Cervical Spondylosis

Dominique Wilson

Description

Cervical spondylosis is a disorder in which there are degenerative changes in the cartilage, discs and bones of the neck (cervical vertebrae). These changes can eventually lead to the development of cervical osteoarthritis and bone spurs.¹

Overview of Cervical Spondylosis

Anatomy

The cervical spine is searated into two groups. The upper and the lower cervical spine. The upper cervical spine is C0-C2 and the lower cerival spine is C3-C7.²
The cervical spine consists of :

7 vertebraes: C1-C7
6 discs: C2-C7
8 nerves:C1-C8
8 joints C0-C7

C0 and C1 together are called the atlanto-occipital joint. There is approximatel 15⁰ to 20⁰ of flexion-extension and 10⁰ of side flexion there is no rotation at this joint.²
C1 and C2 are called the Atlas and the Axis respectively. Together they are called the atlanto-axial joint. There is approximately 10^o of flexion-extension and 5⁰ of side flexion and 50⁰ of rotation, is which is the primary movement.²

Basic Anatomy

Indications

Indications for patients with cervical spondylosis can range from mild to severe.
Some of the most common indications are:

a stiff, painful neck-may worsen with activity
headaches
grinding and/or popping sound/feeling with movement
shoulder, arm and/or chest pain-muscle spasms
tingling sensations in your arms, hands, legs or feet
numbness and weakness in arms, hands, legs or feet
abnormal reflexes
lack of coordination
difficulty walking, loss of balance, or weakness in hands or legs
loss of bladder or bowel control, or urinary or bowel retention³,⁴

Incidence/ Prevalence

Cervical Spondylosis is a very common disorder. Many people have cervical spodylosis that has yet to be diagnosed. It accounts for approximately 2% of hospital admissions.⁵ It can be seen in people as early as 25 years of age.² As age increases so does the incident rate. 60% of the population older than 45 years of age and 8% older than 65 years of age account for the case of cervical spondylosis reported.² It is not usually till the age of 60 and older that osteoarthritis will appear.² Cervical Spondylosis affects both men and women.³It can start in men earlier than in women; 90% of men over the age of 50 and 90% of women over the age of 60 show degeneration in the spine.⁵

Clinical Presentation

A patient diagnosed with cervical spondylosis will have complaints of pain and stiffness, primarily in the lower cervical spine. Pain and stiffness are both episodic and usually varies with time (days and weeks).²The patient's pain and stiffness will generally present at the end of the day and espcially when the head is held in a specific position(usually in extension). The pain and stiffness are unilateral and localized, and not necessarily simultaneously. The patient will also have complaints of 'bouts of pain, where the pain is intermittent, dull and achy. The achy pain usually radiates across the base of the neck and back of shoulders.⁶ There is also a slow onset of pain. The patient will also complain of waking up during the night while sleeping.⁶ There will also be stiffness in the morning.⁶ The patient can present with neural symptoms (tingling and numbness) in the upper traps and arms depending on amount of degeneration and compression of nerve roots. The patients can also present with a dowager's hump (swelling at the base of the neck), and pain with rotation and lateral flexion at end range.⁶ Cervical spondylosis can also be asymptomatic and may not necessarily need treatment.² In the more severe cases cervical spondylosis can lead to a patient complaining of a clumsy walk (out of the norm) and bowel and bladder problems.^1,5,6

Presentation

Potential Etiologies

Congenital

Genetics - there is a family component of neck pain that can relate to neck pain.^2,4

Indirect Trauma

Smoking - clearly linked to increased neck pain but there isn't enough research on this yet.
Occupational - jobs with excesssive neck motion and a forward head position.
Mental health issues - depression/anxiety can increase tension therefore incresing neck pain.^2,4

Direct Trauma

Direct Injuries/trauma - accidents and direct blows to the neck.^2,4

Diagnostic Tests

X-rays-first step in imaging the spine. Aging changes will show up on x-rays when there is approximately 40% of degeneration. It can show loss of disk height or bone spurs.
Magnetic resonance imaging (MRI)-create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord.
Computed tomography (CT) scans-is a specialized x-ray that gives images of the bone and spinal canal.
Myelography- specific x-ray study involves injecting dye or contrast material into the spinal canal. It gives images of the spinal canal and nerve roots.
Electromyography (EMG)-looks for nerve damage or pinching, by measuring the activty in nerves as messages are transmitted to muscles.
Nerve conduction study-measures the speed and strength of te nerve, attaching externally.^3, ^4,⁵

Evaluation/Special Orthopedic Tests

Range of Motion neck flexibility- observe how the cervical spines moves,look for limitations in each direction and trying to find the comparable sign.
Quadrant tests-if unable to find comparable sign this test is the next step in trying to find the comparable sign.
Vertebral Artery Test- this test is done to eliminate vertebral artery involvement. Specificity of rotation to the right is 86% and to the left is 67%.
Neurological exam (as needed-if pain was-dermatomes, myotomes, and reflexes. Look for dimished sensation and neuromuscular deficits.
Alar ligament and Transverse ligament test- test for instability of the upper cervical spine.
Spurling sign - used to look for radicular comparable pain when neck is in extension and lateral flexion toward the lesion(foraminal encroachment). Specificity is 92%for neurologic and radiologicc signs.
Lhermitte sign - used to look for comparable sign in neck extension.
Hoffman sign - looks for a reflex contraction of the thumb and index finger occurs in response to nipping of the middle finger. This sign is evidence of an upper motor neuron lesion. A Hoffman sign may be insignificant if present bilaterally. (Corticospinal tract lesion.^2,3,5

Transverse Ligament Test

Alar Ligament Test

Conservative Treatment

Conservative Treatment for Cervical Spondylosis listed below progresses based on severity of symptoms.^1,3,4

Soft Collars
Ice, heat
Medications:

Acetaminophen
Non-steroidal anti-inflammatory drugs (NSAIDs).
Muscle relaxants.

