Cervical spondylosis

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1. CERVICAL SPONDYLOSIS AND ITS MANAGEMENT DR. NIRAJ KUMAR , PT BPT, MPT (ORTHO), MHA, Ph.D. Physiotherapy (Orthopedics)* Associate Professor Physiotherapy Dept. Shri Guru Rai Institute Of Paramedical Sciences , Dehradun

2. ANATOMY The cervical vertebral column consists of seven vertebrae in total. Morphologically and functionally, the cervical column is divided into two distinct regions: the upper cervical spine, or craniovertebral region, and the lower cervical spine. The craniovertebral region includes the occipital condyles and the first two cervical vertebrae C1 and C2 , or, respectively, the atlas and axis . The lower cervical spine includes the vertebrae of C3 to C7 . All of the cervical vertebrae have the unique feature of a foramen (transverse foramen) on the transverse process, which serves as passage for the vertebral artery. Many ligaments hold these vertebrae together. These are anterior & posterior longitudinal ligaments,ligamentum flavum , supraspinous ligament, interspinous ligament and ligamentum nuchae .

3. ininter Intervertebral Disc Between two adjacent vertebrae, caudally from C-2, there are found intervertebral disks. Each disk is composed of an annulus and a nucleus. The superior and inferior borders of the disk are the cartilaginous endplates of the adjacent vertebrae Fissures in the disk develop along with the uncinate processes and become clefts by approximately 9 years of age. These clefts become the joint cavity of what has been known as the uncovertebral joints or “joints of Luschka . Muscles of the Cervical Spine The neck muscles can be divided functionally into two mjor groups: Those that flex and extend the head upon the spine [Capital movers] Those that flex and extend the entire remaining cervical spine[Cervical movers].

4. BIOMECHANICS Atlanto -occipital and Atlantoaxial Joints Anatomy The atlanto -occipital joint is composed of the right and left slightly concave superior facets of the atlas (C1) that articulate with the right and left covex occipital condyles of the skull. The atlantoaxial joint is composed of three separate articulations: the median atlantoaxial and two lateral joints. Osteokinematics The atlanto -occipital joint is a plane synovial joint that permits flcxion·cxtension , some axial rotation, and latcral flexion. The range of motion in flexion is 10 degrees and the range in extension is 30 degrees.Lateral flexion is approximately 10 degrees. The two lateral atlantoaxial joints are plane synovial joints.The median atlantoaxial joint is a synovial trochoid (pivot) joint. The motions permitted at the three atlantoaxial articulations are flexion-extension, lateral flexion, and rotation.

5. Arthokinematics At the atlanto -occipital joint, the inferior convex condyles of the occiput articulate with the two superior concave zygapophyseal articular facets of the lateral bodies of the atlas. In flexion, the condyles glide posteriorly on the atlas articular surfaces. In extension the occipital condyles glide anteriorly on the atlas, whereas the back of the head moves posteriorly . At the lateral atlantoaxial joints the inferior zygapophysial articular facets of the atlas are convex and articulate with the superior concave articular facets of the axis. At the median joint the atlas forms a ring with the transverse ligament of the cruciate ligament and this ring rotates around the dens ( odontoid process) which serves as a pivot for rotation.

6. Intervertebral and Zygapophyseal Joints Anatomy The intervertebral joints are composed of the superior and inferior surfaces of the vertebral bodies and the intervertebral discs. The zygapophyseal joints are formed by the right and left superior articular facets (processes) of one vertebra and the right and left interior articular facets of an adjacent superior vertebra . Osteokinematics The intervertebral joints are cartilaginous joints of the symphysis type. The zygapophyseal joints are synovial plane joints. Arthrokinematics The intervertebral joints permit a small amount of sliding and tilting of one vertebra on another. The zygapophyseal joints permits small amount of sliding of the right and left inferior facets on the right and left superior facets of an adjacent inferior vertebra.  

7. INTRODUCTION Spondylosis is a term for a condition of pathologic change in the spinal column. The term has several synonyms such as degenerative disc disease, degenerative spondylosis and spondylitis deformans . Cervical spondylosis refers to an osteoarthritic degeneration of the cervical spine. “Wear and Tear” due to years of motion and activity is the common etiology for the cause of degeneration to occur in cervical spine. Usually in patients having cervical spondylosis, there is a history of faulty posture, prolonged immobilization after injury or severe repetitive trauma. The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5.

8. In the majority of cases, patients present between the ages of 40 and 60 shows cervical spondylosis with men being more commonly affected than women at a ratio of 3:2. Three distinct clinical syndromes can result from cervical spondylosis: Type I Cervical Radiculopathy, Type II Cervical Myelopathy and Type III Axial Joint Pain (neck pain). Spondylosis is a term applied to changes noted in the spine of radiologically significant: Narrowing of the disc height, Presence of osteophytes arising from the disc margins and Osteoarthritic changes in the posterior zygapophyseal joint. It is generally felt that the initial management should be nonoperative, and these modalities include physiotherapy, analgesia and selective nerve root injections. Surgery should be reserved for moderate to severe myelopathy patients.

