Cervical spondylosis and cervical radiculopathy

Cervical spondylosis

1. CERVICAL SPONDYLOSIS Dr. B.Sumanth 2nd yr Post graduate Department of Orthopaedics.

2. Relevant anatomy Total 7 cervical vertebrae C1,C2- atypical and C3-C7- typical vertebrae. Unique features of cervical vertebrae:- 1. Vertebral body - smaller , uncovertebral joint 2. Transverse process- transverse foramen 3. Spinous process- bifid 4. Vertebral foramen- triangular 5. Articular process- facet joint.

3. Unique features of 1st cervical vertebrae (atlas) :- Shape - ring shaped No body, no spine Anterior arch is short, posterior arch is long. Two sets of lateral masses. Unique features of 2nd cervical vertebrae (axis) :- Dens/Odontoid process, it fuses with superior part of the body. Lamina - thick and strong Pedicel- upwards and laterally Spine- large,thick and bifid

4. What is it ? Cervical spondylosis also known as cervical osteoarthritis is the result of age related progressive degenerative changes in the cervical spine, inclusive of disk degeneration, facet arthropathy, osteophyte formation, ligamentous thickening and the loss of cervical lordosis. Narrowing of spinal canal, also known as spinal stenosis may develop as a result of the spondylotic changes. The spinal cord and/or nerve root functions may be negatively affected, resulting in symptoms of myelopathy or radiculopathy.

5. Incidence Cervical spondylosis usually appears in men and women older than 40 yrs and progresses with age. 85% of patients >65yrs of age demonstrate spondylotic changes regardless of symptomatology. In males, the prevalence was 13% in the third decade, increasing to nearly 100% by age 70 years In females, the prevalence ranged from 5% in the fourth decade to 96% in women older than 70 years.

6. Causes In addition to age and possibly sex, several risk factors have been proposed for cervical spondylosis. Repeated occupational trauma ( eg. carrying axial loads, professional dancing, gymnastics) may contribute. Smoking also may be a risk factor. Conditions that contribute to segmental instability and excessive segmental motion (eg, congenitally fused spine, cerebral palsy, Down syndrome) may be risk factors for spondylotic disease.

7. Pathoanatomy Cervical spondylosis is a natural aging process of the spine characterised by degeneration of the disc and four joints of the cervical motion segment which include- 2 facet joints , 2 uncovertebral joints of Luschka. Degenerative cycle includes- Disc degeneration Joint degeneration Ligamentous changes Deformity

8. Pathogenesis Cervical spondylosis and all its manifestations are a product of cervical disc degeneration. Though it looks similar disc degeneration and disc rupture or prolapsed are two entirely different pathological entities which need to be differentiated. Although every patient with cervical disc rupture has a preceding cervical disc degeneration, the symptoms are produced by entirely different mechanisms.

9. Disc rupture In disc rupture, there is an annular protrusion, with or without extrusion of nuclear material, producing symptoms by means of tension on the dura or root, or by means of cord compression.

10. Disc degeneration Disc degeneration, on the other hand, implies a mechanical breakdown of the integrity of a cervical disc which produce the initial symptoms, because of mechanical instability Only in later stages produce symptoms of root or cord compression due to development of osteophytic outgrowths.

11. Physiologic degenerative aging process - cartilaginous and ligamentous structures of the cervical spine. Earliest changes consists of posterolateral and posterior fissures in the disc tissue and involved segment become unstable and vulnerable to trauma Loss of intervertebral disc height leads to osteophyte formation by apposition of neurocentral joints. Further loss of disc height can only takes place anteriorly leads to loss of normal cervical lordosis.

12. Osteophyte formation Anteriorly - loss of lordosis Posteriorly - secondary osteoarthritis of facet joint Laterally- vertebral artery syndrome ( dizziness, tinnitus, intermittent blurring of vision, occasional episodes of retrooccular pain) Gradual collapse and protrusion of annulus fibrosus - formation of transverse bar of bone- leads to narrowing of anteroposterior diameter of spinal cord is narrowed- leads to compression of spinal cord - leads to development of progressive myelopathy.

13. CLINICAL FEATURES Various clinical syndromes seen with cervical spondylosis manifest quite differently Intermittent neck and shoulder pain or cervicalgia is the most common syndrome seen in clinical practice. Cervical pain :- Chronic suboccipital headache may be present. Mechanism includes direct nerve compression, degenerative disk, joint or ligament instability. Pain can be perceived locally or it may radiate to the occiput, shoulder, scapula, arm. Pain may be worse when patient is in certain position, can interfere with sleep.

14. Cervical radiculopathy :- Compression of the cervical roots leads to ischemic changes that cause sensory dysfunction (eg, radicular pain) and/or motor dysfunction (eg, weakness). Most commonly occurs in persons aged 40-50 years. The C6 root is the most commonly affected because of the predominant degeneration at the C5-C6 interspace; the next most common site is at C7 and C5. Most cases of cervical radiculopathy resolve with conservative management, only few require surgical intervention.

