outer layer of the annulus fibrosus. Conversely, spondylotic discs showed thicker bony endplates and a more diffuse expression of TNF-alpha and MMP-3 in the inner layer of the annulus fibrosus.

Clinical Presentation

Cervical spondylosis presents in three symptomatic forms as:

1. Non-specific neck pain - pain localised to the spinal column.
2. Cervical radiculopathy - complaints in a dermatomal or myotomal distribution often occurring in the arms. May be numbness, pain or loss of function.
3. Cervical myelopathy - a cluster of complaints and findings due to intrinsic damage to the spinal cord itself. Numbness, coordination and gait issues, grip weakness and bowel and bladder complaints with associated physical findings may be reported.

Symptoms can depend on the stage of the pathological process and the site of neural compression. Diagnostic imaging may show spondylosis, but the patient may be asymptomatic and vice versa. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, so the boundary between normal ageing and disease is difficult to define.

Pain is the most commonly reported symptom. McCormack et al  reported that intermittent neck and shoulder pain is the most common syndrome seen in clinical practice. With cervical radiculopathy the pain most often occurs in the cervical region, the upper limb, shoulder, and/or interscapular region . In some cases the pain may be atypical and manifest as chest or breast pain, although it is most frequently present in the upper limbs and the neck. Chronic suboccipital headache could also be a clinical syndrome in patients with cervical spondylosis , which may radiate to the base of the neck and the vertex of the skull.

Paraesthesia or muscle weakness, or a combination of these are often reported and indicate radiculopathy.

Central cord syndrome may also be seen in relation to cervical spondylosis and in some cases dysphagia or airway dysfunction have been reported.  

Differential Diagnosis

• 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.

Diagnostic Procedures

Cervical spondylosis is often diagnosed on clinical signs and symptoms alone.

Signs:

• Poorly localised tenderness
• Limited range of motion
• Minor neurological changes (unless complicated by myelopathy or radiculopathy)

Symptoms:

• Cervical pain aggravated by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain
• Cervical stiffness
• Vague numbness, tingling or weakness in upper limbs
• Dizziness or vertigo
• Poor balance
• Rarely, syncope, triggers migraine

Most patients do not need further investigation and the diagnosis is made on clinical grounds alone however, diagnostic imaging such as X-ray, CT, MRI, and EMG can be used to confirm a diagnosis.

Radiographic representation of cervical spondylosis

X-ray

Plain radiographs of the cervical spine may show a loss of normal cervical lordosis, suggesting muscle spasm, but most other features of degenerative disease are found in asymptomatic people and correlate poorly with clinical symptoms

Common radiographic findings include osteophyte formation, disc space narrowing, endplate sclerosis, degenerative changes of uncovertebral and facet joints, and calcified/ossified soft tissues. AP, lateral, and oblique views of the spine are adequate to evaluate for foraminal stenosis, sagittal alignment, and the size of the spinal canal. The Torg-Pavlov ratio is obtainable by comparing the sagittal diameter of the spinal canal to the sagittal diameter of the vertebral body. The normal value is 1.0, with a ratio of <0.8 indicating cervical stenosis. Flexion and extension views also merit consideration if there is a concern for ligamentous instability.

It is important to realise that radiological changes with age only represent structural changes in the vertebrae, but such changes do not necessarily cause symptoms. It is believed that this mismatch between radiographic appearance and clinical symptoms is not only because of age, but also because of gender, race, ethnic group, height and occupation.

Magnetic Resonance Imaging (MRI)

MRI 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. Sagittal and axial cuts can help quantify the extent of nerve and cord compression, as well as reveal offending pathological changes (e.g., herniated discs, bony spurs, ligamenta flava hypertrophy, or facet joint arthropathy). Hyperintense spinal cord signal on T2-weighted images can be representative of edema, inflammation, ischemia, myelomalacia, or gliosis.

