Cervical spondylosis

Definition

Cervical spondylosis refers to common age-related changes in the area of the spine at the back of the neck. With age, the vertebrae (the component bones of the spine) gradually form bone spurs, and their shockabsorbing disks slowly shrink. These changes can alter the alignment and stability of the spine. They may go unnoticed, or they may produce problems related to pressure on the spine and associated nerves and blood vessels. This pressure can cause weakness, numbness, and pain in various areas of the body. In severe cases, walking and other activities may be compromised.


Description

As it runs from the brain down the back, the spinal cord is protected by ringlike bones, called vertebrae, stacked one upon the other. The vertebrae are not in direct contact with one another, however. The intervening spaces are filled with structures called disks. The disks are made up of a tough, fibrous outer tissue with an inner core of elastic or gel-like tissue.

One of the most important functions of disks is protecting the vertebrae and the nerves and blood vessels between the vertebrae. The disks also lend flexibility to the spinal cord, facilitating movements such as turning the head or bending the neck. As people age, disks gradually become tougher and more unyielding. Disks also shrink with age, which reduces the amount of padding between the vertebrae.

As the amount of padding shrinks, the spine loses stability. The vertebrae react by constructing osteophytes, commonly known as bone spurs. There are seven vertebrae in the neck; development of osteophytes on these bones is sometimes called cervical osteoarthritis. Osteophytes may help to stabilize the degenerating backbone and help protect the spinal cord.

By age 50, 25-50% of people develop cervical spondylosis; by 75 years of age, it is seen in at least 70% of people. Although shrunken vertebral disks, osteophyte growth, and other changes in their cervical spine may exist, many of these people never develop significant problems.

However, about 50% of people over age 50 experience neck pain and stiffness due to cervical spondylosis. Of these people, 25-40% have at least one episode of cervical radiculopathy, a condition that arises when osteophytes compress nerves between the vertebrae. Another potential problem occurs if osteophytes, degenerating disks, or shifting vertebrae narrow the spinal canal. This pressure compresses the spinal cord and its blood vessels, causing cervical spondylitic myelopathy, a disorder in which large segments of the spinal cord are damaged. This disorder affects fewer than 5% of people with cervical spondylosis. Symptoms of both cervical spondylitic myelopathy and cervical radiculopathy may be present in some people.



Causes and symptoms

As people age, shrinkage of the vertebral disks prompts the vertebrae to form osteophytes to stabilize the back bone. However, the position and alignment of the disks and vertebrae may shift despite the osteophytes. Symptoms may arise from problems with one or more disks or vertebrae.

Osteophyte formation and other changes do not necessarily lead to symptoms, but after age 50, half of the population experiences occasional neck pain and stiffness. As disks degenerate, the cervical spine becomes less stable, and the neck is more vulnerable to injuries, including muscle and ligament strains. Contact between the edges of the vertebrae can also cause pain. In some people, this pain may be referred-that is, perceived as occurring in the head, shoulders, or chest, rather than the neck. Other symptoms may include vertigo (a type of dizziness) or ringing in the ears.

The neck pain and stiffness can be intermittent, as can symptoms of radiculopathy. Radiculopathy refers to compression on the base, or root, of nerves that lead away from the spinal cord. Normally, these nerves fit comfortably through spaces between the vertebrae. These spaces are called intervertebral foramina. As the osteophytes form, they can impinge on this area and gradually make the fit between the vertebrae too snug.

The poor fit increases the chances that a minor incident, such as overdoing normal activities, may place excess pressure on the nerve root, sometimes referred to as a pinched nerve. Pressure may also accumulate as a direct consequence of osteophyte formation. The pressure on the nerve root causes severe shooting pain in the neck, arms, shoulder, and/or upper back, depending on which nerve roots of the cervical spine are affected. The pain is often aggravated by movement, but in most cases, symptoms resolve within four to six weeks.

Cervical spondylosis can cause cervical spondylitic myelopathy through stenosis- or osteophyte-related pressure on the spinal cord. Spinal stenosis is a narrowing of the spinal canal-the area through the center of the vertebral column occupied by the spinal cord. Stenosis occurs because of misaligned vertebrae and out-of-place or degenerating disks. The problems created by spondylosis can be exacerbated if a person has a naturally narrow spinal canal. Pressure against the spinal cord can also be created by osteophytes forming on the inner surface of vertebrae and pushing against the spinal cord. Stenosis or osteophytes can compress the spinal cord and its blood vessels, impeding or choking off needed nutrients to the spinal cord cells; in effect, the cells starve to death.

With the death of these cells, the functions that they once performed are impaired. These functions may include conveying sensory information to the brain or transmitting the brain's commands to voluntary muscles. Pain is usually absent, but a person may experience leg numbness and an inability to make the legs move properly. Other symptoms can include clumsiness and weakness in the hands, stiffness and weakness in the legs, and spontaneous twitches in the legs. A person's ability to walk is affected, and a widelegged, shuffling gait is sometimes adopted to compensate for the lack of sensation in the legs and the accompanying, realistic fear of falling. In very few cases, bladder control becomes a problem.

