Makindo Medical Notes

Cervical spondylosis is a degenerative condition affecting the cervical spine, or neck region. Caused by wear and tear of the vertebrae and intervertebral discs, it leads to changes in the bones, discs, and joints. This condition is very common, particularly in older adults, and is a natural part of aging.

About

• Cervical Spondylosis is a leading cause of neck pain and can result in arm weakness, numbness, and other neurological symptoms.
• It often affects the lower cervical roots, particularly at the C5-6, C6-7, and C3-4 levels, which are common sites for degenerative changes.
• Prevalence increases with age, affecting up to 85% of individuals over 60 years old.

Aetiology

• Age-Related Degeneration: Progressive wear and tear on the cervical spine structures due to aging.
• Disc Degeneration: Loss of disc hydration and elasticity leads to reduced disc height and increased vulnerability to herniation.
• Osteophyte Formation: Bone spurs develop along the edges of vertebrae as a compensatory mechanism to stabilize the spine.
• Articular Facet Hypertrophy: Enlargement of the facet joints contributes to the narrowing of the spinal canal (spinal stenosis).
• Ligamentous Thickening: Thickening of the ligamentum flavum can lead to spinal canal narrowing and nerve compression.
• Herniated Discs: Central protrusions can compress the spinal cord, while posterolateral protrusions affect nerve roots, causing pain, paresthesia, weakness, and reduced reflexes.
• Genetic Factors: Family history may predispose individuals to earlier or more severe degenerative changes.

Risk Factors

• Age: Increased risk with advancing age.
• Smoking: Accelerates degenerative changes and impairs blood flow to spinal structures.
• Family History: Genetic predisposition to spinal degeneration.
• Occupational Neck Strain: Jobs involving repetitive neck movements or prolonged static positions (e.g., painters, plumbers, computer-related work).
• Previous Neck Injury: Trauma can accelerate degenerative processes.
• Heavy Lifting or Exposure to Vibrations: Activities such as heavy lifting or operating vibrating tools (e.g., truck drivers) increase stress on the cervical spine.
• Obesity: Excess weight contributes to increased mechanical stress on the cervical spine.

Cervical Spondylotic Myelopathy may occur when the cervical canal diameter decreases from 17 mm to below 13 mm. The spinal cord itself is 8-11.5 mm in diameter, making it susceptible to compression when the canal narrows significantly.

Clinical Features

• Neck Pain: Persistent and often worsens with movement; may radiate to the shoulders and arms.
• Stiffness: Reduced range of motion, particularly after periods of inactivity or upon waking.
• Headaches: Typically cervicogenic, originating from neck strain or spinal nerve irritation.
• Radiculopathy: Nerve root compression leads to arm or hand pain, numbness, tingling, or weakness.
• Myelopathy: Spinal cord compression results in motor weakness, coordination issues, gait disturbances, and in severe cases, bladder or bowel dysfunction.
• Cervical Crepitus: A grinding or popping sensation heard during neck movement due to degenerative changes.
• Upper Motor Neuron Signs: Hyperreflexia, spasticity, and Babinski sign may be present in myelopathy.

Investigations

• MRI:
  • Reveals cord indentation, gliosis, ischaemia, demyelination, or atrophy.
  • T2 hyperintensities indicate gliosis, which may predict a poorer prognosis.
  • Assess the extent of spinal canal narrowing and soft tissue structures.
• Nerve Conduction Studies (NCS) and Electromyography (EMG):
  • Assess the extent of nerve involvement and differentiate between myelopathy and peripheral neuropathy.
• X-Ray:
  • Shows bone spurs, disc space narrowing, and alignment of the cervical spine.
• CT Scan:
  • Provides detailed images of bone structures and can identify osteophytes and spinal canal stenosis.

Differential Diagnoses

• Motor Neuron Disease (MND): Progressive muscle weakness without sensory involvement.
• Multiple Sclerosis (MS): Demyelinating disease with varied neurological symptoms.
• Vitamin B12 Deficiency: Causes subacute combined degeneration of the spinal cord.
• HTLV-1 Myelopathy: Viral infection leading to chronic progressive myelopathy.
• Adrenoleukodystrophy: Genetic disorder affecting the nervous system and adrenal glands.
• Syringomyelia or Spinal Tumors: Can mimic the symptoms of cervical spondylosis by compressing the spinal cord.