9. EPIDEMIOLOGY Frequency Cervical spondylosis is a common condition that is estimated to account for 2% of all hospital admissions. Mortality/Morbidity The course of cervical spondylosis may be slow and prolonged, and patients may either remain asymptomatic or have mild cervical pain. Morbidity ranges from chronic neck pain, radicular pain, diminished cervical range of motion (ROM), headache, myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis in advanced cases. Sex Cervical spondylosis usually starts earlier in men than in women.  Age Symptoms of cervical spondylosis may appear in persons as young as 30 years but are found most commonly in individuals aged 40-60 years.

10. AETIOLOGY Causes of Cervical spondylosis Cervical spondylosis often develops as a result of changes in the neck joints as age advances at about age of 40 years and onwards. Another cause may be a old injury to the neck and poor posture. By holding neck position uncomfortably for lengthy periods or repeating the same neck movements. People who are very active at work or in sports and certain long term activities, such as carrying axial loads, professional dancing and gymnastics and participation of martial arts for many years are more prone to get cervical spondylosis. Being overweight and not exercising properly quicken this disease. Over load activities that requires heavy lifting or a lot of bending and twisting, put extra strain on the neck. One more cause is long ago spine surgery, ruptured or slipped disk, severe arthritis and petty fractures to the spine due to osteoporosis.

11. PATHOPHYSIOLOGY It is this physiological degenerative cascade that contributes to the biomechanical changes that can cause neural and vascular compression, pain, and loss of function.

12. RISK FACTORS Age >40 years: Population-based MRI studies show nearly 100% of adults aged >40 years have severe degeneration of at least 1 cervical level (commonly C5/6). Head or neck trauma: May accelerate the disc and facet degeneration process.   Previous cervical spine surgery: May predispose adjacent joints to accelerated degenerative changes.   Previous cervical myofascial strain: A previous soft-tissue injury to the neck may have resulted in a cervical myofascial strain, which can predispose to the same types of axial cervical pain symptoms as seen from degenerative changes alone. Genetic predisposition: Both cervical degenerative changes and cervical spondylotic myelopathy show a tendency for genetic predisposition.

13. CLINICAL MANIFESTATIONS There is no simple, accepted aetiological classification, but symptoms cluster into 3 clinical syndromes. Many patients with radiographic cervical spondylosis show no symptoms. Symptoms include: Axial neck pain, which includes reduced motion of the cervical spine, paraspinal muscle spasm, and referred pain, similar to other joints of the body. Cervical spondylotic radiculopathy (CSR), a specific syndrome of radiating arm pain following a single cervical nerve root distribution that arises from mechanical compression and or chemical irritation of that specific nerve root, usually at its exit from the spinal canal. Cervical spondylotic myelopathy (CSM), a specific syndrome of neurological deficit in the upper and lower extremities resulting from spinal cord pressure in the cervical spine, due to degenerative changes in disc and/or facet joints .

14. INVESTIGATIONS

15. DIFFERENTIAL DIAGNOSIS

16. MEDICAL MANAGEMENT The goals of drug therapy in patients with Cervical spondylosis are to relieve pain and decrease inflammation when it is present. Oral analgesics, NSAIDs, and corticosteroid injections are the primary medications used . DRUG MANAGEMENT 1.NSAID:- Diclofenac potassium ( Cataflam ), Diclofenac sodium ( Voltaren , Voltaren XR), Diclofenac sodium , Ibuprofen, Indomethacin , Piroxicam 2. ANTACIDS:- pantoprazole and rabeprazole , Aluminum and Magnesium Hydroxide Oral Suspension , Ranitidine , Zantac , Zoton 3. Calcium therapy with vitamin D3 4. Common Muscle Relaxant Medications Baclofen, Chlorzoxazone , Carisoprodol , Cyclobenzaprine, Metaxalone , Methocarbamol , Tizanidine

17. DRUGS USED IN PERIPHERAL NEUROPATHY Methylcobalamin : - Methylcobalamin , also known as Methyl-B12 or Mecobalamin , is a form of the common vitamin B12. It differs from typical B12 in that it has an additional methyl group, and contains metal-alkyl bonds. It supports nerve function and neuron health in the brain and contributes improved signalling in the central nervous system. This is especially true in patients who have degenerative neurological conditions such as those that affect the myelin sheath like multiple sclerosis (MS ). Gabapentin:- A nti-epileptic drug, also called an anticonvulsan . Gabapentin is used in adults to treat neuropathic pain (nerve pain)caused by herpes virus or shingles (herpes zoster ). 6. Chemonucleolysis : Dissolution of the Nucleus Pulposus by percutaneous injection of a proteolytic enzyme ( chymopapain ). This enzyme has the property of dissolving fibrous and cartilaginous tissue.

