Cervical Spondylosis

What is Cervical Spondylosis?

Cervical spondylosis refers to a variety of progressively worsening changes that affect all parts of the neck’s spinal structure. This includes the spaces between the discs, the small joints in the vertebrae, and the ligaments and components that support the spine. It’s a natural part of aging and is found in most people over the age of 50.

The symptoms of cervical spondylosis usually appear as neck pain or stiffness, and sometimes can cause pain radiating from the neck to other parts of the body if the nerves in the neck get squeezed. Neck pain is a common ailment and the second most frequent reason people complain of pain, following low back pain.

Because neck pain caused by cervical spondylosis could lead to significant disability and cost, it’s crucial for healthcare professionals to identify the signs of this condition and provide effective and reasonable treatments.

What Causes Cervical Spondylosis?

Cervical spondylosis is a condition often linked to age-related wear and tear of the spinal disc and neck bones. As we age, changes occur in our spine and surrounding structure like joints, ligaments, and other spinal elements. These changes can lead to a narrowing of the spaces in the spine and openings between the spinal bones. As a result, pressure can be put on the spinal cord, blood vessels in the spine, and nerve roots. This can lead to cervical spondylosis showing up in three main ways: neck pain, a condition that affects the functioning of the spinal cord in the neck (cervical myelopathy), and a condition that affects the spinal nerve roots in the neck (cervical radiculopathy).

Certain factors can speed up the progression of cervical spondylosis or cause it to develop earlier in life. These include severe spinal injuries, having a naturally narrow spinal canal from birth, a type of cerebral palsy that affects neck muscles, and specific sports that put extra strain on the neck such as rugby, soccer, and horse riding.

Risk Factors and Frequency for Cervical Spondylosis

Many people have spondylotic changes, or wear-and-tear changes, in the cervical (neck) part of their spine, which can be seen on X-ray images. However, most of these people do not experience any symptoms. About 25% of people under 40, 50% of people over 40, and 85% of people over 60 show some signs of these degenerative changes.

The levels of the spine that are most frequently affected are C6-C7, followed by C5-C6. When symptoms do occur, the most common symptom is neck pain.

Studies show a wide range of neck pain in the general population, with some studies suggesting up to 86.8% of people may experience neck pain at some point in their lives. In fact, according to the Global Burden of Disease 2015 report, lower back and neck pain remain the major causes of years lived with disability and are the fourth major causes of disability-adjusted life years.

• Many people show spondylotic changes in their cervical spine but remain symptom-free.
• About 25% of people under 40, 50% of people over 40, and 85% of people over 60 have some signs of these changes.
• The most commonly affected areas are C6-C7, followed by C5-C6.
• When symptoms occur, they most commonly present as neck pain.
• The occurrence of neck pain in the general population is widely varied, with a potential lifetime prevalence of up to 86.8%.
• Neck and lower back pain are major causes of years lived with disability, according to the Global Burden of Disease 2015 report.

Signs and Symptoms of Cervical Spondylosis

When a patient presents with neck pain, doctors should focus on the pain’s timeline, its spread, what makes it worse, and what set it off. Neck pain could be a symptom of cervical spondylosis, a condition that affects the joints and discs in the neck. The condition might show in one of three ways:

• Axial Neck Pain
  With this type of pain, patients often report stiffness and pain in the neck which feel worse when they’re upright and improves when they rest. Movement, especially stretching and twisting, can increase the pain. Depending on the area affected, patients might feel pain radiating to the back ear/occiput or the upper back. Sometimes, patients may experience unusual types of pain such as jaw pain or chest pain, mimicking heart-related conditions.

• Cervical Radiculopathy
  This term refers to pain and other symptoms like numbness, that spread along the nerve pathway, often affecting one or both sides of the neck, arm, and upper back. The pain gets worse when the head tilts towards the affected side.

• Cervical Myelopathy
  This condition begins slowly and might not come with neck pain. It can first appear as a weakness and clumsiness in the hand, causing difficulty in performing intricate tasks such as buttoning a shirt or tying shoelaces. It might lead to walking instability and unexplained falls. In rare instances, urinary problems such as incontinence might occur but generally, this happens late in the progression of the disease.

On examination, a patient might appear stiff, especially in the neck due to worsening pain when the neck moves. Doctors often find tender “trigger” points in the shoulder neck, and upper back muscles. They can test cervical radiculopathy using the Spurling test, which is considered positive if there is pain radiating down the arm when extending and rotating the head to the affected side. In contrast, a positive Lhermitte’s sign, an electric shock-like sensation when the neck bends, is indicative of cervical myelopathy. Doctors would also look out for the Hoffman’s sign which is indicative of cervical myelopathy.

A physical exam usually checks for muscle strength, sensation, and reflexes in both arms and legs. Along with evaluating the patient’s gait and balance, these would help in identifying compromised nerve roots and possible cervical myelopathy. Tests include a toe-to-heel walk test and Romberg’s test. In the Romberg’s test, the patient stands with eyes closed, arms held forward, where increased imbalance indicates issues with the spinal cord.