Physical therapy-2 to 3 times a week for 6 to 8 weeks

strengthening
stretching
mobilizations (pain- grades I and II, stiffness- grades III and IV)
traction

Steroid-Based Injections

Cervical epidural block
Cervical facet joint block.
Medial branch block and radiofrequency ablation^1,3,4

Cervical Epidural Block

Used for severe neck and arm pain from disc or pinched nerve problems, the injections is placed in the epidural space.

Cervical Facet Joint Block

The injection is placed in the capsule of the facet joint, where arthritic changes take place causing neck pain.

Medial branch block and radiofrequency ablation

The injection is placed in the nerve that supplies the facet joint.

Surgery & post-op treatment

Surgery is usually the last option, when the paitent has tried all conservative treatment and they have failed to improve symptoms and/or neurplogical symptoms are very severe. The most common approaches are the anterior and posterior approach. These approaches are usually done to remove bone spurs and to fix stenosis but can also involve other procedures. After bone spurs are removed by the anterior aprroach a spinal fusion can be done. A spinal fusion permanently fuses two bones together making them immobile. A laminectomy is usually done by the posterior approach. It is the removal of the lamina, which then takes pressure off the spinal column or nerve roots. A laminoplasty can done in place ofthe laminectomy. A laminoplasty leaves the neck more stable. The posterior approach is used for a foraminotomy as well. This is to widens the opening in your back where nerve roots leave your spinal column.^1,⁷

Anterior cervical fusion

Laminectomy

Patient should avoid:^1,6,7

high impact extension
holding the head in 1 position for a long period
prolonged neck extension

Physical Therapy Treatment: 2X per week for 4 to 6 weeks⁶

cervical rom
gentle stretching at first then increase gradually
gentle strengthen at first then gradually increase (upper traps and other neck extensors)
apply heat
scar mobilization
e-stim for pain relief
wound care
cervical joint mobilizations Grades I and II for pain and III and IV for stiffness^1,5,7
thoracic joint mobilizations
upper trap stretching and strengthening⁶

Alternative/Homeopathic Treatments

Modalities⁸

Although cervical spondylosis is a disorder in which there are degenerative changes in the cartilage, discs and bones of the neck, these degenerative changes can also affect the muscles of the neck. The most common symptom of cervical spondylosis is pain. Physical Therapy is usually done to treat the pain; it is not a cure for the disease.
The most common modality used to treat the pain is traction. The effects of traction are: joint distraction, reduction of disc protrusion, soft tissue stretching, muscle relaxation, and joint mobilization. The force and the total time of traction depend on the goal of the treatment. For initial/acute phase the force should be 13-20 kg (29-44 lbs), static hold and patient should be on traction for 5 to 10 minutes. For joint distraction force should be 22.5kg (50 lbs)/50% of body weight, 15 seconds of hold 15 seconds of relaxation, and total time on traction 20 to 30 minutes. To decrease muscle spasm force should be 25% of body weight, 5/5(hold/relax) in seconds, and total time of traction is 20 to 30 minutes. For disc problems or to stretch soft tissue force should be 25% of body weight, 60/20 (hold/relax) in seconds, and total time on traction is 20 to 30 minutes.The spondyloptosis can be reduced with closed cervical traction.⁹
Cryotherapy is also a common modality used to treat symptoms of cervical spondylosis. Cryotherapy can be used during an acute flair up of symptoms due to an acute injury. Cryotherapy is used to decrease pain, inflammation and spasticity. The most common application of cryotherapy for cervical spondylosis is an ice pack. One of the major benefits of cryotherapy is that it can increase a patient’s pain threshold which in turn can decrease the sensation of pain. The contraindications of cryotherapy are; cold hypersensitivity, cold intolerance, cryoglobulinemia, paroxysmal cold hemoglobinuria, raynaud’s disease or phenomenon, over regenerating peripheral nerves, and over an area with circulatory compromise or peripheral vascular disease. A few precautions to be aware of are; over a superficial main branch of a nerve, over an open wound, hypertension, poor sensation or poor mentation, and very young or very old patients.
Thermotherapy helps control pain; increase soft tissue extensibility, increase circulation, accelerate healing, increase range of motion and decrease joint stiffness. The most common application of thermotherapy for cervical spondylosis is a moist heat packs. There should be approximately eight layers between the hot pack and skin. Thermotherapy can also increase pain threshold. The contraindications are; recent or potential hemorrhage, thrombophlebitis, impaired sensation, impaired mentation, malignant tumor, and IR irradiation of the eyes. A few precautions of thermotherapy are; acute injury/ inflammation, pregnancy, impaired circulation, poor thermal regulation, edema, cardiac insufficiency, metal in the area, over an open wound, over areas where topical counterirritants have recently been applied, and demyelinated nerves.
Electrical current is also a common modalities used to treat the symptoms of cervical spondylosis. The most common form used is transcuatneous electrical nerve stimulation (TENS). The type of TENS used to treat pain is conventional/high-rate. The pulse frequency is 100 to 150 pps, pulse duration 50 to 80 µs, amplitude should produce tingling, treatment time- may be worn 24 hours, or as needed for pain control, and the possible mechanism of action is gating the spinal cord. Some contraindications are; cardiac pacemaker or unstable arrhythmias, placement of electrodes over carotid sinus, areas where venous or arterial thrombosis/thrombophlebitis is present and pregnancy-around the abdomen or lower back. A few precautions are cardiac disease, impaired mentation, impaired sensation, malignant tumors, and open wounds/skin irritation.

Additional Web Based Resources

Footnotes

Wednesday 2 March 2016

Cervicl Spondylosis

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