History
Common clinical syndromes associated with cervical spondylosis include
the following:
Cervical pain
o
Chronic suboccipital headache may be present. Mechanisms
include direct nerve compression; degenerative disk, joint, or
ligamentous lesions; and segmental instability.
o
Pain can be perceived locally, or it may radiate to the occiput,
shoulder, scapula, or arm.
o
The pain, which is worse when the patient is in certain
positions, can interfere with sleep.
Cervical radiculopathy
o
Compression of the cervical nerve roots leads to ischemic
changes that cause sensory dysfunction (eg, radicular pain)
and/or motor dysfunction (eg, weakness). Radiculopathy most
commonly occurs in persons aged 40-50 years. (See images
below)
A 48-year-old man
presented with neck pain and predominantly left-sided radicular
symptoms in the arm. The patient's symptoms resolved with
conservative therapy. An axial, gradient-echo magnetic resonance
imaging scan shows moderate anteroposterior narrowing of the
cord space due to a ventral osteophyte at the C4 level, with
bilateral narrowing of the neural foramina (more prominently on
the left side).
View Media Gallery
A 48-year-old man
presented with neck pain and predominantly left-sided radicular
symptoms in the arm. The patient's symptoms resolved with
conservative therapy. A T2-weighted sagittal magnetic resonance
imaging scan shows ventral osteophytosis, most prominent
between C4 and C7, with reduction of the ventral cerebrospinal
fluid sleeve.
View Media Gallery
o
An acute herniated disk or chronic spondylotic changes can
cause cervical radiculopathy and/or myelopathy
o
The C6 root is the most commonly affected one because of the
predominant degeneration at the C5-C6 interspace; the next most
common sites are at C7 and C5.
o
Most cases of cervical radiculopathy resolve with conservative
management; few require surgical intervention.
Cervical myelopathy
o
Cervical spondylotic myelopathy is the most serious
consequence of cervical intervertebral disk degeneration,
especially when it is associated with a narrow cervical vertebral
canal. (See image below)
o
o
A 59-year-old
woman presented with a spastic gait and weakness in her upper
extremities. A T2-weighted sagittal magnetic resonance imaging
scan shows cord compression from cervical spondylosis, which
caused central spondylotic myelopathy. Note the signal changes
in the cord at C4-C5, the ventral osteophytosis, buckling of the
ligamentum flavum at C3-C4, and the prominent loss of disk
height between C2 and C5.
View Media Gallery
Cervical myelopathy has an insidious onset, which typically
becomes apparent in persons aged 50-60 years. Complete
reversal is rare once myelopathy occurs.
Involvement of the sphincters is unusual at presentation, as
based on the patient's perception of symptoms.
Five categories of cervical spondylotic myelopathy are
described; these are based on the predominant neurologic
findings, as follows:
Transverse lesion syndrome - Corticospinal and
spinothalamic tracts, as well as the posterior columns, are
involved.
Motor syndrome - This primarily involves the
corticospinal or anterior horn cells.
Central cord syndrome - Motor and sensory involvement
is greater in the upper extremities than the lower extremities.
(See also Central Cord Syndrome.) [6]
Brown-Squard syndrome - Unilateral cord lesion with
ipsilateral corticospinal tract involvement and contralateral
analgesia are present below the level of the lesion. (See
also Brown-Sequard Syndrome, in the Physical Medicine and
Rehabilitation section, and Brown-Sequard Syndrome, in the
Emergency Medicine section.)
Brachialgia and cord syndrome - Predominant upper limb
pain is present, with some associated long-tract involvement.
Less common manifestations
o
Primary sensory loss may be present in a glovelike distribution.
o
Tandem spinal stenosis is a simultaneous cervical and lumbar
stenosis resulting from spondylosis. It is a triad of findings:
neurogenic claudication, complex gait abnormality, and a mixed
pattern of upper and lower motor neuron signs.
o
Dysphagia may be present if the spurs are large enough to
compress the esophagus.
o
Vertebrobasilar insufficiency and vertigo may be observed.
o
Elevated hemidiaphragm, caused by spondylotic compression
of C3-4 (as noted in a case report), may be another finding.
Physical
Findings at physical examination may include the following:
Spurling sign - Radicular pain is exacerbated by extension and lateral
bending of the neck toward the side of the lesion, causing additional
foraminal compromise.
Lhermitte sign - This generalized 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. A Hoffman sign may be
insignificant if present bilaterally.
Distal weakness
Decreased ROM in the cervical spine, especially with neck extension
Hand clumsiness
Loss of sensation
Increased reflexes in the lower extremities and in the upper
extremities below the level of the lesion
A characteristically broad-based, stooped, and spastic gait
Extensor planter reflex in severe myelopathy
Causes
See the list below:
Age
o
Cervical spondylosis is an accumulation of degenerative
changes observed most commonly in elderly individuals.
o
Among persons younger than 40 years, 25% have
degenerative disk disease (DDD), and 4% have foraminal
stenosis, as confirmed with magnetic resonance imaging (MRI).
In persons older than 40 years, almost 60% have DDD, and
20% have foraminal stenosis, as confirmed with MRI.
Trauma
o
The role of trauma in spondylosis is controversial.
o
Repetitive, subclinical trauma probably influences the onset
and rate of progression of spondylosis.
Work activity - Cervical spondylosis is significantly higher in patients
who carry loads on their head than in those who do not (see
Frequency).
Genetics
o
The role of genetics is unclear. However, a retrospective,
population-based study by Patel et al shows that genetics may
play a role in the development of cervical spondylotic myelopathy
(CSM). The study uses The Utah Population Database, which
contains over 2 million residents' health and genealogical data,
and cross-references it with 10 years of clinical diagnosis statistics
from a large tertiary hospital. An abundance of cases showing
relatedness, as well as a considerable amount of elevated relative
risks to close and distant relatives, advances the idea of an
inherited predisposition to CSM. [7]
o
Patients older than 50 years who have normal cervical spine
radiographic findings are significantly more likely to have a sibling
with normal or mildly abnormal radiographic results.
o
