Cervical Spondylosis Flashcards
Background
Cervical spondylosis is a chronic degenerative condition of the cervical spine that affects the vertebral bodies and intervertebral disks 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). Some authors also include the degenerative changes in the facet joints, longitudinal ligaments, and ligamentum flavum.
Spondylosis progresses with age and often develops at multiple interspaces. Chronic cervical degeneration is the most common cause of progressive spinal cord and nerve root compression. 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.
Pathophysiology
Intervertebral disks lose hydration and elasticity with age, and these losses lead to cracks and fissures. The surrounding ligaments also lose their elastic properties and develop traction spurs. The disk subsequently collapses as a result of biomechanical incompetence, causing the annulus to bulge outward. As the disk space narrows, the annulus bulges, and the facets override. This change, in turn, increases motion at that spinal segment and further hastens the damage to the disk. Annulus fissures and herniation may occur. Acute disk herniation may complicate chronic spondylotic changes.
As the annulus bulges, the cross-sectional area of the canal is narrowed. This effect may be accentuated by hypertrophy of the facet joints (posteriorly) and of the ligamentum flavum, which becomes thick with age. Neck extension causes the ligaments to fold inward, reducing the anteroposterior (AP) diameter of the spinal canal.
As disk degeneration occurs, the uncinate process overrides and hypertrophies, compromising the ventrolateral portion of the foramen. Likewise, facet hypertrophy decreases the dorsolateral aspect of the foramen. This change contributes to the radiculopathy that is associated with cervical spondylosis. Marginal osteophytes begin to develop. Additional stresses, such as trauma or long-term heavy use, may exacerbate this process. These osteophytes stabilize the vertebral bodies adjacent to the level of the degenerating disk and increase the weight-bearing surface of the vertebral endplates. (See images below) The result is decreased effective force on each of these structures.
Blood Supply and Pathophysiology
The blood supply of the spinal cord is an important anatomic factor in the pathophysiology. Radicular arteries in the dural sleeves tolerate compression and repetitive minor trauma poorly. The spinal cord and canal size also are factors. A congenitally narrow canal does not necessarily predispose a person to myelopathy, but symptomatic disease rarely develops in individuals with a canal that is larger than 13 mm.
Frequency of Spondylosis
Cervical spondylosis is a common condition that is estimated to account for 2% of all hospital admissions. 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.
Evidence from a 2009 report indicated that cervical spondylosis with myelopathy was the most common primary diagnosis (36%) among elderly US patients admitted to the hospital for surgical treatment of a degenerative cervical spine between 1992 and 2005. [4] The study, which looked at 156,820 hospital admissions for elderly Medicare beneficiaries, also determined that fusion was the most common procedure (70%) performed in these patients for cervical spine degeneration, with 58% of the fusions being anterior.
Epidemiologty
Mortality/Morbidity”
The course of cervical spondylosis may be slow and prolonged, and patients may either remain asymptomatic or have mild cervical pain.
Long periods of nonprogressive disability are typical, and in a few cases, the patient’s condition progressively deteriorates.
Morbidity ranges from chronic neck pain, radicular pain, diminished cervical range of motion (ROM), headache, myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis and/or sphincteric dysfunction (eg, difficulty with bowel or bladder control) in advanced cases. The patient may eventually become chair-bound or bedridden.
Race
No apparent correlation between race and cervical spondylosis exists.
Sex
Both sexes are affected equally. Cervical spondylosis usually starts earlier in men than in women.
Age
Symptoms of cervical spondylosis may appear in persons as young as 30 years but are found most commonly in individuals aged 40-60 years.
Radiologic spondylotic changes increase with patient age; 70% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine.
Cervical sponylosis- what gender gets affected sooner
Cervical spondylosis usually starts earlier in men than in women. When cervical spondylosis develops in a young individual, it is almost always secondary to a predisposing abnormality in one of the joints between the cervical vertebrae, probably as a result of previous mild trauma.
Common clinical syndromes associated with cervical spondylosis include the following:
- Cervical pain
Chronic suboccipital headache may be present. Mechanisms include direct nerve compression; degenerative disk, joint, or ligamentous lesions; and segmental instability.
Pain can be perceived locally, or it may radiate to the occiput, shoulder, scapula, or arm.
The pain, which is worse when the patient is in certain positions, can interfere with sleep.
- Cervical radiculopathy
Compression of the cervical nerve roots leads to ischemic changes that cause sensory dysfunction (eg, radicular pain) and/or motor dysfunction (eg, weakness). Radiculopathy most commonly occurs in persons aged 40-50 years. (See images below)
An acute herniated disk or chronic spondylotic changes can cause cervical radiculopathy and/or myelopathy
The C6 root is the most commonly affected one because of the predominant degeneration at the C5-C6 interspace; the next most common sites are at C7 and C5.
Most cases of cervical radiculopathy resolve with conservative management; few require surgical intervention.
- Cervical myelopathy
Cervical spondylotic myelopathy is the most serious consequence of cervical intervertebral disk degeneration, especially when it is associated with a narrow cervical vertebral canal.
Findings at physical examination may include the following:
- Spurling sign - Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, causing additional foraminal 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
Causes:
- Age
Cervical spondylosis is an accumulation of degenerative changes observed most commonly in elderly individuals.
