Recently, there has been a significant increase in the number of patients undergoing surgery for spinal cervical spondylosis. 10 years ago, I myself performed a few dozen such surgeries a year, but now I perform 200-300 cases a year, and my total number of cervical spine surgeries of all types has accumulated to 1300 (2015.8). Please refer to click on my article: Statistics of 36 spine surgeries performed by me in March (2011). There are three main reasons for this change.
1)aging population ;
2) Brand effect and advancement of surgical techniques;
3) advances in examination equipment and the fact that the majority of patients understand and accept the effects of surgery. In the past, people were very fearful of cervical spine surgery and thought that they would have to live in a wheelchair after cervical spine surgery; today this hardly happens due to the tremendous advances in surgical technology.
What is spinal cord cervical spondylosis?
Spinal cord cervical spondylosis is a general term for a disease in which the spinal cord is damaged, paralyzed, or paralyzed by daily activities or minor trauma because the cervical spine is in a narrowed spinal canal and degenerative changes (herniated discs, bone spurs, congenital dysplasia) occur in the cervical spine with age. In layman’s terms, the cervical spine ages with age, the vertebrae develop spurs, and the intervertebral discs become thin and fracture and protrude, and the ligaments thicken, so the spinal cord is compressed. If there is a narrowing of the spinal canal through the spinal cord, it is more likely to get this disease.
The disease is generally common after the age of 40 and more common after the age of 50. It is twice as common in men as in women, and the cause is unknown and may be related to more physical labor in men. In addition, the risk factors include head and neck trauma, strenuous sports, and smoking.
The main symptoms are “numbness and weakness in the hands and feet,” “dull sensation in the fingers” and “difficulty in fastening buttons” in the motor nerves. “The symptoms of motor neurology are “unsteady walking, feeling of stepping on cotton, unable to walk without holding something” and other motor disorders. In fact, two symptoms appear at the same time in most cases. Once these symptoms appear, it is important to see a specialist in spine surgery, a more specialized specialty in orthopedics.
How is the disease diagnosed?
The first step in a doctor’s visit is to ask the patient about his or her symptoms in detail. Spinal cervical spondylosis can be not only paralysis of the hands and feet and difficulty walking, but also impairment of rectal bladder function such as defecation and urination.
After the consultation, a neurological physical examination is performed. The specialist usually uses a small hammer – a percussion hammer – to check the “tendon reflex”. When the knee is tapped underneath the knee, the knee joint is instantly straightened and the knee tendon reflex is hyperactive when the spinal cord is compressed. The pathological reflexes of the fingers, the pathological reflexes of the soles of the feet and the tendon reflexes of the ankles are also checked.
In the neurological examination, there is also a “10-second test”, which checks the number of times the patient’s fingers can be rapidly extended and flexed in 10 seconds. 20 times or more is considered normal, and generally healthy people can reach about 25-26 times. 20 times or less is suspected of spinal cord damage, and people with spinal cord damage The extension and flexion of the finger will be slow.
The next step is to make an imaging diagnosis. X-ray alone is used to observe the narrowing of the cervical spinal space, the presence of bone spurs and spinal stenosis; CT is used to observe the transverse section of the spinal canal, which is usually oval in normal and becomes triangular in cervical spondylosis; MRI is used to observe the compression status of the spinal cord, which is the most informative test for diagnosing cervical spondylosis. It should be emphasized that each of these three tests has its own focus and cannot be substituted.
Although there are a variety of imaging tests and diagnoses, the most important thing is the interrogation and neurological examination. Some people have no symptoms even though the MRI shows spinal cord compression, so the doctor must examine the patient in person before making a diagnosis.
Spinal cord cervical spondylosis causes symptoms such as paralysis of the limbs, lack of finger movement, and difficulty walking. If the symptoms are not taken seriously or misdiagnosed and mistreated, the patient will be confined to a wheelchair for the rest of his or her life, or be paralyzed in bed.
Treatment options
The treatment of spinal cord cervical spondylosis is mainly surgical because the natural progression of the disease is such that in 60-80% of patients, the symptoms will progressively worsen and end up in paralysis and disability, and surgery is the only possible effective method for most patients. However, in clinical practice, after the diagnosis of spinal cord cervical spondylosis is confirmed, light or before surgery, conservative treatment is usually taken first, including drug therapy, brace therapy, traction therapy, physical therapy and life guidance.
In order to be highly responsible for the patient, typical and serious patients should be operated directly. The efficacy of conservative treatment for mild spinal cord cervical spondylosis, according to a survey published by Japanese scholar Masakazu Morita in 1994, improved in 21%, unchanged in 23%, worsened in 49%, and 77.5% of patients must eventually be treated surgically.