The presence of signs like spasticity, over-reactive reflexes, sustained clonus (muscular twitching), extensor Babinski response (upward movement of the big toe and fanning of other toes), should alert doctors to possible spinal cord compromise. The grip and release test checks the hand’s motor function; a healthy individual should be able to make and release a fist 20 times in 10 seconds.

Testing for Cervical Spondylosis

If you’re experiencing neck and upper limb pain, your doctor may initially order X-rays as the first imaging test, especially if there are no alarming symptoms. However, even if the X-ray shows changes in the neck’s structure indicative of wear and tear, these might not fully explain the cause of the pain. The X-ray might reveal bony outgrowths, disc space narrowing, hardening of the joint ends, and changes in joints and soft tissues.

The X-ray images taken from different angles can help assess any narrowing of the passageway where nerve roots exit the spinal cord, the alignment of the neck, and the size of the spinal canal. One way to detect neck constriction is by comparing the front-to-back diameter of the spinal canal to the same diameter of the vertebral body (Torg-Pavlov ratio). If this ratio is less than 0.8, it may indicate constriction. If the doctor suspects any problems with the stability of the neck’s ligaments, they might request X-rays with the neck bent forwards and backwards.

Magnetic Resonance Imaging (MRI) is the recommended imaging option to examine nerve and soft tissue structures. MRI allows a detailed look at the neck without exposing you to radiation. Images taken in different planes can help determine the degree to which nerves and the spinal cord are compressed and identify potentially causing conditions, such as disc herniation, bony outgrowths, or joint issues. However, keep in mind that MRI studies should not be considered routine due to the frequent occurrence of degenerative findings in people without symptoms.

Computed Tomography (CT) provides a detailed view of bone structures and can detect narrowing of nerve passageways better than X-rays. However, CT is not as good as MRI at visualizing soft tissue and nerve compression.

In some cases, combining CT with a dye (myelogram) might provide a better view of nerve compression. This is slightly more invasive than MRI but might be considered for patients who can’t have an MRI, such as those with a pacemaker or metal implants.

A test called a discogram might be necessary in severe cases—mostly involving cervical disc pain or herniated discs—where surgery might be an option. Although, it’s worth mentioning that this diagnostic procedure remains controversial due to potential hastening of disc degeneration.

An electromyogram(EMG), which measures electrical activity of muscles, could be beneficial towards the diagnosis of nerve root compression and can also rule out other related nerve or muscle conditions.

Treatment Options for Cervical Spondylosis

The treatment plan for cervical spondylosis, which is a type of arthritis impacting the neck, varies based on how much it’s affecting a person. It’s important to ease pain, improve daily functional abilities, and prevent any permanent damage to the nerves. The treatment usually starts off without surgery.

Non-Surgical Treatment

Physical therapy for about a month or a month and a half is an important part of the non-surgical treatment. This includes various exercises to strengthen the neck and upper back muscles.

Medications like nonsteroidal anti-inflammatory drugs (NSAIDs), steroids taken by mouth, muscle relaxants, anticonvulsants (drugs used to prevent seizures), and antidepressants can be used to relieve pain. If neck pain remains severe, stronger pain medication may be considered – although this should be a last resort, as these can be habit-forming and come with side effects.

Some people also get relief from using special equipment. For example, using a soft neck brace for a short period of time can sometimes relieve severe neck pain and muscle spasms. Additionally, using a special pillow at night may help maintain the natural curve of the neck, distribute pressure evenly across the neck, and improve sleep quality.

Although certain physical treatments, such as neck traction, heat therapy, cold therapy, ultrasound, massage, and transcutaneous electrical nerve stimulation (TENS), were not found to be very effective in treating neck pain, if the pain radiates down the arms or legs, neck traction could help reduce pain by relieving pressure on the nerves.

Treatment options that are a little more invasive include different types of injections, such as trigger point injections to treat muscle knots that cause neck, shoulder, and arm pain or epidural steroid injections (ESIs) to reduce inflammation and pain.

Surgical Treatment

If non-operative measures fail, surgery should be considered for those with severely affected or worsening cervical myelopathy (a condition affecting the spinal cord), or persistent neck pain or pain radiating from the neck. The type of surgery depends on the individual’s conditions and the location of the problem.

The anterior approach involves removing a damaged disc or bone in the neck and then fusing the bones together, which can be done using a graft from the person’s body or an artificial one. Artificial plates, cages, or spacers can be used to hold it in place. The long-term effects of these techniques are still being evaluated. For individuals with pain due to disc herniation (when a disc slips out of its normal position), a surgery from the front of the neck (anterior approach) is preferred.

