Spondylosis

Question 1

What is spondylosis?

Answer 1

It is basically spinal osteoarthritis, AKA degenerative disc disease or degenerative joint disease: Progressive degenerative process affecting vertebral bodies and intervertebral discs, eventually causing compression of the spinal cord and nerve roots.

Question 2

What is the aetiology of spondylosis? (x4 (x4))

Answer 2

• Constant abnormal pressure leading to degenerative changes: joint subluxation, stress induced by sports, acute/repeat trauma, poor posture.
• Age
• Genetic component in cervical
• Achondroplasia (cartilage does not change to bone) and acromegaly are risk factors

Question 3

What is the pathophysiology of spondylosis?

Answer 3

• With normal ageing, the intervertebral disc loses proteoglycans and water, leading to diminished height and circumferential disc bulging
• This puts stress on the facet joints leading to facet and ligament hypertrophy, and osteophyte formation (osteoarthritic degeneration)
• These osteophytes protrude on the exit foramina and spinal canal (leading to spinal stenosis)
• Subsequent compression on nerve roots is called radiculopathy
• Subsequent compression on anterior spinal cord is called myelopathy, and associated with severe disc and facet degeneration such as kyphosis and spondylolisthesis (BONE slips out of place)

Question 4

What is the epidemiology of spondylosis: Age? Gender?

Answer 4

Mean age of cervical spondylosis is 48. Lumbar spondylosis has higher age of incidence. Incidence slightly higher in men.

Question 5

! What are the signs and symptoms of cervical spondylosis? (x9)

Answer 5

• Mostly asymptomatic
• ARTHRITIC CHANGES of the NECK: neck pain, stiffness with associated muscle pain and spasm
• Headache or occipital pain: referred pain
• NEUROLOGICAL COMPLICATIONS OF JOINT DEGENERATION: NOTE LMN CHANGES AT THE LEVEL OF COMPRESSION, UMN CHANGES BELOW THE LEVEL OF COMPRESSION (in myelopathy). As such, symptoms in the arm are LMN symptoms, and symptoms at the leg are UMN symptoms.
• Arm pain (does not radiate) – myelopathy is typically painless
• Arm weakness. Atrophy particularly of hand muscles seen.
• Arm paraesthesia
• Pseudoathetosis (writhing finger motions when hands outstretched, fingers spread and eyes closed) caused by loss of proprioception
• REFLEXES: decreased is a sign of radiculopathy; increased is myelopathy
• Hoffman’s sign: flexion of the thumb at DIP when rapidly extending DIP of 2nd or 3rd phalanx (elicited by flicking extended finger). NB: this is an UMN symptom
• LEGS: gait ataxia, increased tone, weakness, hyper-reflexia and Babinski sign. Decreased vibration and joint position sense

Question 6

How does muscle weakness differ depending on site of radiculopathy?

Answer 6

• C5: shoulder abduction and elbow flexion weakness
• C6: elbow flexion and wrist extension weakness
• C7: elbow extension, wrist extension and finger extension weakness
• C8: wrist flexion and finger flexion weakness

Question 7

What are the signs and symptoms of lumbar spondylosis? (x4)

Answer 7

• ARTHRITIC-RELATED PAIN: back pain with neurogenic claudication (activity-related).
• NEUROLIGCAL COMPLICATIONS:
• Leg pain AND lower extremity paraesthesia brought on by ambulation and relieved by sitting
• Shopping cart sign: leaning forwards (onto a shopping cart) relieves symptoms as spine flexion opens the canal
• Muscle weakness/wasting is rare and sign of advanced disease

Question 8

What are the investigations for spondylosis? (x3)

Answer 8

• X-RAY: degenerative changes (narrowing of disc spaces, osteophytes) and spondylolisthesis. Note that (asymptomatic) cervical spondylosis is normal in most elderly, so consider that symptoms may be caused by alternative pathology
• MRI: compression of the neural elements and soft tissue; the most accurate test for diagnosis and treatment purposes
• CT MYELOGRAM: intrathecal injection (subarachnoid space) of dye followed by CT shows ‘hour-glass’ constriction of spinal canal in stenosis and further assessment of bone anatomy