Cervical spondylosis

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"cervical spondylosis"[MeSH Terms] AND management

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Cervical Spondylosis

Cervical spondylosis (also called cervical osteoarthritis or degenerative disc disease of the cervical spine) is a progressive degenerative condition involving the intervertebral discs, vertebral bodies, facet joints, and supporting ligaments of the cervical spine. It is the most frequently observed myelopathy in general practice.

Epidemiology

Peaks between ages 40 and 50 years; ubiquitous with increasing age - approximately 40% of people over 50 have some clinical cervical abnormality
Men affected more than women
C5-C6 most frequently involved, followed by C6-C7 (greatest mobility, greatest disc degeneration)
C5, C6, and C7 roots are those most commonly affected clinically

Risk factors: frequent lifting, cigarette smoking, history of excessive driving; patients with dystonia/cervical movement disorders are predisposed to premature degeneration

Pathoanatomy

Cervical spondylosis involves the interplay of the intervertebral disc and four other articulations:

Two uncovertebral joints of Luschka
Two facet joints (capsules contain sensory receptors involved in pain and proprioception)

The degenerative cascade (Kirkaldy-Willis) proceeds as:

Progressive disc collapse → loss of normal cervical lordosis → chronic anterior cord compression across a kyphotic spine
Subsequent loading of facet and uncovertebral joints → spondylotic foraminal narrowing → spinal cord and/or nerve root compression

"Soft" disc herniation - herniated nucleus pulposus without bony osteophytes; usually posterolateral, may cause acute radiculopathy; anterior herniation can rarely cause dysphagia

"Hard" disc herniation - HNP with disc-osteophytic spur; can cause cord/root compression

The mechanism of cord injury is intermittent compression and ischemia. During flexion/extension, the spinal cord is literally dragged over protruding osteophytes and hypertrophied ligaments. On neck extension, the cord is compressed between degenerative disc/spondylotic bar anteriorly and infolding ligamentum flavum posteriorly. A canal diameter of 7-12 mm (normal: 17-18 mm) produces symptomatic myelopathy; a congenitally narrow canal is a major predisposing factor.

Miller's Review of Orthopaedics, 9th Ed.
Adams and Victor's Principles of Neurology, 12th Ed.

Lateral Cervical X-ray - Typical Changes

Lateral cervical spine X-ray showing typical spondylosis and osteoarthritis changes

Lateral radiograph showing typical changes of cervical spondylosis and osteoarthritis - Bradley & Daroff's Neurology

Canal diameter on plain lateral radiograph (posterior vertebral body to spinolaminar line):

Category	Measurement
Normal	≥14 mm
Relative stenosis	10-13 mm
Absolute stenosis	<10 mm

Pavlov (Torg) ratio (canal width / vertebral body width): Normal = 1.0; ratio <0.8 is abnormal and a risk factor for neurologic involvement

Four Clinical Entities

Syndrome	Description
Discogenic neck pain	Axial pain from disc degeneration alone, no neurologic signs, occipital headache common
Radiculopathy	Nerve root compression - pain + sensory/motor deficits in a dermatomal/myotomal distribution
Myelopathy	Spinal cord compression - the most serious presentation
Myeloradiculopathy	Combined cord + root involvement

Clinical Features

The Characteristic Triad of Myelopathy

Painful, stiff neck with pain in neck, shoulders, upper arms (brachialgia) - aching or radicular, evoked by movement
Numbness and paresthesias of the hands - "wearing gloves," "swollen," or "coated with glue"; may involve digits, palm, or a band along the forearm
Spastic leg weakness with Babinski signs, unsteadiness of gait, and a Romberg sign

Additional sensory features: impaired vibratory sensation and diminished position sense in feet (posterior column signs), a "tabetic" unsteadiness; Lhermitte symptom (electrical feelings down the spine on neck flexion); rarely a Brown-Séquard pattern.

Bladder dysfunction (frequency, urgency, urgency incontinence) indicates need for imaging.

