Cervical Spondylosis

Original Editors - Gertjan Peeters

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Keywords

• Cervical spondylosis
• Cervical spine
• Cervical vertebrae
  
• Cervical Radiculopathy
• Cervical myelopathy
• Cervical osteoarthritis

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;* Formation of osteophytes;
•  Facet and uncovertebral joint arthritis; 
•  Ossification of the posterior longitudinal ligament;
•  Hypertrophy of the ligamentum flavum causing posterior compression of the cord especially as it buckles in extension;
•  Spinal stenosis;* Degenerative subluxation of cervical vertebra;
•  Dislocated fragment of annular cartilage compressing the spinal cord or nerve root.(43) (Level of Evidence: 5)
  

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) It performs 3 important functions. First, it forms the structural support for the head because it’s part of the skeletal framework. Second, it protects the cervical spine cord and exiting nerve roots enclosed within it. At least, it provides mobility, much more than the rest of the spine so it’s able to do big moves.(41) (Level of Evidence: 5) 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. The atlas is a uniquely shaped ring without a vertebral body, it articulates with the skull (atlanto-occipital joint) and allows for approximately 50% of the flexion and extension movements in the neck. It pivots on the odontoid process of the axis, which arises from the superior surface of the latter’s body. The atlanto-axial joint is responsible for approximately 50% of the rotational movement in the neck.(41) (Level of Evidence: 5) There is no discus intervertebrae between C0-C1 and C1-C2. 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

The pathology can lead to different conditions ranging from axial neck pain to cervical myelopathy. (10) (Level of evidence 1B) It is the most common cause of nontraumatic myelopathy, resulting in paraparesis and quadriparesis. The incidence of neck pain in adults is approximately 20-50% per year, much of which is caused by spondylosis. (41) (Level of Evidence: 5) The prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males.(11) (Level of Evidence: 4) (42) (Level of evidence 4) Approximately 95% of people by age 65 have cervical spondylosis to some degree, it’s the most common spine dysfunction in elderly people. (41) (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) 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)

Characteristics/Clinical Presentation

The symptoms can depend on the stage of the pathologic process and the site of neural compression. On imaging studies you can see that there is a spondylosis, but the patient can’t have any symptoms at all. (41) (Level of Evidence: 5)  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;
  
• Adhesive Capsulitis in Physical Medicine and Rehabilitation;
• Brown-Sequard Syndrome;
• Carpal Tunnel Syndrome;
• Central Cord Syndrome;
• Cervical Disc Disease;
• Cervical Myofascial Pain;
• Cervical Sprain and Strain;
• Chronic Pain Syndrome;
• Diabetic Neuropathy;
• Multiple Sclerosis;
• Neoplastic Brachial Plexopathy;
• Osteoporosis and Spinal Cord Injury;
• Physical Medicine and Rehabilitation for Myofascial Pain;
• Radiation-Induced Brachial Plexopathy;
• Rheumatoid Arthritis;
• Traumatic Brachial Plexopathy. (19) (Level of Evidence: 1A)

Diagnostic Procedures

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

Signs:

• Poorly localised tenderness;
• Limited range of motion, forward flexion, backward extension, lateral flexion, and rotation to both sides;
• Minor neurological changes, Like inverted supinator jerks (unless complicated by myelopathy or radiculopathy.

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;
• Rarely, syncope, triggers migraine. (19) (Level of Evidence: 1A)

The diagnosis of the cervical spondylosis was based on the findings of X-radiographic testing, computed tomography (CT), magnetic resonance imaging (MRI), and electromyography (EMG). (55)  (Level of Evidence: 1B) C. Xu et al found that MRI can reliably determine the presence or degree of facet tropism, but not facet arthrosis. Therefore, it is advisable to augment CT with MRI for an accurate diagnosis. (45) (level of evidence 1B)
Symptoms of cervical spondylosis are various, they could range from mild to severe, and some patients suffering from cervical spondylosis don’t even have noticeable symptoms. Which makes the examination without using imaging tests very hard. (44) (level of evidence 1A)

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)

The different test to differentiate and diagnose a shoulder disorders and cervical spondylosis. These are as follow. Spurling’s test (A)and the Bakody’s test (shoulder abduction release test : B) were for cervical spondylosis.53 (Level of Evidence: 3A)

Examination

Muscle atrophy was inspected in the upper limbs, shoulders and scapular regions which will be compaired with the other side of the body. Muscle strength was tested in four muscles representing the myotomes C5-C8. Anterior, middle, and posterior parts of the deltoid muscle were tested by resisting flexion, abduction, and extension of the humerus. Biceps brachii muscle strength was assessed by resisting elbow flexion when the forearm was supinated. Triceps brachii muscle strength was tested resisting elbow extension from 90 degrees of elbow flexion. The dorsal interosseus muscles were tested by resisting the separation of the second through fifth fingers. Sensitivity to light touch and to pain were tested using indicator areas for different cervical dermatomes. (54) (Level of Evidence: 2B)

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.The initial management should be nonoperative. (28) (level of evidence: 2C) 

There are different medications to treat cervical spondylosis:

• Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) (28)

There is an absence of clinical trials in the use of NSAIDs in the treatment of cervical spondylosis, however their efficacy has been shown efficacy in acute low back pain. Theoretically the NSAIDs will reduce inflammation around the nerve decreasing its sensitivity to compression.