18. SURGICAL MANAGEMENT Surgery is not appropriate , however , for every individual with cervical spondylosis, and the careful selection of the patient and the timing of the procedure are critical. The primary indications for surgery are pain, loss of function, and progression of deformity. Operative Techniques 1 . Anterior decompression and fusion 2 . Posterior approach

19. PHYSIOTHERAPY MANAGEMENT The Goals of the Treatment To relieve pain To provide support to the neck To improve or restore the neck movements To re-educate the patient for posture correction To strengthen the cervical muscles To decreases muscle stiffness To decrease consumption of pain medication and muscle relaxants To analyse the basic precipitating causes of the patient's problem and aim at alleviating those causative The Techniques of the Treatment Heat Therapy Cold Therapy Electric Muscle Stimulation Transcutaneous Electric Muscle Stimulation Exercise Therapy Soft Tissue Mobilization Postural Awareness Relaxation Cervical Traction Neck Support

20. Acute Stage:- Conservative Management :- Aim of physiotherapy- -- ► To accelerate healing . ► To relief pain. ► To restore mobility. ► To restore posture & strength ► Prevention ► To accelerate healing :- ●Rest:- 1 – 2 days but in severe cases 7 to 10 days (1 to 2wks.) ● Corset or Cervical belt ( Cerival belt). ● If severe disabling pain crutches are advised ● Elastic adhesive strapping applied over the neck to immobilised the spine. It should be used up to 10 days & replace the tape 2 to 3 times.

21. ► To relief pain:- 1. Traction :- ICT is used for relives intradiscal pressure & increase the disc space. 2. Electrotherapy modalities--- Cryotherapy : Reduces muscle spasm and inflammation in acute phase. TENS: Relieves pain in both acute and chronic phases. UST: As phonophoresis increases extensibility of connective tissues Moist heat: used as an adjunct before applying specialised techniques to decrease muscle spasm. SWD - Pulsed SWD in acute condition and continuous SWD in chronic cases for 20 to 25 mints . LWD Pulsed SWD in acute condition and continuous SWD in chronic cases. 08 to 12 mints. IFT – 20 to 25 mints LASER :- Laser therapy treatment is very advance method for pain relief and decrease inflammation,

22. ► To restore mobility. 1. Mobility exe.:- Mobility exe. of cervical can also include. 2. AROM exercises within pain free range to the cervical can be done except flexion Maintain / improve mobility of neural tissues- ULTT-1,2,3 & 4 ► To restore posture & strength a) Cervical Isometric exe:- Neeraj K et al (2016). Isometric Strengthening Exercise The patient was in sitting position. These were initially done with the neck in neutral postures and with a therapist resisting flexion, extension, lateral flexion and rotation by the therapist. Contraction were held for 5 seconds/repetitions and repeated 10 times, with 3 seconds rest in between them. These exercises were done for 2 sets with 1 to 2 minutes rest in between each set.

23. Neeraj K et al (2016). McKenzie Exercise McKenzie exercise is one of the numerous techniques used by physical therapists to assess and treat patients. McKenzie exercise used in the form of neck retraction exercise. The patient is instructed to move the head backwards as far as possible but at the same time maintain forward facing position. It is important that the movement is made to the maximum. On completion the patient returns to the neutral rest position. The movement is done for four sets of 10-15 repetitions with 1-2 minutes rest between each set. Prevention & Postural Correction The patients in all groups were given postural correction and postural awareness as home program. The postural correction was recommended as axial extension or neutral neck position. These were done to correct neck position for patient with neck pain and spasm of upper trapizius . The postural awareness program consists of the following points

24. Reading Posture 1.Neck should not be kept in one position for prolong time. 2.Adjust the height of reading table such that the books are at the level of eyes and arms are comfortably place. Avoid slouching lower back and shoulders. Sit tall with whole back against chair back and head erect. 3.Computer and TV screen should be at proper height and distance. Position & height of monitor should be within 20 . Sleeping Posture 1.Avoid big pillows: they make neck rest higher than body causes it to bend forward. 2.Use pillows of adequate height that aligns the head and neck at the same level of body. The pillows should support the head and neck fully and should extend up to shoulders.

25. PROGNOSIS Axial neck pain Many patients with severe cervical spondylosis (on radiographic studies) have no axial neck pain. Patients presenting with axial neck pain typically improve over time, although the pain may recur and may be severe. The patient may need lifelong pain management treatment if the pain is persistent and prolonged.   Cervical spondylotic radiculopathy Cervical radiculopathy eventually resolves in most patients over 1 to 2 years if not treated surgically. The role of surgery is therefore primarily to speed up or enhance the natural degree of recovery, particularly if the patient has severe pain.   Cervical spondylotic myelopathy Once patients undergo adequate decompressive surgery, their neurological function typically stabilises for many years.

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