Radiculopathy by Level

Disc Level	Root	Pain/Sensory Distribution	Motor Weakness	Reflex Loss
C4-C5	C5	Shoulder, outer upper arm	Deltoid, biceps, brachioradialis	Biceps, supinator
C5-C6	C6	First two digits, lateral forearm	Brachioradialis, wrist extensors	Biceps, brachioradialis (may be inverted)
C6-C7	C7	Index, middle, ring fingers	Triceps, wrist flexors, pronators	Triceps

Note: Spread of biceps reflex to finger flexors, an increased triceps reflex, or a paradoxical biceps reflex signals concurrent myelopathy.

MRI: Spondylotic Myelopathy

Sagittal T2 MRI of the cervical spine showing cord compression at C5-C6

Sagittal T2 MRI: severe spinal cord compression at C5-C6 interspace with faint T2 hyperintensity within the cord, indicating advanced myelopathy - Adams & Victor's Neurology

MRI features supporting spondylotic cord compression:

Clear deformation of the cord into a "kidney bean" shape
Obliteration of surrounding CSF spaces in transverse images
Intrinsic T2 signal changes within the cord at or within half a segment of compression (indicates some irreversibility)
"Pancake-like" gadolinium enhancement at/just caudal to site of maximal compression

Diagnosis

MRI is the imaging study of choice - identifies nerve root compression, causes of myelopathy, and disc herniation. Must be interpreted with caution as degenerative changes are extremely common in asymptomatic spines.

CT myelography is preferred when:

MRI-incompatible hardware (pacemakers, SCS)
Prior cervical fusion surgery (hardware artifact)
Severe claustrophobia
Need to distinguish non-calcified disc from osteophytes

EMG/NCS in cervical radiculopathy: loss of CMAP amplitude on affected side with preserved SNAP (characteristic - intraspinal lesion proximal to DRG). Useful to exclude brachial plexopathy or peripheral neuropathy.

Plain cervical radiography is of little value in diagnosing or excluding radiculopathy.

Differential diagnosis of myelopathy:

Spinal multiple sclerosis (oligoclonal bands, optic nerve/brain lesions)
ALS (widespread denervation, no sensory symptoms, progressive)
Subacute combined degeneration (B12 deficiency - symmetric)
Normal-pressure hydrocephalus (Romberg sign absent, magnetic gait)
HTLV-I myelopathy, HIV myelopathy
Ossification of the posterior longitudinal ligament (OPLL)
Spinal cord tumor

Treatment

Conservative (Non-operative)

Appropriate for mild symptoms, radiculopathy without significant neurologic deficit, and discogenic neck pain:

Soft cervical collar (limits harmful neck movement, especially extension)
Cervical traction
NSAIDs and analgesics
Physical therapy - cervical strengthening, posture correction
Fluoroscopically guided cervical nerve blocks (for radiculopathy)
Activity modification - avoid activities that extend or compress the neck

Surgical Indications

Cervical myelopathy - surgery is generally indicated to halt progression; conservative management alone carries risk of irreversible cord damage
Radiculopathy not responding to conservative measures (6-12 weeks)
Progressive neurologic deficit
Significant cord compression on imaging with symptoms

Operative approaches:

Anterior - Anterior cervical discectomy and arthrodesis (ACDA/ACDF): Robinson approach; ideal for 1-2 level disease, anterior compression
Posterior - Laminectomy, laminoplasty: for multi-level disease, preserving motion; expansive laminoplasty particularly for radiculomyelopathy
Disc arthroplasty - alternative to fusion for single-level disease, preserves motion

Important caveat: Cervical spine surgery for degenerative pathology is rarely if ever indicated purely for headache or neck pain in the absence of radiculopathy or myelopathy.

Sources: Bradley and Daroff's Neurology in Clinical Practice; Adams and Victor's Principles of Neurology, 12th Ed.; Miller's Review of Orthopaedics, 9th Ed.

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