Cervical Spondylosis

Original Editors - Gertjan Peeters

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

Search Strategy

 Databases:
 * PubMed
 * PEDro
 * Public library
 * Google Scholar
 * Web of knowledge

Keywords:
* Cervical spondylosis
* Cervical spine
* Cervical vertebrae

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.

Outcomes Measures

Patients with cervical spondylosis can be asked to make their own assessment of pain using a visual analogue scale (VAS) and of general health and functionality with the Short Form 36 (SF-36) and the Neck Disability Index (NDI). (20) (Level of evidence 4) Spondylotic changes may result in direct compressive and ischemic dysfunction of the spinal cord. (21) (Level of evidence 1B) Therefore several clinical measures of disease severity have been developed such as the Japanese Orthopaedic Association (JOA) and the Nurick Classification scoring systems. These popular scales are developed to quantify the extent and progression of this disease. (22) (Level of evidence 2A)

Medical Management 

Cervical spondylosis tends to be a chronic condition, but in most cases it is not progressive. Only in rare cases surgery is required. Poor prognostic indicators and, therefore, absolute indications for surgery are:

- Progression of signs and symptoms;
- Presence of myelopathy for six months or longer;
- Compression ratio approaching 0,4 or transverse area of the spinal cord of 40 square millimeters or less. (23) (level of evidence 2A)

The goals of surgical treatment of cervical spondylosis are the following: 1. Improvement or preservation of neurological function; 2. Prevention or correction of spinal deformity; and 3. Maintenance of spinal stability. (24) (level of evidence 2A)

Decompression may be achieved using an anterior, a posterior, or a combined approach. Several important questions should be carefully considered while choosing the surgical approach. 1. Location of compression: anterior or posterior; 2. Single or multi-level compression; 3. Presence or absence of congenital spinal stenosis; 4. Alignment of the cervical spine; 5. Presence or absence of instability; 6. Patient's lifestyle-related factors (smoking etc); 7. Other factors such as the presence of developmental stenosis, pre-existing neck pain and prior cervical spine surgery.

The recommended decompression is anterior when there is anterior compression at one or two levels and no significant developmental narrowing of the canal. For compression at more than two levels, developmental narrowing of the canal, posterior compression, and ossification of the posterior longitudinal ligament, posterior decompression is recommended. In order for posterior decompression to be effective there must be lordosis of the cervical spine. If kyphosis is present, anterior decompression is needed. Kyphosis associated with a developmentally narrow canal or posterior compression may require combined anterior and posterior approaches.(23) (level of evidence: 2A) If a multilevel corpectomy is necessary for patients with severe osteoporosis, those with poor bone quality due to renal disease or heavy smokers in whom poor bone fusion is anticipated, a combined approach should be undertaken. (24) (level of evidence 2A) Fusion is required for instability.(23) (level of evidence 2A)

The most anterior used approaches are: 1. anterior cervical discectomy without fusion; 2. anterior cervical discectomy with fusion, with or without supplemental instrumentation; 3. anterior cervical corpectomy and fusion, with or without instrumentation. (26)(27) (level of evidence 2A& 3A)
An anterior cervical discectomy and fusion from the side (left) and front (right) (26)

26. Image: http://siemionow.com/conditions_treated/anterior_cervical_disc_fusion/02.jpg

The most posterior used approaches are: 1. Laminectomy; 2. laminectomy with lateral mass fusion and; 3. Laminoplasty. (24) (25) (level of evidence: 2A & 3A)

As with any surgery, there is a possibility of infection or complications. (23) (level of evidence 2A)
Posterior laminectomy with fusion (27)

27. Image: http://orthoinfo.aaos.org/figures/A00539F03.jpg

Physical Therapy Management

There have been several trials and systematic reviews into the use of a structured physical therapy programme for the treatment of cervical spondylosis and its sequelae. 3 Recent reviews[17][18][19] 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.
Typically the therapy regime requires 15–20 sessions over a 3-month period. The treatment should be tailored to individual patients but includes supervised isometric exercises, proprioceptive reeducation, manual therapy and posture education.38, 39 (Level of evidence 1A, Level of evidence 1B) Exercises included cervical retraction, cervical extension, deep cervical flexor strengthening, and scapular strengthening. Manual therapy is defined as high-velocity; low-amplitude thrust manipulation or non-thrust manipulation. Thrust manipulation of the thoracic spine could include techniques in a prone, supine, or sitting position based on therapist preference. Non- thrust manipulation included posterior-anterior (P-A) glides in the prone position. The cervical spine techniques could include retractions, rotations, lateral glides in the ULTT1 position, and P-A glides. The techniques are chosen based on patient response and centralization or reduction of symptoms. 39 (Level of evidence 1B) When we investigate the efficacy of some vertebral mobilization techniques in the management of unilateral spondylosis we see that Anterior-Posterior Unilateral Pressure (APUP) and Posterior-Anterior Unilateral Pressure (PAUP) achieve faster pain relief in more patients with unilateral cervical spondylosis than Cervical Oscillatory Rotation (COR) and Transverse Oscillatory Pressure (TOP). 40 (level of evidence 5) Posture education includes the alignment of the spine during sitting and standing activities.39 (Level of evidence 1B)

Cervical Retraction Exercise
The patient is instructed to move his or her head backward (over the spine) as far as
possible with the head and eyes remaining level.

Cervical Extension Exercise

The patient is instructed to retract the cervical spine, lift the chin up, and extend the cervical spine to end range. The patient then is instructed to perform 2–3 small right to left oscillations of the head. The patient then will return his or her head to the midline position, tuck the chin, and return to the retracted position

Deep Neck Flexor Exercise

The patient is instructed to slowly nod the head and flatten the curve of the neck without pushing the head back into the table. The therapist or patient monitors the sternocleidomastoid muscle to ensure minimal activation of this muscle during the deep neck flexor contraction.

Scapular Strengthening Exercises

The patient is instructed to squeeze his or her shoulder blades together with or without resistance (seated or standing). Instruction is given not to shrug the shoulders (activate the upper trapezius muscle) during the exercise.

Thermal therapy provides symptomatic relief only, and ultrasound appears to be ineffective. The overall message of the prospective randomized trials appears to be that surgically treated patients receive greater improvements in pain, muscle strength, and sensory function in the early follow-up period, but at 1 year there is no difference between groups either objectively or in terms of patient satisfaction. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. More invasive treatments such as epidurals may be of benefit in a select group of patients that do not respond to simpler measures. 38(Level of evidence 1A)

Key Evidence

Kieran Michael Hirpara, Joseph S. Butler, Roisin T. Dolan, John M. O'Byrne, and Ashley R. Poynton , Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis, Advances in Orthopedics, 2011 (Level of evidence 1A)

Case studies

• Spondylolysis of C-2 in children 3 years of age or younger: clinical presentation, radiographic findings, management, and outcomes with a minimum 12-month follow-up.
• Familial cervical spondylosis. Case report.

Recent Related Research (from Pubmed)

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• [Outcome of microsurgical decompression combined with cervical artificial disc replacement].

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