However, normal people can show important pathological abnormalities on imaging so scans need to be interpreted with care.

Multilevel-cervical-spondylosis ST T1

Multilevel-cervical-spondylosis ST T2

Computed Tomography (CT)

CT provides a good definition of bony structures and is more sensitive than plain radiographs in assessing intervertebral foraminal stenosis in the setting of uncovertebral or facet hypertrophy. However, it is less sensitive than MRI for the evaluation of soft tissues and nerve root compression.

CT Myelogram

CT is most useful when combined with the injection of intrathecal contrast (myelography) to better evaluate the location and amount of neural compression. It is more invasive than an MRI but can be a consideration in patients who have a contraindication to MRI (e.g., pacemaker) or have an artifact from the hardware.

Discogram

Provocative discography is rarely necessary for cervical spondylosis. It is useful for the evaluation of patients who are experiencing cervical discogenic pain or have multiple herniations in which surgery is a strong possibility. However, the diagnostic procedure remains controversial as it may accelerate the degeneration of normal discs.

Electromyogram (EMG)

EMG can be useful in supplementing neuroimaging findings in the diagnosis of cervical radiculopathy. It is especially valuable in differentiating nerve root compression from other possible concomitant neurologic conditions, including peripheral neuropathies, entrapment neuropathies, brachial plexopathies, myopathies, and motor neuron diseases.

Outcomes Measures

The following outcome measures can be used to evaluate neck pain :

• Visual analogue scale (VAS)
• Short Form 36 (SF-36)
• Neck Disability Index (NDI)

Spondylotic changes may result in direct compression and ischaemic dysfunction of the spinal cord. Several clinical measures of disease severity include: Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ); Nurick Classification scoring systems. These scales have been developed to quantify the extent and progression of this disease.

Pain provocation tests such as Spurling’s test can be used to differentiate between shoulder disorders and cervical spondylosis.

Examination

Patient history should focus on the timeline of the pain, radiation of pain, aggravating factors, and inciting events. Classically, symptomatic cervical spondylosis presents as one or more of the following three primary clinical syndromes:

• Axial neck pain
  • Commonly complain of stiffness and pain in the cervical spine that is most severe in the upright position and relieved with bed rest when removing the load from the neck
  • Neck motion, especially in hyperextension and side-bending, typically increases the pain
  • In upper and lower cervical spine disease, patients may report radiating pain into the back of the ear or occiput versus radiating pain into the superior trapezius or periscapular musculature, respectively
  • Occasionally, patients can present with atypical symptoms cervical angina such as jaw pain or chest pain

• Cervical radiculopathy
  • Radicular symptoms usually follow a myotomal distribution depending on the nerve root(s) involved and can present as unilateral or bilateral neck pain, arm pain, scapular pain, paraesthesia, and arm or hand weakness
  • Pain is exacerbated by head tilt toward the affected side or by hyperextension and side-bending toward the affected side
• Cervical myelopathy
  • Typically has an insidious onset with or without neck pain (frequently absent)
  • Can initially present with hand weakness and clumsiness, resulting in the inability to complete tasks requiring fine motor coordination (e.g., buttoning a shirt, tying shoelaces, picking up small objects)
  • Frequent reports of gait instability and unexplained falls
  • Urinary symptoms (i.e., incontinence) are rare and typically appear late in disease progression

On the first appearance, the patient may appear immobile and stiff at the head and neck due to increasing axial neck pain with cervical spine movement. Tender “trigger” points are frequently present within the superior trapezius muscles, cervical paraspinal muscles, and/or periscapular muscles.

If there is radiating pain down the upper limb with head extension and ipsilateral head rotation to the affected side, then it is considered a positive Spurling test for cervical radiculopathy. In a 2011 study by Shabat et al., the Spurling test was found to be 95% sensitive and 94% specific for diagnosing nerve root pathology in 257 patients as confirmed by cervical spine CT and/or MRI . In some cases, manual neck distraction may alleviate radicular pain.

