Cervical spondylosis is a chronic degenerative condition of the cervical spine that affects the vertebral bodies and intervertebral discs of the neck (in the form of, for example, disk herniation and spur formation), as well as the contents of the spinal canal (nerve roots and/or spinal cord).

Spondylotic changes can result in stenosis of the spinal canal, lateral recess, and foramina. Spinal canal stenosis can lead to myelopathy, whereas the latter 2 can cause radiculopathy.

Incidence

It is the most frequent cause of spinal cord dysfunction in patients older than 55 years. On the basis of radiologic findings, 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the cervical spine.

Radiographically, the most frequently involved level is C5-C6 followed by C6-C7, and C4-05. Upper-level (occiput-C3) involvement is less common.

Clinical features- Cervical pain

•           Chronic suboccipital headache maybe present.

•           Pain can be perceived locally, or if may radiate to the occiput, shoulder, scapula, or arm.

•           Nerve roots may be directly compressed. Osteophytes, which develop as a reaction to the process of degenerative disc disease extending across the posterior and posterolateral aspect of the vertebral bodies, may cause direct compression. An inflammatory component of the neuroelements may be a more significant cause of pain than actual mechanical changes

Cervical radiculopathy

•           Radiculopathy—root compression leads to ischemic changes. It is a lower motor neuron problem and is manifested by pain in the distribution of a nerve root. It can be associated with neck pain, sensory deficit, and motor deficiency.

•           The associated reflex may be diminished.

•           The pain of cervical radiculopathy may be described as dull, aching, boring, to neck motion. It may or may not be related to sneezing or cough.

Cervical myelopathy

•           Cervical spondylotic myelopathy is the most serious consequence of intervertebral disc degeneration.

•           Myelopathy involves compression of the spinal cord, and thus, it can effect the upper and lower extremities with a mixture of upper and lower motor neuron lesions.

•           Patients with myelopathy do not necessarily complain of pain.

•           The hallmark is extremity dysfunction such as hand clumsiness with fine motor tasks and gait instability. Cervical myelopathy has an insidious onset, which typically becomes apparent in persons aged 50-60 years. Complete reversal is rare once myelopathy occurs.

•           Anterior compression of the spinal cord results from posterior osteophytes. Posterior compression may result by infolding of the ligomenfum flavum particularly in extension Nutritional and vascular involvement with decreased blood supply through the spinal arteries resulting in ischemic changes to the spinal cord has been identified.

•           Arthrosis of the facet joints in the spondylofic cervical spine may be a source of a dull, aching axial pain or radiating pain secondary to direct nerve root compression.

Physical findings

Findings at physical examination may include the following:

•           Spurting sign - Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, causing additional for aminal compromise.

•           Lhermitte sign - This generalized electrical shock sensation is associated with neck extension.

•           Hoffman sign - Reflex contraction of the thumb and index finger occurs in response to nipping of the middle finger. This sign is evidence of an upper motor neuron lesion. A Hoffman sign may be insignificant if present bilaterally.

•           Distal weakness

•           Decreased ROM in the cervical spine, especially with neck extension

•           Hand clumsiness

•           Loss of sensation

•           Increased reflexes in the lower extremities and in the upper extremities below the level of the lesion

•           A characteristically broad-based, stooped, and spastic gait

•           Extensor planter reflex in severe myelopathy

Differential Diagnoses

Shoulder soft tissue and articular pain syndromes

•           Primary spinal cord tumors

•           Syringomyelia

•           Extramedullary lesions (tumors, thoracic disc herniation)

•           Hereditary spastic paraplegia

•           Normal pressure hydrocephalus

•           Spinal cord infarction

•           Spinal sepsis

•           Whiplash syndrome (hyperextension- hyperilexion injury)

•           Pancoast tumors

•           Brachial plexopathy

•           Thoracic Outlet

•           Vascular Malformations

Work Up:

X Rays

Plain radiographsof the spine provide a clue to the level or levels of spine disease that may be responsible for the radicular syndrome in cervical spondylosis.

Studies can include AP, bilateral obliques, lateral, odontoid open mouth, and lateral flexion and extension views.

Look for evidence of foraminal encroachment, vertebral malalignment, sclerosis, facet joint subluxation, osteophyte protrusions, destructive changes within the disc or vertebral body, and ossification of the posterior longitudinal ligament.

