Cervical Spondylosis

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.[1] The image on R shows a neck affected by Spondylosis.

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[2].

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,[1] 

Although ageing is the primary cause[3], 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 [4].
  • The prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males[5][6][7].
  • Repeated occupational trauma may contribute to the development of cervical spondylosis[8].
  • 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.[9]

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.[1]

Clinical Presentation

Cervical spondylosis presents in three symptomatic forms as[7]:

  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[10] 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[11].

Pain is the most commonly reported symptom. McCormack et al [9] 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 [12]. 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 [13] , 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. [14][15] 

Differential Diagnosis[11]

Diagnostic Procedures

Cervical spondylosis is often diagnosed on clinical signs and symptoms alone[11].

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[16]

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[17].  

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[11]. 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[4]

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. However, normal people can show important pathological abnormalities on imaging so scans need to be interpreted with care[11]

Outcomes Measures

The following outcome measures can be used to evaluate neck pain [18]:

Spondylotic changes may result in direct compression and ischaemic dysfunction of the spinal cord.[19] Several clinical measures of disease severity include: Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ)[20]; Nurick Classification scoring systems[21]. These scales have been developed to quantify the extent and progression of this disease[22].

Pain provocation tests such as Spurling’s test can be used to differentiate between shoulder disorders and cervical spondylosis[23].

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[24]

Medical Management

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.[1]

Non-surgical

  1. The mainstay of non-surgical treatment is a four- to six-week course of physical therapy, see below.
  2. Pharmacologic agents, including nonsteroidal anti-inflammatory drugs (NSAIDs), oral steroids, muscle relaxants, anticonvulsants, and antidepressants can be prescribed for pain relief. Therapy can be escalated to opioid analgesics for refractory axial neck pain but are not recommended as first-line or for long-term use due to their potential adverse effects.
  3. Durable medical equipment can be a consideration for symptomatic relief. Short-term use of a soft cervical collar can sometimes alleviate acute neck pain and spasm. Nighttime use of a cervical pillow may relieve neck pain by helping to maintain the normal cervical lordosis, which would improve the distribution of biomechanical loads between discs, thereby promoting better sleep quality.[1]
  4. More invasive interventional treatment options include epidural steroid injections (ESIs), zygapophysial (facet) joint injections, medial branch blocks, and radiofrequency lesioning (RFL). In a 2019 systematic review and meta-analysis by Conger et al., approximately half of the patients with cervical radicular pain experienced at least 50% pain reduction at one and three-month follow-up after cervical transforaminal ESIs. There are long-term reports of success have shown 40 to 70% of patients who underwent interlaminar or transforaminal ESIs for the treatment of cervical radiculopathy. In a 2015 systematic review by Manchikanti et al., long-term pain relief was observed with cervical RFLs, MBBs, and facet joint injections.[1]

Surgery

Surgical intervention should be considered in patients with severe or progressive cervical myelopathy, as well as those with persistent axial neck pain or cervical radiculopathy following failure of non-operative measures. These affected individuals must also have a pathological condition demonstrated on neuroimaging studies that correspond to their clinical features. The surgical approach depends on the clinical syndrome and the site(s) of pathology.[1]

The mainstay of surgical treatment for degenerative cervical disorders involves decompression of the neural elements often combined this arthrodesis[24]. Decompression may be achieved using an anterior, a posterior, or a combined approach. Recommended decompression is anterior when there is anterior compression at one or two levels and no significant developmental narrowing of the canal. [25]

Anterior decompression, the different surgical options:[26]

  • Anterior cervical foraminotomy
  • Anterior cervical discectomy without fusion
  • Anterior cervical discectomy with fusion
  • Cervical arthroplasty

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: Posterior laminoforaminotomy/foraminotomy and/or discectomy[26]

There continues to be a concern for development of adjacent level disease which has led to the development of total disc arthroplasty.[24]

Physical Therapy Management

  • There is little evidence for using exercise alone or mobilisation and/or manipulations alone.
  • 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[27][28][29].

Treatment should individualised, but generally includes rehabilitation exercises, proprioceptive re-education, manual therapy and postural education[30][31]

  • 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[32]
  • 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[1].
  3. Trigger point injections can be employed to treat myofascial trigger points, which can clinically manifest as neck, shoulder, and upper arm pain.

Manual therapy is defined as high-velocity; low-amplitude thrust manipulation or non-thrust manipulation. Manual therapy of the thoracic spine can be used for reduction of pain, improving function, to increase the range of motion and to address the thoracic hypomobility[33]

Thrust manipulation of the thoracic spine could include techniques in a prone, supine, or sitting position based on therapist preference. Also cervical traction can be used as physical therapy to enlarge the neural foramen and reduce the neck stress [26] [2a]

Non-thrust manipulation included posterior-anterior (PA) glides in the prone position. The cervical spine techniques could include retractions, rotations, lateral glides in the ULTT1 position, and PA glides. The techniques are chosen based on patient response and centralisation or reduction of symptoms.[31]

Postural education includes the alignment of the spine during sitting and standing activities.[31]

Thermal therapy provides symptomatic relief only and ultrasound appears to be ineffective[34].

Soft tissue mobilisation was performed on the muscles of the upper quarter with the involved upper extremity positioned in abduction and external rotation to pre-load the neural structures of the upper limb.[34]

Home Exercises include cervical retraction, cervical extension, deep cervical flexor strengthening, scapular strengthening, stretching of the chest muscles via isometric contraction of flexor of extensor muscles to encourage the mobility of the neural structures of the upper extremity.[33] [34]

Education. The natural history of cervical spondylosis is highly variable, as well as challenging to prevent, given that it is part of the normal aging process. The client should receive training on ways to deter early onset of cervical spondylosis, including maintaining good neck strength and flexibility, leading an active and healthy lifestyle, and preventing neck injuries (e.g., good ergonomics, avoiding prolonged neck extension, proper equipment for contact sports, safe tackling technique, and seatbelt use in automobiles)[1].

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[1].  
  • Treatment should be tailored to the individual patient and include supervised isometric exercises, proprioceptive reeducation, manual therapy and posture education. 

References

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  2. Xiong W, Li F, Guan H. Tetraplegia after thyroidectomy in a patient with cervical spondylosis: a case report and literature review. Medicine (Baltimore) 2015;94(6):e524. Available from:https://www.ncbi.nlm.nih.gov/pubmed/25674751 (last accessed 1.2.2020)
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