Electric shock-like sensations radiating down the spine and into the extremities with cervical flexion is a positive Lhermitte's sign, which is concerning for cervical spondylotic myelopathy (CSM). A more specific sign for CSM is Hoffman’s sign, which is elicited by flicking the patient’s distal phalanx of the middle finger and observing reflexive flexion of the thumb and/or index finger. All physical exams should include a meticulous evaluation of bilateral extremities for muscle strength, sensation, and deep tendon reflexes in order to look for weakness in a myotomal distribution, sensory deficits in a dermatomal pattern, and reflex changes, respectively; all of which can help to identify the compromised nerve root(s) and/or myelopathy.

The clinician can evaluate the patient’s gait and balance with a toe-to-heel walk test and Romberg’s test. In the latter, the patient stands with eyes closed, and arms held forward. An increased loss of balance is interpreted as a positive Romberg’s test and is indicative of dysfunction involving the dorsal columns of the spinal cord.

The presence of upper motor neuron signs (e.g., spasticity, hyperreflexia, sustained clonus, extensor Babinski response) should raise the examiner’s clinical suspicion for spinal cord compromise. Another screening test for CSM is the grip and release test. Typically, a patient can make a fist and release it 20 times in 10 seconds, with decreasing cut-off values with increasing age and lower cut-off values in females compared to males.

Management & Treatment

The treatment strategy for cervical spondylosis depends on the severity of a patient’s signs and symptoms. In the absence of “red flag” symptoms or significant myelopathy, the goals of treatment are to relieve pain, improve functional ability in day-to-day activities, and prevent permanent injury to neural structures. Symptomatic cervical spondylosis should be approached in a stepwise fashion, starting with non-operative management.

Conservative Treatment

The primary treatment for cervical spondylosis is a structured, progressive physical therapy program lasting four to six weeks. Early stages should focus on pain management, reduction of inflammation, and gradual reintroduction of mobility exercises. As patients progress, they should transition to strengthening and proprioception exercises targeting cervical and thoracic musculature.

• Pharmacologic Agents: These include nonsteroidal anti-inflammatory drugs (NSAIDs), oral steroids, muscle relaxants, anticonvulsants, and antidepressants for pain relief. Therapy can escalate to opioid analgesics for refractory axial neck pain, though they are not recommended for long-term use due to their potential adverse effects. Current evidence suggests that combining pharmacologic agents with structured rehabilitation improves outcomes compared to medication alone .
• Durable Medical Equipment: Short-term use of a soft cervical collar may alleviate acute symptoms, but prolonged use beyond 2-3 weeks can result in muscle atrophy and reduced cervical stability. Nighttime use of a cervical pillow, designed to maintain normal cervical lordosis, can also relieve symptoms by improving biomechanical load distribution .
• Interventional Treatments: If conservative management is insufficient, more invasive treatments such as epidural steroid injections (ESIs), zygapophysial (facet) joint injections, medial branch blocks, or radiofrequency lesioning (RFL) may be considered. A 2019 systematic review found that nearly half of patients with cervical radicular pain experienced over 50% pain reduction after cervical transforaminal ESIs at 1-3 months follow-up.

Physical Therapy Management

• Mobilisation and/or manipulations in combination with exercises are effective for pain reduction and improvement in daily functioning in sub-acute or chronic mechanical neck pain with or without headache.
• There is moderate evidence that various exercise regimens, like proprioceptive, strengthening, endurance, or coordination exercises are more effective than usual pharmaceutical care.