Conservative treatment
* Pharmacotherapy: Vitamin B12, vitamin E, anti-inflammatory and analgesic drugs, muscle relaxants, sedatives, precleavage preparations and steroid hormones are often used, among others. Vitamin B12 and vitamin E improve blood circulation and help improve nerve function and are used when the fingers are paralyzed. Anti-inflammatory and analgesic drugs are mainly used when the pain is severe; muscle relaxants are used when there is limited movement of the shoulder joint or inflexible hand movement due to muscle spasm.
In order to suppress acute inflammation, steroid hormones are sometimes used for a week or so; in addition, proliferative preparations with vasodilatory effects can be used to improve blood circulation, and sedatives can be used for patients with poor sleep. It is important to note that elderly patients taking muscle relaxants and sedatives are prone to falls, so they are not often used.
* Brace therapy: The use of braces is a way to reduce the burden on the cervical spine, often using cervical braces and soft collars.
* Traction therapy: People generally hope that cervical traction can reduce nerve compression, but sometimes it is also ineffective, and even the symptoms can worsen. So when the symptoms are not relieved or aggravated after traction, it should be terminated immediately.
* Physiotherapy: Mainly warm therapy, physical therapy such as divine light, ultrasound and ultrashort wave can heat the affected area, expecting to increase the blood circulation of the compressed spinal cord, hoping to relieve the symptoms.
* Life guidance: “Do not fall”, “lower your head less and do not tilt it too much”, “quit smoking”, “avoid getting cold and try not to go out on cold days “, “sleep on a comfortable pillow, generally choose a low pillow and a soft pillow”, “do not exercise your head and neck strenuously”, etc. The purpose of all these life guidance is not to add a burden to the cervical spine.
Surgical treatment
Regarding the surgical treatment of spinal cord cervical spondylosis, the most important thing is the timing of surgery. As long as there are symptoms such as instability and difficulty in walking and finger movement, surgery should be performed; if the symptoms gradually worsen, surgery should also be performed. Relatively speaking, senior patients choose conservative treatment on their own, but if it is so serious that they cannot walk, there is not much hope for recovery even with surgery. Therefore, we emphasize that surgery must be performed when you can still walk.
There are two types of surgery: anterior cervical surgery (anterior cervical decompression and fixation) and posterior cervical surgery (cervical canal enlargement and plasty). For cervical spondylosis with short segments, mainly herniated discs and mild osteophytes, minimally invasive surgery is an option, please refer to my other article: Series of minimally invasive surgery for cervical spondylosis .
Anterior cervical surgery is performed by entering from the front of the patient’s neck, removing the bone spurs, discs and other parts of the spine that compress the nerves and cause symptoms, and doing bone grafting and fixation. In the past, the bone was mostly taken from the pelvis, but nowadays artificial bone and titanium alloy materials are used. Posterior cervical surgery is performed from the back of the neck to enlarge the narrow spinal canal and relieve the compression of the spinal cord. This is done by cutting off one side of the vertebral arch that forms the spinal canal and using a miniature grinding drill to make a hinge on the other side to open and fix the arch like a door. They have different indications for surgery.
The indications for anterior cervical surgery are: a spinal canal diameter of 14 mm or more; and compression of a segment within 2-3 intervertebral spaces. The indications for posterior cervical surgery are: spinal canal diameter below 13 mm – presence of spinal stenosis; compression of more than 3 segments. So, which surgical approach has better results? According to more than 10 years of postoperative follow-up, both approaches will achieve excellent results as long as the above indications for surgery are strictly mastered.
Typing of cervical spondylosis
Definition of cervical spondylosis: cervical spondylosis is defined as degenerative changes in the intervertebral disc tissue and its secondary pathological changes involving the surrounding tissue structures (nerve roots, spinal cord, vertebral artery, sympathetic nerve, etc.), and the corresponding clinical manifestations appear. In China, cervical spondylosis is divided into cervical, spinal cord, nerve root, sympathetic, vertebral artery, other types, etc. (or plus mixed types), which is a clinical typology of cervical spondylosis based mainly on symptoms and arose in 1984 and 1992 at the Qingdao Symposium on Cervical Spondylosis.
This definition encompasses three basic elements.
(1) degeneration of the cervical discs or degeneration of the intervertebral joints;
(2) Involvement of the surrounding tissue structures;
(3) the presence of corresponding clinical manifestations. These 3 components are interrelated and cannot be separated from each other.
Therefore, the following diagnostic principles must be met to establish the diagnosis of cervical spondylosis.
(1) Clinical manifestations (i.e. clinical symptoms and signs) of cervical spondylosis are present;
(2) Imaging shows degenerative changes in the cervical intervertebral discs or intervertebral joints;
(3) the imaging signs can explain the clinical manifestations.
According to this diagnostic principle, two biases in the diagnosis of cervical spondylosis should be avoided.