• Opioid Analgesics (28)

The use of opoid analgesics has been limited/reduced because of the ineffectiveness in neuropathic pain. Despite this, there is evidence that oxytocyne can be effective in the treatment of cervical spondylosis.

• Muscle Relaxations (28)

The use of muscle relaxants is effective for any associated spasm of the trapezius muscle. But the duration of the treatment with muscle relaxants is relative short, last for a maximum of two weeks.

• Corticosteroids (28)

There is limited evidence to support the use of systemic corticosteroids in the treatment of cervical spondyolosis.

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:

• Improvement or preservation of neurological function;
• Prevention or correction of spinal deformity;
• Maintenance of spinal stability. (24) (level of evidence 2A)

Decompression may be achieved using an anterior, a posterior, or a combined approach.The recommended decompression is anterior when there is anterior compression at one or two levels and no significant developmental narrowing of the canal. (level of evidence: 2A)( 24)

Anterior decompression, the different surgical treaments (49) (Level of Evidence: 1A)
-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 (49) (Level of Evidence: 1A)

Physical Therapy Management

There have been several trials and systematic reviews into the use of a structured physical therapy program for the treatment of cervical spondylosis and its consequences.

3 Recent reviews17,18,19 concluded (level of evidence 1A):

• There is little evidence for using exercises alone or mobilization and/or manipulations alone as physical treatment.
• 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.
• There is moderate evidence that various exercise regimens, like proprioceptive, strengthening, endurance, or coordination exercises are more effective than usual care (analgesics, non-steroïdal anti-inflammatory drugs, or muscle relaxants)

They concluded that there was no different between the mobilization and the manipulations, this can only be used for multimodal treatment.
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. (28, 39) (Level of evidence 1A, Level of evidence 1B) In another study the physiotherapy was based on mobilizing and stabilizing the cervical spine, was given twice a week for six weeks. Then they were given home exercices consisted of graded activity exercices to strengthen the superficial en deep neck muscles. (48) (level of evidence: 1B )
For the treatment of cervical spondylosis there was one systematic review that used forms of non-thrust mobilization and exercises which targeted the thoracic and/or cervical regions of the spine. (46) (level of evidence: 1A)

Manual therapy is defined as high-velocity; low-amplitude thrust manipulation or non-thrust manipulation.
Manuel Therapy of the thoracic spine will be used for reduction of pain, improving function, to increase the range of motion and to address the thoracic hypomobility (47) (level of evidence:4 ) There was showing the greatest results for improvement in function , with the therapeutic exercise/manual therapy combination group. (46) (level of evidence: 1A)

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 (49) (level of evidence:1A )

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)

Posture education includes the alignment of the spine during sitting and standing activities.(39) (Level of evidence 1B)

Thermal therapy provides symptomatic relief only, and ultrasound appears to be ineffective. Other methods, like: infrared radiation, interferential therapy and massage can also be used in the treatment of cervical spondylosis. (50) (Level of evidence 1B)

Soft Tissue Mobilization was performed on the muscles of the upper quarter with the involved upper extremity positioned in abduction and external rotation to preload the neural structures of the upper limb.(50)  (Level of evidence: 1B)

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)

Resources

Links to other physiopedia’s: Degenerative_Disc_Disease, spinal stenosis, cervical radiculopathy, cervical spondylotic myelopathy. Whiplash, Fibromyalgia, Rheumatoid arthritis, Ankylosing spondylitis or Polymyalgia rheumatica, Paget's disease, osteoporosis, gout or pseudo-gout, osteomyelitis and tuberculosis.

Clinical Bottom Line

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. It is the most common cause of nontraumatic myelopathy, resulting in paraparesis and quadriparesis. The incidence of neck pain in adults is approximately 20-50% per year, much of which is caused by spondylosis. Approximately 95% of people by age 65 have cervical spondylosis to some degree, it’s 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. On imaging studies you can see that there is a spondylosis, but the patient can’t have any symptoms at all. Most of the time cervical spondylosis is diagnosed on clinical signs and symptoms alone. C. Xu et al found that MRI can reliably determine the presence or degree of facet tropism, but not facet arthrosis. Therefor, it is advisable to augment CT with MRI for an accurate diagnosis. Surgical intervention is only in rare cases required, it should be chosen with great care. The treatment should be tailored to individual patients but includes supervised isometric exercises, proprioceptive reeducation, manual therapy and posture education.

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)

• [Outcome of microsurgical decompression combined with cervical artificial disc replacement]. Effect of different surgical methods on    headache associated with cervical spondylotic myelopathy and/or radiculopathy;
• [Progress on cervical spondylosis in youths];

• The correlation between ossification of the nuchal ligament and pathological changes of the cervical spine in patients with cervical spondylosis;

• [Efficacy observation of cervical spondylosis treated with acupuncture at three lines of cervical Jiaji (EX-B 2)];

• [Clinical observation on cervical type cervical spondylosis treated with sword-like needle and chiropractic spinal manipulation];

• [Controlled observation of clinical efficacy on cervical spondylosis of neck type treated with scraping and acupuncture];

• A 12-Words-for-Life-Nurturing Exercise Program as an Alternative Therapy for Cervical Spondylosis: A Randomized Controlled Trial.

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for recent onset cervical radiculopathy: randomised trial, Department of Neurology, (Level of Evidence 1B)
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