Management

The management approach depends on the severity of symptoms and degree of spinal involvement:

• Conservative Treatment:
  • Physical Therapy: Strengthens neck muscles, improves flexibility, and alleviates pain through targeted exercises and stretches.
  • Medications: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), muscle relaxants, and analgesics for pain management.
  • Neck Brace: Provides support and reduces pain by limiting neck movement; recommended for short-term use.
  • Heat or Cold Therapy: Applies heat to relax muscles or cold to reduce inflammation and numb pain.
  • Postural Training: Educates patients on maintaining proper posture to minimize neck strain and prevent exacerbation of symptoms.
  • Ergonomic Adjustments: Modifying workstations to promote neck alignment and reduce repetitive strain.
• Interventional Treatments:
  • Epidural Steroid Injections: Reduce inflammation around compressed nerves, providing temporary pain relief.
  • Facet Joint Injections: Alleviate pain stemming from facet joint arthritis by delivering corticosteroids directly to the affected area.
  • Radiofrequency Ablation: Uses heat to disrupt nerve pathways, reducing chronic pain.
• Surgical Treatment:
  • Anterior Cervical Discectomy and Fusion (ACDF): Removes herniated or degenerated discs and fuses adjacent vertebrae to stabilize the spine.
  • Laminectomy: Removes the vertebral lamina to decompress the spinal cord and relieve pressure.
  • Foraminotomy: Expands the foramen (where nerve roots exit) to ease nerve compression and alleviate radiculopathy.
  • Artificial Disc Replacement: Replaces damaged discs with prosthetic devices, maintaining better range of motion compared to fusion.
  • Posterior Cervical Decompression and Fusion: Combines laminectomy with spinal fusion from the back to stabilize the cervical spine.
• Alternative Therapies:
  • Acupuncture: May provide pain relief for some patients.
  • Chiropractic Care: Manual manipulation to improve spinal alignment; should be approached with caution.

Prognosis

Cervical spondylosis is a chronic, progressive condition. While there is no cure, symptoms can often be managed effectively with conservative treatment. Severe cases with neurological impairment may require surgical intervention. Early diagnosis and management improve quality of life and help prevent complications.

• Functional Recovery: Many patients experience significant improvement with physical therapy and lifestyle modifications.
• Persistent Deficits: Sensory disturbances, chronic pain, and motor impairments may persist despite treatment.
• Complications: Without proper management, cervical spondylosis can lead to severe neurological deficits, including loss of motor function and coordination.
• Quality of Life: Effective pain management and physical therapy can enhance daily functioning and overall well-being.

Prevention

• Maintain Good Posture: Ensures even distribution of mechanical stress on the cervical spine.
• Regular Exercise: Strengthens neck and back muscles, improving spinal support.
• Ergonomic Workspaces: Adjust chairs, desks, and computer screens to promote proper neck alignment.
• Avoid Prolonged Static Positions: Take regular breaks to move and stretch, especially during activities like typing or using a smartphone.
• Healthy Weight: Reduces mechanical stress on the cervical spine.
• Quit Smoking: Improves blood flow to spinal structures and slows degenerative changes.

References

• Ferrero, E. L., & Heary, R. (2007). Cervical spondylosis and myelopathy. Archives of Physical Medicine and Rehabilitation, 88(2), 232-242.
• Ghim, L. S., & Kwon, Y. J. (2011). Cervical spondylotic myelopathy: pathophysiology, diagnosis, and management. Spine, 36(3), S90-S100.
• Peel, A., & Van Der Kraaij, M. (2015). Cervical spondylosis: an update on the epidemiology, pathogenesis, clinical features and management. European Spine Journal, 24(7), 1381-1388.
• Glassman, S. D., Carreon, L. Y., & Kim, D. J. (2007). Cervical spondylotic myelopathy: epidemiology, natural history, and diagnosis. Neurosurgical Clinics of North America, 18(2), 213-224.
• Fritsch, T., & Heiss, W. D. (1999). Cervical spondylotic myelopathy: magnetic resonance imaging findings and their correlation with clinical features. Neurosurgery, 44(6), 1269-1276.

Images

• Figure 1: MRI showing degenerative changes in the cervical spine with spinal canal narrowing.