Treatment should individualised, but generally includes rehabilitation exercises, proprioceptive re-education, manual therapy and postural education

• A 2018 study comparing isometric exercises to dynamic exercises, both with traditional physiotherapeutic methods concluded that short-term physiotherapy plays a significant role in the treatment of cervical spondylosis. Comparison between the two treatment techniques gives priority to dynamic exercises, contrary to isometric exercises
• The 2001 meta-analysis by the Philadelphia Panel finding were

1. Physical modalities such as cervical traction, heat, cold, therapeutic ultrasound, massage, and transcutaneous electrical nerve stimulator (TENS) lacked sufficient evidence regarding their efficacy in the treatment of acute or chronic neck pain. 
2. In patients experiencing radicular pain, cervical traction may be incorporated to alleviate the nerve root compression that occurs with foraminal stenosis.
3. Trigger point injections can be employed to treat myofascial trigger points, which can clinically manifest as neck, shoulder, and upper arm pain.

Exercise Therapy

Growing evidence supports exercise-based rehabilitation as a crucial intervention for cervical spondylosis. Various exercise regimens, including proprioceptive, strengthening, endurance, and coordination exercises, have been shown to be more effective than pharmaceutical treatments alone for addressing neck pain and improving function.

1. Deep Cervical Flexor Strengthening: Exercises like chin tucks and isometric cervical flexion target the deep cervical flexors, helping to restore cervical spine muscular balance and improve postural alignment. Proprioceptive re-education plays an essential role in reducing pain intensity and restoring normal cervical motion.
2. Dynamic Exercises: Dynamic exercises are more effective than isometric exercises in enhancing functional performance. Recent studies support introducing dynamic exercises once the patient demonstrates improvement in pain and mobility.

Manual Therapy

1. Thoracic and Cervical Mobilization and Manipulation : Combining cervical mobilization techniques with thoracic spine manipulations significantly reduces pain and improves cervical range of motion. Techniques such as thoracic high-velocity low-amplitude (HVLA) thrust manipulations, whether performed in prone, supine, or seated positions, help alleviate cervical pain and increase thoracic mobility.
2. Non-Thrust Manipulation: Techniques such as posterior-anterior (PA) glides, retractions, and rotations should be applied based on the patient's response, with symptom centralization guiding their use.
3. Soft Tissue Techniques: Myofascial release and trigger point therapy targeting muscles like the upper trapezius, levator scapulae, and suboccipitals help reduce referred pain and improve range of motion, especially in cases of myofascial pain syndrome.

Postural Education

Postural education is critical in preventing the recurrence of symptoms.

Patients should receive training in proper ergonomic practices, particularly if they spend extended periods sitting or working at a computer. Adjusting workstation setup and taking regular breaks are recommended to reduce cervical strain.

Home Exercise Program

A well-rounded home exercise program should include cervical retraction, cervical extension, deep cervical flexor strengthening, and scapular stabilization exercises. These exercises, when performed regularly, contribute to maintaining neck stability and improving mobility.

Aerobic Exercise

Aerobic exercises, such as walking or cycling, are vital in managing chronic neck pain associated with cervical spondylosis. Studies have shown that patients who engage in regular low-impact aerobic exercise experience improved neck function and reduced disability.

Thermal Therapy and Ultrasound

While ultrasound has limited evidence in the treatment of cervical spondylosis, other thermal modalities, such as moist heat or ice packs, can provide symptomatic relief during the early phases of treatment. However, these passive interventions should be paired with active therapeutic exercises for optimal recovery.

Patient Education

Since cervical spondylosis is primarily a natural part of the aging process, educating patients on maintaining good neck strength and flexibility is essential. Promoting a healthy lifestyle, practicing proper ergonomics, and emphasizing injury prevention can help minimize early symptom onset. Ergonomic recommendations, such as proper desk posture, avoiding prolonged neck extension, and regular stretching, should be reinforced during patient education.

Suggested Physical Therapy Protocol for Cervical Spondylosis Management

Objective:

To reduce pain, improve function, and increase the range of motion in individuals with cervical spondylosis through a combination of manual therapy and exercise.

