Cervical Spondylosis

Question 1

What is cervical spondylosis

Answer 1

Degeneration of the cervical spine with age is inevitable and has a wide clinical spectrum ranging from asymptomatic to progressive spastic quadriparesis and sensory loss
- due to compression of the cord (myelopathy)

Question 2

Pathogenesis of cervical spondylosis

Answer 2

Degeneration of annulus fibrosis, combined with osteophyte formation on the adjacent vertebra
- leads to a narrowing of the spinal canal and intervertebral foramina
As the neck flexes and extends, the cord is dragged over these protruding bony spurs anteriorly, and indented by a thickened ligamentum flavum posteriorly

Question 3

Presenting complaint for cervical spondylosis

Answer 3

Neck stiffness (but common in anyone over the age of 50)
Crepitus on moving neck
Stabbing or dull arm pain (brachialgia)
Forearm and wrist pain

Question 4

Clinical features of cervical spondylosis

Answer 4

Limited and painful neck movement + crepitus
Lhermitte’s sign (neck flexion causes tingling down the spine)
Root compression (radiculopathy)
- pain/electrical sensation in arms or fingers at the level of the compression
- numbness
- dull reflexes
LMN weakness
- eventual wasting of muscles innervated by the affected root
Cord compression
- progressive symptoms (increasingly weak/clumsy hands and gait disturbance)
- UMN leg signs (spastic weakness and upgoing plantars)
- LMN arm signs (wasting, hyporeflexia)
- incontinence, hesitancey and urgency are always late features

Question 5

Differential diagnoses for cervical spondylosis

Answer 5

MS
Nerve root neurofibroma
Subacute combined degeneration of the cord (vitamin B12 deficiency)
Compression by bone or cord tumours

Question 6

How to work out which nerve root is affected

Answer 6

C5
- weak deltoid and supraspinatus 
- decreased supinator jerks 
- numb elbow
- pain in neck/shoulder that radiates down front of arm to elbow 
C6
- weak biceps and brachioradialis 
- decreased biceps jerk
- numb thumb and index finger
- pain in shoulder radiating down below the elbow
C7
- weak triceps and finger extension
- decreased triceps jerk
- numb middle finger
- pain in upper arm and dorsal forearm
C8
- weak finger flexors and small muscles of the hand 
- numb fifth and ring finger
- pain in upper arm and medial forearm

Question 7

Management of cervical spondylosis

Answer 7

Urgent MRI and specialist referral guided by red flag symptoms of back pain
Otherwise give analgesia (as per WHO ladder) and encourage gentle activity
If no improvement in 4-6 weeks, consider neurosurgery referral for
- interlaminar cervical epidural injections
- transforaminal injections
- surgical decompression

Question 8

Surgical management of cervical spondylosis

Answer 8

Surgical decompression
- discectomy (anterior approach)
- laminectomy or laminoplasty (posterior approach)
These interventions are best only reserved for those with progressive deterioration, myelopathy causing disabling neurologic deficits or those at risk for deterioration (severe spinal compression on MRI)