Cervical Spondylosis

Cervical spondylosis is chronic cervical disc degeneration with herniation of disc material, calcification and osteophytic outgrowths.

• There may be compression, stretching or angulation of the cervical nerve roots.
• Myelopathy can also occur due to compression, compromised blood supply or recurring minor trauma to the cord.

After back pain, neck pain is the most frequent musculoskeletal cause of consultation in primary care worldwide.

Prevalence

• A UK study found that 18% had neck pain at the time of the survey, and half of those (58% of the symptomatic patients responded) still had pain when asked one year later.¹ It is the most common cause of spinal cord problems in patients older than 55 years.
• X-ray findings suggest that 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the cervical spine.² The boundary between normal ageing and disease process is difficult to define.³
• Both sexes are affected equally, but problems begin earlier in males.

Symptoms

• Cervical pain worsened by movement
• Referred pain (occiput, between the shoulder blades, upper limbs)
• Retro-orbital or temporal pain (from C1 to C2)
• Cervical stiffness—reversible or irreversible
• Vague numbness, tingling or weakness in upper limbs
• Poor balance

Signs

• Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides)
• Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy)
• Poorly localised tenderness

These symptoms identify the small number of patients who need magnetic resonance imaging, blood tests and other investigations.

Myelopathy

• Gait disturbance or clumsy hands, or both
• Objective neurological deficit—upper motor neurone signs in the legs and lower motor neurone signs in the arms
• Sudden onset in a young patient suggests disc prolapse

Other

• History of severe osteoporosis
• History of neck surgery
• Drop attacks, especially when moving the neck, suggest vascular disease
• Intractable or increasing pain

• Other non-specific neck pain lesions; acute neck strain, postural neck ache or whiplash
• Malignancy; primary tumours, secondary deposits or myeloma
• Infections; osteomyelitis or tuberculosis
• Mechanical lesions; disc prolapse
• Fibromyalgia
• Psychogenic neck pain
• Inflammatory disease; rheumatoid arthritis
• Metabolic diseases; Paget's disease, osteoporosis

Most patients do not need further investigation and the diagnosis is made on clinical grounds alone.

• Plain X-ray of cervical spine showing formation of osteophytes, narrowing of disc spaces with encroachment of intervertebral foraminae - not diagnostic as common in normal middle aged patients.
• Patients with neurological abnormality will need magnetic resonance imaging of the cervical spine at an early stage, particularly if they have progressive myelopathy, radiculopathy or intractable pain. High-signal-intensity lesions on MRI indicates a poor prognosis.²

There is little robust evidence to support many of the commonly used treatments. Most GPs will employ a 'wait and see' strategy, expecting a favourable natural course supported by medication, or referral to a physiotherapist.⁵

General measures

• Stress management and postural advice on daily activities, work, and hobbies may be useful in some patients.
• Application of heat to the tissues in the cervical region by superficial devices e.g. moist-heat packs, or mechanisms for deep-heat transfer e.g. ultrasound, diathermy.
• Patients should be advised to use only one pillow at night.

Mechanical

There is moderate evidence that various exercise regimens are more effective than general care and stress management, although not all studies have found exercise beneficial.⁶

• Yoga, pilates, and the Alexander technique all improve neck posture, but their value in treating neck pain is uncertain.
• The use of cervical exercises has been advocated in patients with cervical spondylosis.⁷ Isometric exercises are often beneficial to maintain strength of the neck muscles.
• Mobilisation, manipulation, and exercise seem to be equally effective. A study comparing combined exercise and manipulation with either modality alone found the combination to be more effective at three months, but no difference was seen compared with exercise alone at one and two years.
• There is no conclusive evidence about the effectiveness of acupuncture or traction compared with a range of other treatments in patients with chronic neck pain.⁸ Traction has been widely used, because it was thought to immobilise the cervical region and widen the foraminal openings.⁹

Pharmacological

• When pain is severe, analgesics and anti-inflammatory agents are widely used, despite the lack of evidence that they work. Low dose tricyclic antidepressants, like amitriptyline 10-30 mg per night, might be more effective.⁴

Surgical

Indications for surgery include progressive neurological deficits, documented compression of the cervical nerve root, spinal cord, or both and intractable pain.

• The outcome of decompressive surgery is often disappointing, especially for myelopathy complicating cervical spondylosis. While progression of the neurological deficit may be slowed by surgery, lost function may not recover or symptoms may progress at a later date. Poor outcome after surgery may reflect irreversible damage to the cervical cord or compromise to the vascular supply to the cord.⁴
• One randomised controlled trial in patients with cervical radiculopathy compared surgical intervention with physiotherapy or immobilisation. While the surgical group had less pain at three to four months, no difference was seen between the three treatment groups at one year.¹⁰
• A Cochrane review looked at the risk-benefit of surgical vs conservative management. The short-term effects of surgery, in terms of pain, weakness, or sensory loss were superior. However there was no significant difference between the groups at long term follow-up i.e. >1 year.¹¹
• Epidural injection in the cervical region is more invasive than in the lumbar region, and it should be considered in patients with severe intractable pain or radiculopathy only if surgical intervention is not an option.¹²

Radiculopathy (nerve root compression):

• Usually occurs at the C5 to C7 levels
• Sensory symptoms (shooting pains, numbness, hyperaesthesia) are more common than weakness
• Reflexes are usually diminished at the appropriate level (biceps - C5/6), supinator - C5/6, or triceps - C7)

Myelopathy:

• Causes clumsiness of the hands or gait disturbance, or both
• Bladder dysfunction is a late symptom
• Upper limbs may show increased tone
• Wasting and fasciculation of biceps (C5/C6) or triceps (C7) are occasional findings
• The lower limbs usually show an increase in tone with spasticity, but little true weakness

The best predictors of an unfavourable outcome one year after presentation with neck pain are severity of the initial pain and concomitant back pain.^13,14 At least 10% of affected people develop chronic neck pain, although this figure is much higher in some studies.

Cervical spondylosis progresses slowly. It is a chronic joint disability, especially when it is associated with neuronal compression.