Initial Evaluation and Assessment:

• Subjective Examination: Assess for symptoms like neck stiffness, pain, and radiating pain into the shoulders or arms.
• Objective Examination: Include posture assessment, cervical spine range of motion (ROM), neurological examination (if needed), and pain assessment using a scale like the Numeric Pain Rating Scale (NPRS).

Treatment Plan (8-12 weeks):

1. Manual Therapy Techniques:

Manual therapy focuses on cervical and thoracic spine mobilizations, manipulations, and soft tissue techniques to reduce stiffness and improve mobility. Based on the findings from the systematic review:

• Cervical Mobilization:
  • Perform central and unilateral posteroanterior (CPA/UPA) mobilizations.
  • Apply gentle joint mobilizations to relieve pain and restore normal cervical movement.
  • Duration: 3-5 minutes per session, 2-3 times a week.
• Cervical Spine Manipulation:
  • High-velocity, low-amplitude thrusts (HVLAT) targeting the upper thoracic and cervical spine for pain relief.
  • Manipulations should be used cautiously depending on the patient’s comfort and tolerance.
  • Duration: 1-2 manipulations per session, 1-2 times a week.
• Soft Tissue Mobilization:
  • Use myofascial release or trigger point release techniques on the upper trapezius, levator scapulae, and suboccipital muscles.
  • Duration: 5-10 minutes, included in every session.

2. Exercise Therapy:

Exercise therapy should include strengthening, stabilization, and stretching exercises that address key muscle groups around the neck and upper back, focusing on endurance and neuromuscular control.

Phase 1: Pain Reduction and Flexibility (Weeks 1-4)

• Isometric Cervical Strengthening:
  • Target the deep neck flexors (DNF) using isometric neck exercises (e.g., chin tucks, neck flexion).
  • 3 sets of 10 reps, performed daily.
• Cervical Range of Motion (ROM) Exercises:
  • Gentle ROM exercises like neck flexion, extension, lateral flexion, and rotation.
  • 2 sets of 10 reps for each movement, performed 2-3 times a day.
• Scapular Stabilization Exercises:
  • Strengthening exercises for scapular stabilizers (e.g., shoulder blade retraction, scapular squeezes).
  • 3 sets of 10-15 reps, 3 times per week.
• Upper Thoracic Mobility:
  • Thoracic extension exercises, using a foam roller or exercise ball.
  • 1-2 sets of 10 reps, performed daily.

Phase 2: Strengthening and Stability (Weeks 4-8)

• Dynamic Cervical Strengthening:
  • Include isotonic neck exercises (neck extension, lateral flexion against resistance bands).
  • 3 sets of 10 reps, 3-4 times a week.
• Deep Neck Flexor Endurance Training:
  • Progress from isometric exercises to more dynamic ones that challenge the endurance of the DNF (e.g., holding a chin tuck with slight head lifts).
  • Hold for 10-20 seconds, progressing to 3 sets of 10 reps.
• Upper Extremity Strengthening:
  • Shoulder elevation and strengthening with resistance bands targeting upper back muscles (e.g., rows, external rotation).
  • 3 sets of 10-12 reps, 3 times per week.

Phase 3: Functional Exercises and Posture Training (Weeks 8-12)

• Proprioception and Balance Training:
  • Incorporate exercises that challenge balance and proprioception (e.g., head nods while maintaining a neutral cervical position on a stability ball).
  • 3 sets of 10 reps, 2-3 times per week.
• Posture Re-education:
  • Focus on correcting poor postures with ergonomic adjustments and postural awareness exercises.
  • Perform daily, especially during prolonged sitting activities.
• Functional Integration:
  • Integrate neck and upper back exercises into daily activities (e.g., using correct posture while lifting or bending).
  • Perform during everyday activities as needed.

3. Education and Ergonomics:

• Educate the patient on maintaining good posture during daily activities, especially at work or while using electronic devices.
• Ergonomic adjustments, like proper computer monitor height and chair support, should be emphasized to reduce neck strain.

