Week 4 - B - Cervical spine - Spondylosis, disc polapse, instability (Down Syndrome, Rheumatoid)

Question 1

What is spondylosis and which area of the spine is it most common?

Answer 1

Spondylosis is a degenerative disorder of the spine where the interveterbal discs lose water content with age (basically OA of the spine)

It is most common in the lumbar spine but can occur throughout the spine

Question 2

What does spondylosis lead to?

Answer 2

This results in less cushioning and increased pressure on the facet joints leading to secondary OA and the development of oteophytes

Question 3

What will patients with cervical spondylosis complain of?

Answer 3

Patients will complain of slow onset of stiffness and pain in the neck which can radiate locally to shoulders and occiput

Question 4

What is the mainstay of treatment in cervical spondylosis? (same as for mechanical back pain)

Answer 4

Mainstay of treatment is analgesia and physiotherapy

Question 5

What can the osteophytes that are formed in spondylosis cause? What is done for treatment?

Answer 5

The osteophytes can impinge on exiting nerve roots resulting in a radiculopathy involving the upper limb dermatomes and myotomes -

may require decompression for severe symptoms resistant to conservative management

Question 6

Acute and degenerative disc prolapse can also occur in the cervical spine producing neck pain and potentially nerve root compression What disc are typically involved in a cervical prolapse and which nerve roots at these disc would be affected?

Answer 6

Typically C5/6 and C6/7 intervetebral discs are involved in cervical disc prolapses

Typically it is the lower nerve root which is involved - eg

* C5/6 prolapse -> C6 nerve root compressed * C6/7 prolapse –> C7 nerve root compressed

Question 7

How can cervical disc prolapse causing nerve compression present?

Answer 7

Can present with

Neck pain

Patients complaining of shooting neuralgic pain (burning pain) down dermatomal distribution with weakness (myotomal distribution) and loss of reflexes depending on the affected nerve root

Question 8

A large central disc prolapse can compress the cord leading to a myelopathy

How would this present?

Answer 8

A myelopathy would present with upper motor neuron symptoms and signs below the level of the lesion

Question 9

How is a cervical disc prolapse diagnosed?

Answer 9

Clinical findings and MRI will aid diagnosis of the affected level and again for cases resistant to conservative management

Question 10

What is the problem with MRI investigations of the spine?

Answer 10

The problem with MRI is that the number of asymptomatic disc prolapses increases with age resulting in a higher rate of ‘false positives’ or ‘incidental finding’ on MRI scanning

Clinical findings should correlate with MRI findings before contemplating surgery.

Question 11

What is the treatment of a cervical disc prolapse? What is considered if first line treatment fails?

Answer 11

Conservative management is first line - analgesia and physiotherapy

If this fail to control symptoms, MRI and consideration of surgical decompression via discectomy

Question 12

Atraumatic cervical spine instability can occur in Down syndrome and rheumatoid arthritis. What cervical level are children with Down syndrome at risk of developing subluxation? What can this cause?

Answer 12

Children with Down syndrome are at risk of developing atlantoaxial (C1,2) instability with subluxation

This can potentially cause spinal cord compression

Question 13

How can screening be carried out for atlantoaxial instability in children with Downs? If there are minor degrees of instability, what may children be told to avoid?

Answer 13

Screening can be carried out with flexion-extension xrays - they can demonstrate the abnormal motion (high atlanto-dens interval)

If there are minor degrees of instability - possibly prevent children from high impact / contact sports

Question 14

If there is severe instbility on flexion-extension xrays in childrenw ith Down syndrome or the presence of abnormal neurology, what may be carried out as treatment?

Answer 14

Severe instability of the presence of abnormal neurology may require surgical stabilisation

Question 15

Why can atlatno-axial subluxation occur in rheumatoid arthritis?

Answer 15

Atlanto-axial subluxation can occur in rheumatoid arthritis due to destruction of the synovial joint between the atlas and the dens and rupure of the transverse ligament of the dens

Question 16

What can result from atlanto-axial subluxation in RA? What may less severe cases be treated with?

Answer 16

Atlanto axial subluxation, like in Down Syndrome, can result in cord compression which can be fatal

Less severe subluxed cases may be treated with a collar to prevent flexion of the neck

Question 17

What may severe C1/2 subluxation cases in RA be treated with?

Answer 17

C1/2 subluxation severe cases in RA may require surgical fusion

Question 18

In RA, atlanto‐axial subluxation occurs due to destruction of the synovial joint between the atlas and the dens and rupture of the transverse ligament. How can lower cervical subluxations occur in RA?

Answer 18

They can occur due to destruction of the synovial facet joint (between superior and inferior articular facet) and destruction of the synovial uncovertebral joints