The spondylotic spine may be hypermobile, resulting in instability. This can usually be identified on lateral flexion and extension radiographs. Anterior-posterior movement of one vertebral body on another of 3.5 mm or greater in the adult is considered abnormal.

Computed tomography (CT) scanning

High-quality CT scans are extremely useful in assessing the size of the neuroforamina, which are normally 5 to 8 mm in vertical diameter.

A non contrast CT scan is also very useful in delineating bone from soft tissue in planning a decompressive procedure.

Myelography

Adds anatomic information in evaluating spondylosis and is useful in visualizing the nerve root takeoff.

Water-soluble contrast myelography in combination with CT scanning remains the securest way of defining root sleeve pathology. Myelography with flexion and extension views can demonstrate dynamic cord compression related to bulging of the posterior longitudinal ligament and lugamentumflavum, orto spinal instability.

MRI

MRI scanning has become the gold standard in evaluating the cervical spine. MRI is far superior in defining soft tissue anatomy. The disc material and nerve anatomy can be seen as well as demonstrating pathophysiolocal effects such as "gliosis" associated with chronic spinal cord compression. Infections, hematomas, and tumors are also much better visualized by MRI.

Direct imaging in multiple planes & Better definition of neural elements.

NCV & EMG (Nerve Conduction Velocity & Electromyography)

Electrodiagnostic studies may be useful in establishing the diagnosis particular by documenting the distribution of involvement, and distinguishing peripheral syndromes and generalized peripheral neuropathy, from radiculopathy.

Local Injection

In older patients with multiple levels of abnormality shown on radiologic and other imaging studies in whom cervical radiculopathy cannot be localized, injection of local anesthetic into the interspace under fluoroscopic control and injections of local anesthetic into the facet joints maybe useful in localizing the pain syndrome.

Treatment:

Physical Therapy (Approximately 80% of radiculopathy patients can be successfull nonoperatively).

•           Immobilization of the cervical spine is the mainstay of conservative treatment for patients with cervical spondylosis. Immobilization limits the motion of the neck reducing nerve irritation.

•           Soft cervical collars are recommended for daytime use only, but they are unable to appreciably limit the motion of the cervical spine.

•           More rigid orthoses (e.g. Philadelphia collar, Minerva body jacket) can significantly immobilize the cervical spine.

•           A program of isometric cervical exercises may help to limit the loss of muscle tone that results from the use of more restrictive orthoses. Molded cervical pillows can better align the spine during sleep and provide symptomatic relief for some patients.

•           Mechanical traction is a widely used technique. This form of treatment may be useful because it promotes immobilization of the cervical region and widens the foraminal openings. Gentle traction using 5 to 10 lb with a head halter and a neutral position of flexion-extension to open up the neuro foramina may be of value. Traction applied in either flexion or extension may aggravate the patient's pain problem.

•           The use of cervical exercises has been advocated in patients with cervical spondylosis. Isometric exercises are often beneficial to maintain the strength of the neck muscles. Neck and upper back stretching exercises, as well as light aerobic activities, also are recommended. The exercise programs are best initiated and monitored by a physical therapist.

•           Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (e.g. moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).

•           Manual therapy, such as massage, mobilization, and manipulation, may provide further relief for patients with cervical spondylosis.

Occupational Therapy

Disability can be improved with specific strengthening exercises of the upper extremities, special splinting to compensate for weakness, and the use of assistive devices that allow the patient to perform previously impossible activities.

Cervical spondylosis may result in complications including the following:

•           Cervical myelopathy

•           Paraplegia

•           Tetraplegia

•           Recurrent chest infection

•           Pressure sores

•           Recurrent urinary tract infection

Surgical Intervention

•           Surgical treatment for rodiculopathy is usually indicated if there has been a documented failure of appropriate nonoperative treatment or if there is progressive neurologic deficit with a radiculopathy & Intractable pain. Options are Anterior or posterior decompression with or without fusion.

•           Cervival myelopathy- Patients presenting with cervical myelopathy seldom improve with nonoperative management and roughly one-third will continue to deteriorate, sometimes suddenly with hyperextension. The intent of surgical decompression in myelopathy patients is to prevent progression with neurological improvement being secondary and unpredictable. Options are

•                          Anterior decompression via corpectomy, discectomy, and fusion

•                          Posterior complete laminectomy and decompression.

