para>Most individuals >65 years of age have evidence of cervical spondylosis on x-ray.
Consider myelopathy in elderly patients complaining of balance/gait disturbance or bilateral pain/weakness of the upper and/or lower extremities.
Pediatric Considerations
Radiographic changes can be seen when patients achieve skeletal maturity. Younger patients are more likely to present due to an acute disk herniation.
Congenital spinal stenosis predisposes to early onset of symptoms especially after minor trauma.
EPIDEMIOLOGY
Incidence
Predominant sex: male > female (3:2 ratio) (1,2)
Prevalence
- 10% by age 25 years
- 95% by age 65 years
ETIOLOGY AND PATHOPHYSIOLOGY
- Disk desiccation leads to loss of disk height and biomechanical changes in the spine.
- Spinal ligaments and annular fibers weaken, shifting the load to the dorsal vertebral column
- Altered load balance results in loss of cervical lordosis and overloading of the uncovertebral and facet joints, triggering osteophyte formation; bony and ligamentous hypertrophy and ossification
- Load transfer to adjacent spinal levels contributes to cervical kyphosis.
- The most common level of disk degeneration is C5-C6 and C6-C7.
- The most common level of facet degeneration is C2-C3.
Genetics
Genetic predisposition has been described (1).
RISK FACTORS
- Age
- Previous C-spine trauma (1)
- Smoking
- Congenital anomalies of the cervical spine (2)
- Dystonic cerebral palsy (2)
COMMONLY ASSOCIATED CONDITIONS
- Arthritis, spinal stenosis, radiculopathy, myelopathy, and cervical spine injury
- 10-15% of patients have coexisting lumbar stenosis.
- Ossification of the posterior longitudinal ligament
DIAGNOSIS
HISTORY
- Onset can be either insidious (typical) or acute (after fall or hyperextension injury).
- Three basic clinical presentation, depending on the presence or absence of nerve root (radiculopathy) or spinal cord (myelopathy) compromise (1):
- Axial symptoms:
- Decreased range of motion, "stiff neck"
- Mechanical symptoms (popping, snapping)
- Paraspinal muscle pain/spasm
- Trapezius, scapular, or periscapular pain
- Pain (referred) of shoulders and upper back (67%) (1)
- Headaches, suboccipital pain (30%) (1)
- CSR
- Pain, weakness, and paresthesias radiating along the specific nerve root distribution
- Unilateral in most cases
- Axial symptoms may or may not be present.
- Neck extension, coughing, sneezing might exacerbate arm pain.
- CSM
- Clumsiness, scissoring gait, leg stiffness
- Fine motor deficits (i.e., penmanship, buttoning shirt)
- Urinary urgency; (rarely) incontinence
- Pain, weakness, and numbness in the upper and/or lower extremities
- Red flags:
- History of a recent fall/trauma to the head, neck, upper and lower back; landing on one's feet after a fall from height
- Unexplained weight loss or fever
- Severe pain or severe local tenderness
- Progressive neurologic deficits
- Bladder or bowel incontinence
- Cervical lymphadenopathy
- History of cancer
- History of long-term steroid use
PHYSICAL EXAM
- Axial findings:
- Decreased range of motion, especially neck extension
- Cervical paraspinal spasm/tenderness
- Trapezius, periscapular spasm/tenderness
- CSR (lower motor neuron findings most common)
- Myotomal sensory and motor deficits
- Corresponding decreased reflex: bicep (C5, C6), brachioradialis (C5, C6), triceps (C7)
- Spurling maneuver (axial compression of the cervical spine during extension and rotation to the ipsilateral side) may reproduce or worsen arm pain through neuroforaminal narrowing (1).
- "Shoulder abduction sign"-the patient reaches affected arm overhead and rests the wrist/forearm on top of the head, decreasing arm/shoulder pain (1).
- CSM (variable upper motor neuron findings depending on the location and severity of spinal compression)
- Balance/gait dysfunction, scissored gait
- Long tract signs: spasticity, hyperreflexia, and clonus and abnormal reflexes such as Babinski or Hoffman (1)
- Motor weakness (usually proximal in the legs, and distal in the arms); hand atrophy
- Sensory deficits of arm(s) and/or leg(s)
- Lhermitte phenomenon, a shocklike paresthesia occurring with neck flexion (1)
- Lower motor neuron findings may also be present if coexisting radiculopathy is present.