Progress Monitoring:

• Reassess the patient every 4 weeks for pain, ROM, and functional improvements.
• Adjust the intensity of manual therapy and exercises based on the patient’s response and progress.

Expected Outcomes:

• Pain Reduction: Significant pain relief (similar to findings in the systematic review).
• Improved Function: Enhanced cervical ROM and decreased disability scores.
• Enhanced Quality of Life: Although manual therapy and exercise showed no significant improvement in quality of life in the study, improved pain management and functional mobility are expected to contribute to better daily functioning.

Caution:

• Avoid aggressive mobilizations or manipulations in patients with severe osteophyte formations or neurological deficits.
• Modify exercises based on pain tolerance and progression.

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Surgical Intervention

Surgical intervention is considered for patients with severe or progressive cervical myelopathy, persistent axial neck pain, or cervical radiculopathy who have not responded to non-operative measures. The choice of surgical approach depends on the clinical presentation and the location of pathology.

Surgical Approaches

1. Anterior Cervical Discectomy and Fusion (ACDF):
   • Procedure: Involves removal of the degenerated disc material through an anterior approach and fusing the adjacent vertebrae with a bone graft or an intervertebral cage.
   • Indications: Recommended for anterior compression at one or two levels, without significant developmental narrowing of the spinal canal.
2. Cervical Arthroplasty:
   • Procedure: Involves the replacement of a degenerated disc with an artificial disc, aiming to preserve motion at the affected segment.
   • Indications: Suitable for single or two-level disc degeneration, particularly when there is concern for adjacent segment degeneration following fusion.
3. Posterior Decompression:
   • Procedure: Includes techniques like laminoforaminotomy, foraminotomy, or posterior cervical discectomy to relieve pressure from neural structures.
   • Indications: Effective for cases with posterior compression, developmental canal narrowing, or ossification of the posterior longitudinal ligament.
4. Combined Anterior and Posterior Approaches:
   • Procedure: Utilized when addressing multi-level or complex pathologies that require both anterior and posterior decompression.
   • Indications: Recommended for extensive cervical spondylotic myelopathy or severe cases involving both anterior and posterior structures.

Prognosis

Cervical spondylosis is a degenerative disease that progresses slowly over time and is associated with aging. However, the severity of symptoms does not always correspond with the degree of spondylosis seen on neuroimaging.

Patients with axial neck pain generally improve over time, but they may experience a recurrence of pain. One study found that 79% of patients with neck pain improved or became symptom-free within 15 years of the onset of symptoms.

Around 50 to 75% of individuals with current neck pain are likely to experience neck pain again within 1 to 5 years. According to a 2008 study by Carroll et al., psychosocial factors such as psychological health, coping patterns, and social needs were identified as the most influential prognostic factors of neck pain.

Patients primarily experiencing axial neck pain are unlikely to develop more severe spondylotic changes leading to radiculopathy or myelopathy. Most patients with cervical radiculopathy eventually see an improvement in symptoms over 1 to 2 years without needing surgery.

Conversely, the long-term outlook for cervical spondylotic myelopathy is less certain.

In patients with mild-to-moderate symptoms, the course of the disease varies widely, with symptoms sometimes remaining unchanged and occasionally improving.

However, for patients with a progressive decline in neurologic function, moderate-to-severe signs and symptoms, or significant spinal cord injury, surgery is likely to be more beneficial than further.

Complications

In a 2019 cohort study by El-Yahochouchi et al., the overall incidence of immediate and delayed adverse events following an epidural steroid injection was 2.4% and 4.9%, respectively.