The posterior approach, done from the back, consists of either partial removal of disc or bone, or making the space within the spinal canal larger. It’s typically chosen if the bone spurs or herniated discs are located on the side of the cervical spine, or if decompression (taking pressure off the nerves) is needed at four or more levels or the front part of the neck is already fused. If the natural curve of the neck has been lost, additional equipment may be needed to help restore it and move the spinal cord backward after the pressure has been relieved.

What else can Cervical Spondylosis be?

Here are some health conditions that are important to consider when dealing with issues related to neck and upper body pain:

• Cervical sprain and strain
• Cervical myofascial pain (pain in the soft tissue)
• Cervical disc disease (problem with the cushions between the neck bones)
• Cervical fracture (broken neck bone)
• Chronic pain syndrome (long-term pain)
• Fibromyalgia (widespread pain and fatigue)
• Adhesive capsulitis (restricted movement in the shoulder)
• Brachial plexopathy (nerve damage in the upper spine)
• Thoracic outlet syndrome (compressed nerves or blood vessels in the lower neck and upper chest)
• Carpal tunnel syndrome (compressed nerve in the wrist)
• Cubital tunnel syndrome (compressed nerve in the elbow)
• Parsonage-Turner syndrome (sudden onset of shoulder and arm pain)
• Multiple sclerosis (disorder affecting the brain and spinal cord)
• Vitamin B12 deficiency
• Amyotrophic lateral sclerosis (ALS; a nervous system disease that weakens muscles)
• Guillain-Barre syndrome (a rare neurological disorder where your body’s immune system attacks your nerves)
• Vertebral metastasis (cancer spread to the spine)
• Discitis/osteomyelitis (inflammation of disc or bone in the spine)

What to expect with Cervical Spondylosis

Cervical spondylosis is a slow-moving disease that gets worse with age and is caused by wear and tear of the bones and tissues in the neck. However, the seriousness of the symptoms doesn’t always match with what we see in imaging tests (like MRI or CT scans). Some patients who have neck pain will see it get better over time, but the pain might come back. In a particular study, it was noted that 79% of people with neck pain got better or had no symptoms 15 years after they first started feeling the pain. However, half to three-quarters of people with current neck pain will likely have pain again 1 to 5 years later.

An interesting find from one 2008 study is that the strongest factors predicting neck pain were not physical, but psychological. Things like mental health, how a person deals with stress, and their social interactions really mattered.

Now, if you mostly have neck pain from cervical spondylosis, it’s unlikely that you’ll develop more serious problems like radiculopathy (nerve root inflammation causing pain, numbness or weakness) or myelopathy (spinal cord injury). For most people with cervical radiculopathy, their symptoms clear up within 1 to 2 years without the need for surgery.

On the other hand, the long-term outlook for cervical spondylotic myelopathy (damage to the spinal cord from narrowing of the spinal canal) is not as clear. In patients with mild to moderate symptoms, this disease can go in many directions: it might stay the same, or the symptoms might even improve. But if a person is showing signs of a steady decline in neurological function, severe symptoms, or significant spinal cord injury, surgery is likely to be more beneficial than just continuing with usual medical treatment.

Possible Complications When Diagnosed with Cervical Spondylosis

A 2019 study showed that some people experienced immediate and delayed side effects after getting an epidural steroid injection. The rate of immediate side effects was 2.4%, and the delayed side effects was 4.9%. These side effects can include some of the following:

• Nerve injury
• Spinal cord infection
• Blood clots in the spine
• Increased pain
• Fainting spells
• Reactions to steroids including facial redness and headaches
• Changes in hormone balance, including higher blood sugar, reduced stress hormone levels, and decreased bone density

Similarly, there can be many complications following neck surgery, whether the surgery is performed from the front (anterior) or back (posterior) of the neck. Some of the potential complications include:

• Injury to the spinal cord and nerves
• Infections
• Tears in the covering of the spinal cord resulting in leakage of spinal fluid
• Injury to the nerves controlling the voice, tongue, and swallowing
• Injuries to the esophagus leading to swallowing difficulties
• Injury to the arteries supplying the brain and the neck bones
• Injury to the windpipe
• Breakdown of the normal alignment of the spinal segments
• Failure of the neck bones to fuse together
• Curvature of the spine after surgery

Preventing Cervical Spondylosis

The condition known as cervical spondylosis, which affects the neck joints, can be quite unpredictable. It’s hard to prevent because it’s just a regular part of getting older. However, there are ways to potentially delay its onset. These include keeping your neck strong and flexible, living an active, healthy lifestyle, and preventing injuries to your neck.

Preventing neck injuries can involve things like:

• Using good body posture, especially if you sit a lot for work (this is known as ergonomics).
• Avoiding extending or straining your neck for long periods of time.
• Wearing the right equipment when playing contact sports.
• Using safe tackling techniques if you play sports like football.
• Always wearing your seatbelt when you’re in a car.

It’s also important for people to be aware of the different ways cervical spondylosis can be treated – both surgically (with an operation), and non-surgically (without an operation). Each method has its own benefits and risks which need to be considered.