Cervical Spondylosis

• This 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.

Prevalence

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.¹Both sexes are affected equally, but problems begin earlier in males.

Symptoms

• Occipital headache
• Radicular pain
• Sensory disturbances in the arms, weakness in extremities.

Signs

• Limitations to lateral flexion and rotation of neck.
• Segmental pattern of weakness and/or dermatomal sensory loss in upper limbs.
• Depressed tendon reflexes.
• Usually affects C5/6 nerve roots.
• May be spastic paraparesis if there is associated myelopathy and there can be concomitant posterior column or spinothalamic sensory loss in the legs.
• Spurling sign is when nerve root pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, which results in further foraminal compromise.
• Lhermitte sign is a generalised electrical shock sensation that is associated with neck flexion.
• The presence of a positive Hoffmann's reflex in asymptomatic patients strongly suggests underlying cervical pathology, but it does not warrant further evaluation with either cervical x-rays or MRI since the management and clinical course are not affected by positive studies. (Hoffmann's reflex is contraction of the thumb and index finger in response to nipping of the middle finger. A Hoffman sign may be insignificant if present bilaterally.)

• Plain X-ray of cervical spine showing formation of osteophytes, narrowing of disc spaces with encroachment of intravertebral foraminae - not diagnostic as common in normal middle aged patients.
• CT/MRI to exclude other causes.

Non-Drug

• Immobilisation of the cervical spine is the mainstay of conservative treatment for patients with cervical spondylosis. Immobilisation limits the motion of the neck, thereby reducing nerve irritation. Soft cervical collars are recommended for daytime use only, but they are unable to appreciably limit the motion of the cervical spine.
• Mechanical traction is widely used. This is useful because it immobilises the cervical region and widens the foraminal openings.³
• The use of cervical exercises has been advocated in patients with cervical spondylosis.⁴ Isometric exercises often are beneficial to maintain strength of the neck muscles.
• 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.
• Manual therapy e.g. massage, manipulation may provide further relief for patients with cervical spondylosis. Contra-indications include myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability, and vertebrobasilar insufficiency.

Drugs

• Analgesics. Simple e.g. paracetamol based or NSAID.
• Fluoroscopically guided therapeutic selective nerve root block.⁵

Surgical

Indications for surgery include progressive neurologic deficits, documented compression of the cervical nerve root, spinal cord, or both and intractable pain.
There are anterior and posterior approaches for surgery and a variety of procedures.

• If the pain is severe and unresponsive to conservative measures, and/or there is significant neurological deficit, anterior removal of disc material with spinal fusion⁶ is recommended.
• If several segments are involved laminectomy with foraminotomy⁷is advised.
• Partial corpectomy is used to treat multilevel cervical disc disease. It has a high fusion rate. By providing a good view of the dural interface it allows a complete decompression.⁸

A recent 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, at 1 year there was no significant difference between the groups. Another trial compared the effects of surgery with those of conservative treatment in patients who had a mild functional deficit. No significant difference was observed between the groups up to 2 years after treatment.⁹

Cervical spondylosis progresses slowly. It is a chronic joint disability, especially when it is associated with neuronal compression.
Large proportion of patients have long periods of remission or stabilisation of symptoms.
Cervical spondylotic myelopathy is the most serious consequence.
High-signal-intensity lesions on MRIs indicates a poor prognosis.¹