Diagnosis

Cervical spondylosis is often suspected based on the symptoms and their history. Careful neurological examination can help determine which nerve roots are involved, based on the location of the pain and numbness, and the pattern of weakness and changes in reflex responses. To confirm the suspected diagnosis, and to rule out other possibilities, imaging tests are ordered. The first test is an x ray. X rays reveal the presence of osteophytes, stenosis, constricted space between the vertebrae, and misalignment in the cervical spine-in short, an x ray confirms that a person has cervical spondylosis. To demonstrate that the condition is causing the symptoms, more details are needed. Other imaging tests, such as magnetic resonance imaging (MRI) and computed tomography myelography, help assess effects of cervical spondylosis on associated nerve tissue and blood vessels.

An MRI may be preferred, because it is a noninvasive procedure and does not require injecting a contrast medium as does computed tomography myelography. MRIs also have greater sensitivity for detecting disk problems and spinal cord involvement, and the test allows the physician to create images of a larger area from various angles. However, these images may not show enough detail about the vertebrae themselves. Computed tomography myelography yields a superior image of the bones involved in cervical spondylosis. Added benefits include that it takes less time to perform and tends to be less expensive than an MRI. A good diagnosis may be reached with either a computed tomography myelography or an MRI, but sometimes complementary information from both tests is necessary. Nerve conduction velocity, electromyogram (EMG), and/or somatosensory evoked potential testing may help to confirm which nerve roots are involved.

Treatment

When possible, conservative treatment of symptoms is preferred. Conservative treatment begins with rest-either restricting normal activities to a less strenuous level or bed rest for three to five days. If rest is not adequate to relieve symptoms, a cervical orthosis may be prescribed, such as a soft cervical collar or stiffer neck brace to restrict neck movement and shift some of the head's weight from the neck to the shoulders. Cervical traction may also be suggested, either at home with the advice of a physical therapist or in a health-care setting.

Pain is treatedwith nonsteroidal anti-inflammatory drugs, such as aspirin or ibuprofen. If these drugs are ineffective, a short-termprescription for corticosteroids or muscle relaxants may be given. For chronic pain, tricyclic antidepressants can be prescribed. Although these drugs were developed to treat depression, they are also effective in treating pain. Once any pain is resolved, exercises to strengthen neck muscle and preserve flexibility are prescribed.

If the pain is severe, a short treatment of epidural corticosteroids may be prescribed with discretion. A corticosteroid such as prednisone can be combined with an anaesthetic and injected with a long needle into the space between the damaged disk and the covering of the nerve and spinal cord. Injection into the cervical epidural space relieves severe pain that is not managed with conventional treatment. Frequent use of this treatment is not medically recommended and is used only if the more conservative therapy is not effective.

If pain is continuous and does not respond to conservative treatment, surgery may be suggested. Surgery is usually not recommended for neck pain, but it may be necessary to address radiculopathy and myelopathy. Surgery is particularly recommended for people who have already developed moderate to severe symptoms of myelopathy, although age or poor health may prohibit that recommendation. The specific details of the surgery depend on the structures involved, but the overall goal is to relieve pressure on the nerve root, spinal cord, or blood vessels and to stabilize the spine.

Alternative treatment

Alternative therapy is not meant to replace conventional medical treatment, but it can be a useful adjunct. Its main roles are to relieve tension, manage pain, and strengthen neck and back muscles. Massage is one way to relieve tension, and yoga provides the additional benefit of strengthening muscles. Chiropractic and acupuncture have been reported to relieve the pain associated with disk problems, although great care needs to be taken to avoid exacerbating them. Practitioners of the Alexander technique or the Feldenkrais method can provide instruction on correct posture and exercise that may help prevent further symptoms. Vitamin and mineral supplementation along with herbal therapies and homeopathy can help build and rebalance the weakened structure.

Prognosis

The gradual progression of cervical spondylosis cannot be stopped; however, it doesn't always cause symptoms. For the individuals who do experience problems, conservative treatment is very effective in managing the symptoms. Nearly all people with neck pain, approximately 75% of persons with radiculopathy, and up to 50% of people with myelopathy find relief through therapy alone. For the remaining people with radiculopathy or myelopathy, surgery may be recommended. Surgery is deemed successful in 70-80% of cases.

Prevention

Since cervical spondylosis is part of the normal aging process, not much can be done to prevent it. It may be possible to ward off some or all of the symptoms by engaging in regular physical exercise and limiting occupational or recreational activities that place pressure on the head, neck, and shoulders. The best exercises for the health of the cervical spine are noncontact activities, such as swimming, walking, or yoga. Once symptoms have already developed, the emphasis is on symptom management rather than prevention.