15. Cervical spondylotic myelopathy :- The most serious consequence of cervical intervertebral disc degeneration, especially when it is associated with a narrow cervical vertebral canal. Insidious onset,which typically becomes apparent in persons aged 50-60 years. Complete reversal is rare once myelopathy occurs. Gait disturbances like spastic gait followed by upper extremity numbness and loss of fine motor control of the hands usually present.

16. Physical examination Decreased range of movements in the cervical spine, especially with neck extension Hand clumsiness Sensory deficits Hyper-reflexia in the lower and upper extremities below the level of lesion. A characteristically broad-based, stooped, and spastic gait.

17. Spurring sign - Radicular pain is exacerbated by extension and lateral bending of the neck towards the Side of the lesion, causing additional foraminal compromise. Lhermitte sign - This generalised electrical shock sensation is associated with neck extension. Hoffman sign - 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.

18. IMAGING Plain cervical radiography- Routine in every patient with suspected cervical spondylosis. Valuable in evaluating the uncovertebral and facet joints, the foramen, intervertebral disk spaces, and osteophyte formation. Flexion-extension views may be needed to detect instability.

19. MRI is a considerable advance in the use of imaging to diagnose cervical spondylosis with following advantages - direct imaging with multiple planes, better definition of neural elements, increased accuracy in evaluating intrinsic spinal cord diseases, Non- invasiveness. False-positive and false-negative MRI results occur frequently in patients with cervical radiculopathy; therefore mri results and clinical findings should be used when interpreting root compression. Myelography with computed tomography (CT) scanning can also be used to asses spinal and foraminal stenosis. Since it is an invasive procedure mostly common not used.

20. Histology Thinning and fragmentation of the articular cartilage may be observed. The normal smooth,white articular surface becomes irregular and yellow. Continued loss of articular cartilage leads to exposure of areas of subcondral bone , which appears as shiny foci on the articular surface.(eburnation). Fibrosis, increased bone formation and cystic changes frequently occur in the underlying bone. Loss of articular cartilage stimulates new bone formation, usually in the form of nodules (osteophytes) at the bone edges.

21. Differential diagnosis Congenital- Arnold chiari malformations, Syringomyelia Acquired- trauma, herniated intervertebral disc, khyphosis, extramedullary hemotopoiesis, epidural lipomatosis Neoplastic- spinal cord tumors, carcinomatous meningitis, paraneoplastic syndrome Vascular- haematoma, spinal cord infraction, spinal cord avm. Autoimmune- multiple sclerosis. Infections- paraspinal abscess, osteomyelitis, pyogenic discitis, aids related myelopathy, tuberculosis, spinal meningitis, viral and syphilitic involvement . Amyotrophic lateral sclerosis. Others- cervical rib, thoracic outlet syndrome, acute stiff neck syndrome, cervical fracture.

22. TREATMENT Physical therapy:- Immobilization of cervical spine is the mainstay of conservative treatment for patients with cervical spondylosis Immobilization limits the motion of 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. More rigid orthoses can significantly immobilise the cervical spine (like Philadelphia collar, Minerva body jacket)

23. The use of cervical exercises has been advocated in patients with cervical spondylosis. Isometric exercises are often beneficial to maintain the strength of neck muscles. Neck and upper back strengthening exercises, as well as light aerobic activities are also recommended. Molded cervical pillows can better align the spine during sleep and provide symptomatic relief for some patients. Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (moist-heat packs) or mechanisms for deep heat transfer (eg, ultrasound, diathermy).

24. Mechanical traction is widely used technique. useful because it promotes Immobilization of the cervical region and widens the foraminal openings. Manual traction is better tolerated than mechanical traction in some patients.

25. Occupational therapy Patients with upper extremity weakness often lose there ability to perform activity of daily living, vocational activities or recreational activities. Lifestyle modification may involve an evaluation of workplace ergonomics, postural training, stress management and vocational assistance. Disability can be improved with specific strengthening exercises of the upper extremities, special splinting to compensate for weakness, and the use of assistive devices that allow the patient to perform previously impossible activities.

26. Medical management NSAIDS Steriods Opioids Drugs for radicular pain like pregabaline, carbamazepine. With non-operative treatment, approximately 75% of patients have complete or partial, but significant relief of symptoms. Conclusion- patients should be treated conservatively if they have a spinal transverse area larger than 70sq mm,or older age. Surgery is more suitable for patients with clinically worse status and a lesser transverse area of spinal cord.

27. Surgical intervention Indications for surgery include the following- Progressive neurological deficits Compression of the cervical nerve root and/or spinal cord. Intractable pain. The aim of surgery is to relieve pain and neuronal structure compression, as well as, in selected cases to achieve stabilisation.

28. Approaches for surgery Includes- Anterior or posterior or combined. Anterior approach includes- discectomy with/without bone graft, cervical instrumentation. Poster approach includes- decompressive laminectomy and foraminotomy, hemilaminectomy, Laminoplasty.

29. Prevention Avoid high-impact exercises/activities( eg, running,jumping). Maintain cervical ROM with daily ROM exercise. Maintain neck muscle strength, especially neck extensor strength. Avoid holding the head in 1 position for longer period.(eg, while driving,while watching tv). Avoid prolonged neck extension.

30. Thank you