Cervical Spondylosis

Original Editors - Gertjan Peeters

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Definition/Description

Cervical Spondylosis is a degenerative disorder at the level of the cervical spine. It can be described as the result of degeneration of the intervertebral discs or the corpus vertebrae in the cervical region. Possible characteristics are Degenerative_Disc_Disease, the formation of osteophytes, facet and uncovertebral joint arthritis, ossification of the posterior longitudinal ligament, hypertrophy of the ligamentum flavum, spinal stenosis. In some cases this degeneration also leads to a posterior protrusion of the annulus fibers of the intervertebral disc. This protrusion can cause compression of nerve roots, which in turn can lead to pain, motor disturbances such as muscle weakness, and sensory disturbances. As the spondylosis progresses there may be even interference with the blood supply to the spinal cord where the vertebral canal is narrowest.

Clinically Relevant Anatomy

The cervical spine is made up of seven segments. (9)The construction of this region is so adjusted that it’s able to do big moves. There is an important distinction between the high and mid cervical and low cervical region(6)(Level of evidence 5).The first two (atlas and axis) are anatomically and functionally different segments. These two segments work together to produce rotation, lateral flexion, flexion and extension of the head and neck. (7) C0-C1 and C1-C2 are very different in construction and function comparing to lower cervical segments, as there is no discus inter vertebrae between C0-C1 and C1-C2. Between C1 – C2 occurs 50% of the total rotation. The lower five cervical vertebrae are roughly cylindrical in shape with bony projections (8) (Level of evidence 2A).Between each of the lower vertebrae’s there is a disc. The discs act as shock absorbers, stabilizer and allow the spine to be flexible. It’s also captures the most important part of the forces during daily activities. (Running, walking, jumping…)

The sides of the vertebrae are linked by small facet joints. Strong ligaments attach to adjacent vertebrae to give extra support and strength. We can split the cervical spine in three columns; anterior, middle and posterior part.(8) (Level of evidence 2A)

- Anterior: consists of ligament longitudinal anterior, the annulus of the disc and the anterior part of the corpus vertebrae

- Middle: consists of ligament longitudinal posterior, the posterior part of the annulus and the corpus vertebrae.

- Posterior: All the structures that are posteriorly positioned compared to the ligament longitudinal posterior.
 

Epidemiology /Etiology

Cervical spondylosis is a common cause of acquired disability in patients over 50 years. This pathology can lead to different conditions ranging from axial neck pain to cervical myelopathy. (10) (Level of evidence 1B) The prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males. (11) (Level of evidence 4) Spondylotic changes in the cervical spine occur at solitary disc space levels in 15-40% of patients and at multiple levels in 60-85%. The discs between the third and seventh cervical vertebrae are most commonly affected. Repeated occupational trauma may contribute to the development of cervical spondylosis. An increased incidence has been noted in patients who carried heavy loads on their heads or shoulders, dancers, gymnasts, and in patients with spasmodic torticollis. Not everyone agrees that trauma is an important causal factor in the production of this disorder. 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. (5) (Level of evidence 1A) Prevalence was about 3.5 in 1000; it increased to a peak at age 50–59 years and decreased thereafter. The age-specific prevalence was consistently higher in women.(35) (level of evidence 2C) Cervical spondylosis is the most common progressive disorder in the aging cervical spine. It results from the process of degeneration of the intervertebral discs and facet joints of the cervical spine.(36) ( level of evidence 5) It has been estimated that 75% of persons over the age of 50 have narrowing of the spinal canal or intervertebral foramina, and 50% of these cases are symptomatic. With advancing years the number with positive symptomatology increases until an incidence of 75% is reached in persons over the age of 65.(37) (level of evidence 5)

Characteristics/Clinical Presentation

Pain, paresthesias or muscle weakness, or a combination of these symptoms are the most common symptoms in patients with cervical spondylosis. A 1996 study report that intermittent neck and shoulder pain is the most common syndrome seen in clinical practice. Another study showed that, due to 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 pain or breast pain. This study also reports that the pain is most frequently present in the upper limbs and the neck. Another study showed that also chronic suboccipital headache could be a clinical syndrome in patients with cervical spondylosis. This headache may radiate to the base of the neck and the vertex of the skull. Also central cord syndrome is a syndrome that may be seen in relation to cervical spondylosis. 2 studies demonstrate that in some cases dysphagia or airway dysfunction has been reported to cervical spondylosis. Various studies report that cervical spondylosis often causes cervical spondylotic myelopathy.

Differential Diagnosis

• Other non-specific neck pain lesions - acute neck strain, postural neck ache or Whiplash,
• Fibromyalgia and psychogenic neck pain
• Mechanical lesions - disc prolaps 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, secundary deposits or myeloma
  

Diagnostic Procedures

Most of the time cervical spondylosis is diagnosed on clinical signs and symptoms alone.

Signs:

• poorly localised tenderness,
• limited range of motion,
• minor neurological changes.

Symptoms:

• cervical pain aggravated by movement,
• referred pain,
• retro-orbital or temporal pain,
• cervical stiffness,
• vague numbness, tingling or weakness in upper limbs,
• dizzyness or vertigo,
• poor balance.
  

Medical Management 

The most commonly used medical treatment in patients with cervical spondylosis is a conservative treatment. This includes pharmacological treatments (NSAID’s, opioids, …), lifestyle modifications (neck schools, ergonomics, workplace modifications, …) and physical therapy (see next chapter: “Physical Therapy Management”). There isn’t enough evidence for neck immobilisation: various sources contradict each other.

Physical Therapy Management

3 Recent reviews reach similar conclusions. First they conclude that there is little evidence for using exercises alone or mobilization and/or manipulations alone as physical treatment. Then they also conclude that mobilization 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. When they compare mobilization with manipulations, they concluded that there is no difference between both. The end conclusion of these reviews is that there is only for multimodal treatment (manual therapy in combination with exercises and education) enough evidence. Another study reported that cervical traction leads to symptomatic relief in 81% of the patients with cervical spondylosis.

A 2011 study on the effects of three different conservative treatments (active + passive physiotherapy methods, active treatment methods and medication-therapy) on pain, disability, quality of life, and mood in patients with cervical spondylosis reports that there was more improvement in the two groups receiving exercise treatment than the group receiving medical treatment, especially during long-term follow up.

Recent Related Research (from Pubmed)

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