First, the diagnosis of cervical spondylosis should not be made solely on the basis of the presence of degenerative changes in the cervical spine on imaging signs. Because 80% of people over 55 years of age have degenerative changes in the cervical spine, but most of them do not have clinical manifestations, it is inappropriate to diagnose cervical spondylosis based on imaging findings alone.
Secondly, the diagnosis should not be made only on the basis of clinical manifestations without the necessary imaging examinations to confirm degenerative changes in the corresponding cervical spine, because without degenerative changes in the cervical spine there is no basis for the development of cervical spondylosis.
In addition, many clinical manifestations of cervical spondylosis can also exist in diseases other than cervical spondylosis, for example, numbness and weakness of the upper limbs can be caused by thoracic outlet syndrome; dizziness can also be caused by cerebrovascular disease, hypertensive disease, and otologic disease; spastic incomplete paralysis of the extremities can also be caused by intraspinal occupational disease, spinal cavernous disease, and amyotrophic lateral sclerosis. Therefore, the diagnostic principle emphasizes that imaging signs can explain the clinical manifestations.
According to the discussion at our 1992 symposium on cervical spondylosis, the classification was made from the 3 basic elements included in the definition of cervical spondylosis. The basis of each type is as follows.
1, cervical type: there are cervical symptoms and pressure points; the cervical spine on X-ray has curvature changes and instability; other disorders of the neck (such as drop pillow, frozen shoulder, myofasciitis, etc.) should be excluded.
2, nerve root type: there are radicular symptoms and signs consistent with the lesion segment; positive pressure neck test or brachial plexus pull test; imaging is consistent with the clinical manifestations; painful point closure without significant effect; can exclude thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, etc.
3, spinal cord type: there are signs and symptoms of cervical spinal cord damage; imaging has cervical spinal stenosis, cervical degenerative changes; should exclude amyotrophic lateral sclerosis, intra-vertebral canal tumor, spinal cord injury, multiple peripheral neuritis, etc.
4.Vertebral artery type: cervical vertigo, history of sudden collapse, positive spin neck test, cervical segmental instability or crooked vertebral joint hyperplasia on X-ray, mostly accompanied by sympathetic nerve symptoms, ophthalmogenic and otogenic vertigo should be excluded, except for insufficiency of blood supply to vertebral artery segment I and III, intracranial lesions, neurosis, etc. Vertebral arteriogram should be performed to confirm the diagnosis. This type is very controversial and should be further studied.
5, sympathetic type: manifested as dizziness, blurred vision, tinnitus, hand numbness, tachycardia, precordial pain and a series of symptoms of plant nerve disorders, cervical intersegmental instability or degenerative changes on X-ray, vertebral arteriography is not abnormal, and cardiovascular and cerebrovascular diseases should be excluded. The basis of this type is also more controversial. 6, other types: refers to the cervical vertebrae anterior bird’s mouth-like osteophytes compression of the esophagus caused by dysphagia, and confirmed by barium esophageal fluoroscopy, etc.? Although this typing has great guiding significance for the diagnosis and treatment of cervical spondylosis, it is not common internationally, and there are unsatisfactory points in its application.
There is no agreement on the typing of cervical spondylosis at home and abroad. Foreign – European, American and Japanese typing, based on pathological typing, cervical spondylosis – cervical disc degenerative disease – cervical ankylosing (degenerative, proliferative) spondylitis, mainly divided into Three types
(1) Simple neck pain;
②Cervical radiculopathy;
cervical myelopathy.
There are also cervical disc herniation (acute) and cervical posterior longitudinal ligament ossification (opll), both of which can cause nerve root or/and myelopathy symptoms, mainly because of the different sites of lesion involvement (compression, irritation, blood flow changes, etc.). Cervical vertigo and other sympathetic symptoms of cervical origin are predominant: Barre-Lieou syndrome. Cervical spinal stenosis (developmental), cervical instability (traumatic), and Klippel-Feil syndrome (congenital cervical fusion deformity) are also very common diagnoses.
Therefore, there are two concepts and understandings of cervical spondylosis, broad and narrow. The more specialized the physician, the closer to the narrower the concept, “cervical spondylosis” is the cervical spondylosis that meets the definition. In contrast, cervical spondylosis diagnosed by general clinicians or specialists without sufficient information, especially imaging data, includes both cervical spondylosis (cervical hyperplastic spondylitis) and cervical disc herniation (acute) and ossification of the posterior longitudinal ligament (opll), cervical spinal stenosis, cervical instability, Klippel-Feil syndrome, and other cervical spine disorders that do not meet the definition of cervical spondylosis For example, “cervical spinal stenosis”, “cervical instability” and “Klippel-Feil syndrome” do not meet the definition of cervical spine disease. For example, “spinal cord cervical spondylosis” actually becomes a broad concept of cervical myelopathy – a compression of the cervical medulla excluding intra-medullary tumors and other lesions of the nerve itself.