•                          In the case of multilevel disease (3 or more levels), open door hinged laminoplasty, to expand the spinal canal, has been gaining favor. Open-door laminoplasty for multiple-level decompression seems to prevent postoperative swan-neck-type deformities, which sometimes occur after extensive multilevel posterior laminectomies.

Injections

Cervical epidural steroid injections can prove useful in treatment of radiculopathy especially if an inflammatory component is present.

Epidural and selective nerve root blocks can be diagnostically and therapeutically helpful in cases of radiculopathy. Trigger-point injections maybe helpful.

Cervical, zygapophyseal, intra-articular steroid injection can be helpful for active synovitis.

Mechanical facet pain is better evaluated with facet joint nerve blocks.

Medication

·                 NSAIDS- Add to Patient's comfort.

·                 Corticosteroids Can be administered as-

·                 Pulse corticosteroid therapy with methylprednisolone or Dexamethasone - Intravenous pulse steroid therapy consists of administration of supraphysiological doses of glucocorticoids. It is useful in conditions where rapid antiinflammatory effect is deskW with less long-term systemic side effects associated.

Prednisone (20-30mg/kg) or Dexamethasone (4-5mg/kg) per pulse usually repeated interval of 24-48hrs usuallyforó pulses.

•                          Long term Therapy- in form of tapering regimen started with Moderately high dosesood Tapered graduallylo prevent Adrenal suppression.

•                          Muscle relaxants

Lumbar spondylosis

Lumbar spondylosis, describes bony overgrowths (osteophyfes), predominantly those at the anterior, lateral and less commonly, posterior aspects of the superior and inferior margins of vertebral centra (bodies). This dynamic process increases with, and is perhaps an inevitable concomitant, of age.

Lumbar spondylosis usually produces no symptoms. When back or sciatic pains are symptoms, lumbar spondylosis is usually an unrelated finding.

Lumbar spondylosis appears to be a nonspecific aging phenomenon.

Pathophysiology

Lumbar spondylosis occurs as a result-of new bone formation in areas where the annular ligament is stressed.

Presentation

Lumbar spondylosis usually produces no symptoms (Due to wider spinal canal in lumbar region).

When back or sciatic pains are symptoms, lumbar spondylosis is usually an unrelared finding.

Lumbar spondylosis is usually not found unless a complication ensues.

Other problems to consider include the following:

•   Spondyloarthropathy

•   Spinal stenosis

•   Diffuse idiopathic skeletal hyperostosis

•   Fibromyalgia

•   Postural disturbance

•   Aortic aneurysm

•   Ischial bursitis

•   Trochanteric bursitis

•   Hip arthritis

•   Spondylolisthesis

•   Osteoporosis

•   Compression fracture

•   Neoplasia

•   Hemangioma

•   Infectious spondylitis

•   Endocarditis

•   Disc disease

Imaging Studies

Radiographs, CT scans, and MRls are used only in the event of complications.

Bone density scan (e.g. dual-energy x-ray absorptiometry scan [DEXA]) are used. Ensure that no osteophytes are in the area used for density assessment for spinal studies. Osteophytes produce the impression of increased bone mass, thus invalidating bone density tests if in the field of interest and masking osteoporosis..

Electromyography (EMG) and nerve conduction velocity (NCV) are used only in the event of complications.

Medical Therapy

•                          Because back pain is an unrelated finding of lumbar spondylosis, seek the real cause of the patient's back or sciatica- type symptoms.

•                          Do not assume that the patient's symptoms are related to osteophytosis.

•                          Look for an actual cause of a patient's symptoms.

•                          If actual symptomatic nerve root impingement occurs, 2 days of absolute bed rest is indicated.

•                          If that does not solve the problem, then surgical excision is indicated. Medication is not indicated in the absence of complications.

•                          Surgical excision is performed for impingement-documented sciatica that is unresponsive to 2 days of absolute bed rest.

Complications

•                          Nerve compression from posterior osteophytes is a possible complication only if a neuroforamen is reduced to less than 30% of normal.

•                          Posterior disc height reduction to less than 4 mm or foraminal height to less than 15 mm is compatible with diagnosis of osteophyte- induced nerve compression.

•                          If lumbar spondylosis projects into the spinal canal, spinal stenosis is a possible complication.