DIFFERENTIAL DIAGNOSIS
- Axial symptoms:
- Cervical sprain/strain
- Myofascial pain
- Somatic dysfunction/facet joint dysfunction
- Bone metastases
- Thoracic outlet syndrome
- Radiculopathy (lower motor neuron conditions)
- Cardiac pain
- Shoulder disorders
- Herniated cervical disk
- Peripheral nerve entrapment (i.e., carpal tunnel syndrome, cubital tunnel syndrome)
- Diabetic polyradiculopathy
- Polymyalgia rheumatica
- Myelopathy (upper motor neuron conditions) (2)
- Spinal cord lesions: multiple sclerosis, tumor, syringomyelia, epidural abscess, vascular insults
- Amyotrophic lateral sclerosis
- Central herniated disk
- Metabolic disorders: B12, folic acid deficiency
- Postinfectious myelitis (HIV, Lyme, zoster, syphilis)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Plain radiographs: anteroposterior (AP), lateral, open-mouth odontoid, and obliques
- Look for changes in facet and uncovertebral joints, osteophytes, disk space and joint space narrowing
- Ancillary tests and labs are not needed if history, physical exam, and radiographic findings confirm diagnosis
- Labs: ESR, CBC with differential, B12; rapid plasma reagin
- Advanced imaging is indicated if clinically concerned for CSR or CSM.
Follow-Up Tests & Special Considerations
- MRI is diagnostic test of choice when invasive procedure or surgery is contemplated or when the diagnosis is not clear (1,3)[A].
- Because DJD and disk herniations are commonly seen in asymptomatic patients, it is important to correlate radiographic findings with symptoms/exam.
- CT myelography is used instead of MRI in patients with metal hardware or pacemaker.
Diagnostic Procedures/Other
For patients with neurologic symptoms, electromyogram (EMG) and nerve conduction studies (NCS) are indicated if the diagnosis is in question.
TREATMENT
GENERAL MEASURES
- Treat patients without neurologic findings conservatively:
- Oral analgesics (NSAIDs) (2)[C]
- Muscle relaxants
- Soft cervical collar (2)[C]
- Avoid provocative activities.
- Physical therapy: isometric exercise, gradual mobilization, and stretching
- Manual therapy in conjunction with therapeutic exercise increases function and range of motion while decreasing pain and disability.
- Patients with radicular symptoms, without weakness
- Conservative treatment for 6 to 12 weeks
- Interlaminar and transforaminal steroid injections (2)[C]
- Patients with weakness and/or myelopathy
- Consider surgical decompression which is universally recommended for progressive CSM (4)[B].
- Close observation, medical management, and interlaminar epidural steroid injections may be appropriate for patients with mild or stable symptoms (1,3)[B].
MEDICATION
First Line
- NSAIDs (ibuprofen 800 mg TID or naproxen 500 BID) for flares of pain (2)[C]
- Contraindications: GI bleeding or ulcer
- Precautions in patients with renal disease, hepatic disease, heart failure, or coagulation disorders
- Acetaminophen 650 mg/dose 5 times per 24 hours or maximum of 3,250 mg/day
- Muscle relaxants (during flares)
- Topical patches or creams: ketoprofen 20% gel, diclofenac 1% gel, lidocaine 2-5%; apply sparingly BID or TID. Diclofenac 1.3% patch BID
- Anticonvulsants for radiculopathy: gabapentin, pregabalin, tiagabine, or oxcarbazepine (2)[C]
Second Line
- Short course of oral corticosteroids may benefit patients with acute radicular pain.
- Opioids in patients who do not improve with other conservative treatments and are not surgical candidates.
ISSUES FOR REFERRAL
- Progressive neurologic symptoms or myelopathy: immediate referral to a spine surgeon for consideration of surgical treatment
- Referral to pain management, physical therapy or physical medicine, and rehabilitation helpful for team-based care
SURGERY/OTHER PROCEDURES
- Transforaminal steroid injections
- Facet joint steroid injections
- Reserve surgical intervention for patients with intractable pain or progressive neurologic symptoms
- Surgical approach dependent on individual clinical scenario
- No single surgical approach is superior (3,4 and 5)[B].