Among persons younger than 40 years, 25% have degenerative disk disease (DDD), and 4% have foraminal stenosis, as confirmed with magnetic resonance imaging (MRI).
In persons older than 40 years, almost 60% have DDD, and 20% have foraminal stenosis, as confirmed with MRI.
- Trauma
The role of trauma in spondylosis is controversial.
Repetitive, subclinical trauma probably influences the onset and rate of progression of spondylosis.
Work activity - Cervical spondylosis is significantly higher in patients who carry loads on their head than in those who do not (see Frequency).
- Genetics
The role of genetics is unclear. However, a retrospective, population-based study by Patel et al shows that genetics may play a role in the development of cervical spondylotic myelopathy (CSM). The study uses The Utah Population Database, which contains over 2 million residents’ health and genealogical data, and cross-references it with 10 years of clinical diagnosis statistics from a large tertiary hospital. An abundance of cases showing relatedness, as well as a considerable amount of elevated relative risks to close and distant relatives, advances the idea of an inherited predisposition to CSM.
Patients older than 50 years who have normal cervical spine radiographic findings are significantly more likely to have a sibling with normal or mildly abnormal radiographic results.
Spondylosis Wiki
Spondylosis is a broad term meaning degeneration of the spinal column from any cause. In the more narrow sense it refers to spinal osteoarthrosis, the age-related wear and tear of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints (facet syndrome). If severe, it may cause pressure on nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, and muscle weakness in the limbs.
When the space between two adjacent vertebrae narrows, compression of a nerve root emerging from the spinal cord may result in radiculopathy (sensory and motor disturbances, such as severe pain in the neck, shoulder, arm, back, or leg, accompanied by muscle weakness).
Less commonly, direct pressure on the spinal cord (typically in the cervical spine) may result in myelopathy, characterized by global weakness, gait dysfunction, loss of balance, and loss of bowel or bladder control. The patient may experience shocks (paresthesia) in hands and legs because of nerve compression and lack of blood flow. If vertebrae of the neck are involved it is labelled cervical spondylosis. Lower back spondylosis is labeled lumbar spondylosis.
There are multiple techniques used in the diagnosis of Spondylosis, these are;
Wiki
Cervical Compression Test a variant of Spurling’s test, is performed by laterally flexing the patient’s head and placing downward pressure on it. Neck or shoulder pain on the ipsilateral side (i.e. the side to which the head is flexed) indicates a positive result for this test. However it should be noted that a positive test result is not necessarily a positive result for spondylosis and as such additional testing is required. [2]
Lhermitte sign: feeling of electrical shock with patient neck flexion
Reduced range of motion of the neck, the most frequent objective finding on physical examination
MRI and CT scans are helpful for pain diagnosis but generally are not definitive and must be considered together with physical examinations and history
Causes Wiki
Spondylosis is caused from years of constant abnormal pressure, from joint subluxation, sports, or poor posture, being placed on the vertebrae, and the discs between them. The abnormal stress causes the body to form new bone in order to compensate for the new weight distribution. This abnormal weight bearing from bone displacement will cause spondylosis to occur. Poor postures and loss of the normal spinal curves can lead to spondylosis as well. Spondylosis can affect a person at any age; however, older people are more susceptible
Treatment Wiki
Treatment is usually conservative in nature. Patient education on lifestyle modifications, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, chiropractic,and osteopathic care are common forms of manual care that help manage such conditions.[5] Other alternative therapies such as massage, trigger-point therapy, yoga and acupuncture may be of limited benefit. Surgery is occasionally performed.
Many of the treatments for cervical spondylosis have not been subjected to rigorous, controlled trials. Surgery is advocated for cervical radiculopathy in patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. Surgical indications for cervical spondylosis with myelopathy (CSM) remain somewhat controversial, but “most clinicians recommend operative therapy over conservative therapy for moderate-to-severe myelopathy.” (Baron, M.E.)
Physical therapy may be effective for restoring range of motion, flexibility and core strengthening. Decompressive therapies (i.e. manual mobilization, mechanical traction) may also help alleviate pain. However, physical therapy and osteopathy cannot “cure” the degeneration, and some people view that strong compliance with postural modification is necessary to realize maximum benefit from decompression, adjustments and flexibility rehabilitation.
It has been argued, however, that the cause of spondylosis is simply old age, and that posture modification treatment is often practiced by those who have a financial interest (such as Worker’s Compensation)[7] in proving that it is caused by work conditions and poor physical habits. Understanding anatomy is the key to conservative management of spondylosis.
Surgery
Current surgical procedures used to treat spondylosis aim to alleviate the signs and symptoms of the disease by decreasing pressure in the spinal canal (decompression surgery) and/or by controlling spine movement (fusion surgery).[8]
Decompression surgery: The vertebral column can be operated on from both an anterior and posterior approach. The approach varies depending on the site and cause of root compression. Commonly, osteophytes and portions of intervertebral disc are removed.[9]
Fusion surgery: Performed when there is evidence of spinal instability or mal-alignment. Use of instrumentation (such as pedicle screws) in fusion surgeries varies across studies.