Complications include:

• Neurologic injury
• Epidural abscess
• Epidural hematoma
• Increased pain
• Vasovagal reactions
• Central steroid response (e.g., facial flushing, nonpositional headaches)
• Endocrinologic effects (e.g., hyperglycemia, hypothalamic-pituitary axis suppression, decreased bone density)

Complications from anterior and posterior cervical spine surgery include:

• Injury to spinal cord and nerve roots
• Infection
• Dural tear and CSF leak
• Recurrent laryngeal, superior laryngeal, and hypoglossal nerve injuries
• Esophageal injury and dysphagia
• Vertebral and carotid artery injuries
• Tracheal injury
• Adjacent segment degeneration
• Pseudoarthrosis
• Post-laminectomy kyphosis

Clinical Bottom Line

• Cervical spondylosis is considered a natural process of ageing with a 95% prevalence by age 65 years. Most people remain asymptomatic but can present with axial neck pain, as well as progress to cervical radiculopathy and/or cervical myelopathy. 

• Cervical spondylosis is the most common spine dysfunction in elderly people
• The symptoms can depend on the stage of the pathologic process and the site of neural compression. 
• The treatment approach should be in a stepwise fashion. Patients experiencing axial neck pain without neurologic symptoms will typically have a resolution of symptoms within days to weeks, without any intervention. If symptoms persist, conservative therapy should initiate, including NSAIDs and physical therapy. Patients with axial neck pain, cervical radiculopathy, or mild cervical myelopathy should work formally with a physical therapist on neck-specific strengthening and range of motion exercises, general exercises, and pain coping strategies before undergoing surgical treatment.  
• Treatment should be tailored to the individual patient and include supervised isometric exercises, proprioceptive reeducation, manual therapy and posture education. 

Enhancing Healthcare Team Outcomes

Cervical spondylosis, a degenerative condition affecting the cervical spine, is common in older adults. Effective management requires a multidisciplinary approach involving physicians, physical therapists, occupational therapists, and nurses. Collaboration optimizes patient outcomes through accurate diagnosis, individualized treatment plans, and timely interventions.

Importance of Multidisciplinary Collaboration:

Managing cervical spondylosis is complex due to degenerative and biomechanical changes. It requires input from various healthcare professionals, including primary care physicians, neurologists, orthopedic surgeons, physical therapists, occupational therapists, nurses, and pain management specialists.

Key Roles:

• Primary care physicians recognize early symptoms and refer patients to specialists.
• Neurologists and orthopedic surgeons diagnose and manage cases with neurological symptoms, and surgical intervention may be necessary.
• Physical therapists focus on non-surgical management, occupational therapists help patients manage daily activities, and nurses and pain management specialists provide supportive care and administer pharmacologic treatments.

Interprofessional Communication and Coordination

Effective communication among healthcare professionals is crucial to ensure that patients receive timely and appropriate care.

For example, it is essential for physical therapists and surgeons to coordinate their efforts in deciding whether conservative management is adequate or if surgical intervention is necessary.

Collaborative team meetings and case discussions can improve the decision-making process, ultimately leading to better patient outcomes. Additionally, the use of shared electronic health records (EHRs) can facilitate seamless transfer of patient information among healthcare providers, reducing the risk of miscommunication and treatment delays.

Evidence-Based Treatment Approaches

An essential element in improving healthcare team outcomes for cervical spondylosis is the integration of evidence-based practices across all medical disciplines. Specifically, studies have shown that a combination of manual therapy and therapeutic exercises yields better results in reducing pain and enhancing function in cervical spondylosis patients compared to individual treatments.

Additionally, recent research underscores the benefits of early intervention, with patients receiving early physical therapy demonstrating superior long-term outcomes compared to those initiating treatment at a later stage. Ensuring that all healthcare team members are versed in the latest evidence can lead to optimized patient care.

Outcome Measurement and Quality Improvement

To continuously improve the management of cervical spondylosis, healthcare teams must track patient outcomes and engage in quality improvement initiatives.

Standardized outcome measures such as the Neck Disability Index (NDI) and the Visual Analog Scale (VAS) for pain can help assess the effectiveness of treatment interventions .

Regular audits and feedback sessions can also identify areas for improvement in care delivery, leading to better patient outcomes and reduced healthcare costs