- Anterior approach: discectomy or corpectomy, with or without fusion
- Posterior approach: laminectomy or laminoplasty, with or without fusion
- Combined or circumferential approaches
- Isolated disk arthroplasty: relatively new; long-term data is emerging (3)[C].
- Patients with CSM who undergo early decompression (<1 year of symptoms) tend to have better outcomes than those with longer duration of symptoms.
- Age is not a strong predictor of neurologic outcomes. Age should not preclude surgical treatment for DSM (4)[B].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Refer for continued severe pain despite conservative treatment, significant or progression of neurologic deficits, or myelopathy
Patient Monitoring
Due to the variable nature and unpredictability of progression, there is no true consensus on monitoring. In the setting of CSR or CSM, reexamine in 3 to 4 weeks to evaluate stability. If no change, follow at intervals of 3 to 6 months, depending on severity of symptoms (2).
PATIENT EDUCATION
- The natural history of cervical spondylosis is highly variable. Patients need to be educated on warning signs of progression to myelopathy (weakness, bladder or bowel incontinence, gait disturbance, loss of dexterity, or fine motor control).
- If considering conservative management for mild CSM, patients should be counseled to compare the risks of progression and loss of neurologic function versus the risks of surgery (1,3)[B].
PROGNOSIS
- In most people, spondylosis remains asymptomatic. In 10-15% of cases, the condition worsens to require surgery (5).
- In the absence of CSM, 75% of patients have complete or significant relief of symptoms with nonoperative approaches.
- In the presence of CSM, the prognosis is variable. 20-60% will deteriorate neurologically over time without surgical intervention (4)[B].
- 50-75% of patients who undergo surgery for CSM improve (2)[C].
REFERENCES
11 Kelly JC, Groarke PJ, Butler JS, et al. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop. 2012;2012:393642.22 Toledano M, Bartleson JD. Cervical spondylotic myelopathy. Neurol Clin. 2013;31(1):287-305.33 Boselie TF, Willems PC, van Mameren H, et al. Arthroplasty versus fusion in single-level cervical degenerative disc disease. Cochrane Database Syst Rev. 2012;(9):CD009173.44 Fehlings MG, Tetreault LA, Wilson JR, et al. Cervical spondylotic myelopathy: current state of the art and future directions. Spine (Phila Pa 1976). 2013;38(22)(Suppl 1):S1-S8.55 Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010;(1):CD001466.
ADDITIONAL READING
- Corey DL, Comeau D. Cervical radiculopathy. Med Clin North Am. 2014;98(4):791-799.
- Ferrara LA. The biomechanics of cervical spondylosis. Adv Orthop. 2012;2012:493605.
- Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including 140 patients. Evid Based Spine Care J. 2012;3(3):13-20.
- Richards O, Choi D, Timothy J. Cervical arthroplasty: the beginning, the middle, the end? Br J Neurosurg. 2012;26(1):2-6.
- Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist. 2010;16(3):176-187.
SEE ALSO
See Neck Stretch
CODES
ICD10
- M47.812 Spondylosis w/o myelopathy or radiculopathy, cervical region
- M47.12 Other spondylosis with myelopathy, cervical region
- M47.892 Other spondylosis, cervical region
- M47.22 Other spondylosis with radiculopathy, cervical region
ICD9
- 721.0 Cervical spondylosis without myelopathy
- 721.1 Cervical spondylosis with myelopathy
SNOMED
- Cervical spondylosis (disorder)
- Cervical spondylosis without myelopathy
- Cervical spondylosis with myelopathy (disorder)
- Cervical arthritis
CLINICAL PEARLS
- Spondylosis is noninflammatory degenerative arthritis of the facet joints and intervertebral disks.
- Most patients with cervical spondylosis remain asymptomatic. Symptomatic patients fall into three groups: axial neck pain, CSR, and CSM.
- Correlate radiographic findings (plain x-ray, MRI/CT) with history and physical exam. Many patients who are asymptomatic will have radiographic change.
- Refer patients who have continued severe pain despite conservative treatment. Also refer those with significant (or progressive) neurologic deficits or myelopathy.
- CSM is generally treated surgically. Early identification of CSM may prevent permanent disability.
- In the absence of myelopathy, 75% of patients have complete or significant relief of symptoms when managed conservatively.
- Do not confuse cervical spondylosis with spondylolysis, which is a stress fracture of the pars interarticularis.