Diagnosis and treatment of cervical spondylosis
Those who suffer from various symptoms and signs caused by degenerative stimulation or compression of the muscles, blood vessels, nerves and spinal cord around the cervical discs due to degeneration, herniation, cervical spine osteophytes, ligament thickening and calcification are called cervical spondylosis. Through the analysis and comprehensive observation of the whole process of cervical spondylosis, it has been shown that the disease mainly originates from degenerative changes of the cervical intervertebral disc.
Pathogenesis of cervical spondylosis.
1, cervical degenerative changes: with the development of different stages of age, different changes can occur in the cervical spine and intervertebral discs, and while degenerative changes occur in the cervical vertebral body, corresponding changes occur in the intervertebral discs. The First Affiliated Hospital of Xinjiang Medical University, Changji Branch of Traditional Chinese Medicine General Department Wang Dehui
2, trauma factors: on the basis of intervertebral disc degeneration, strenuous activities or uncoordinated sports.
3, chronic strain: long-term in a poor labor posture, the intervertebral disc is subject to strain, extrusion or twisting from various aspects.
4, cold, humidity: especially on the basis of intervertebral disc degeneration, affected by cold, humidity factors, can cause local muscle tension increase, muscle spasm, increase the pressure on the intervertebral disc, causing damage to the fibrous ring.
Cervical spondylosis is divided into cervical, radicular, spinal, vertebral artery, sympathetic and mixed types according to the clinical manifestations of different nerve and vascular involvement.
Cervical type: It is extremely common and is the earliest form of cervical spondylosis, with the prominent manifestation being neck pain. It is most common in young adults. The clinical symptoms are mostly triggered by improper head and neck position during sleep, cold or sudden twisting of the neck during physical work.
Nerve root type: This type has the highest incidence and is most commonly seen in people over 40 years of age. It starts with neck pain and neck stiffness; followed by shoulder and back pain or upper limb pain. There is a feeling of heaviness in the upper limbs, loss of grip strength, sometimes falling objects, and numbness in the fingers.
Spinal cord type: The incidence accounts for about 10%-15% of cervical spondylosis, with more middle-aged and older people. The acute onset is mostly due to trauma, and paraplegia or hemiplegia may occur. Most of them have slow onset, with upper limb symptoms first, such as numbness or immobility of the hands; or lower limb symptoms first, such as numbness and unstable walking, and tightness of the trunk.
Vertebral artery type: The incidence is similar to that of spinal cord type. Dizziness, vertigo, and even falls are most common; sometimes nausea, vomiting, blurred vision, tinnitus, and deafness occur. When the head and neck are in a certain position, the above manifestations are often induced.
Sympathetic type: The clinical manifestations are more complicated, commonly including migraine and retrooccipital pain; or blurred vision, photophobia, tearing, eye swelling, eyelid drooping; or tinnitus, hearing impairment, facial numbness, etc.
Mixed type: two or more of the above types of symptoms appear at the same time.
Cervical spondylosis typology and treatment procedures
(I) Cervical type cervical spondylosis
In most cases, the cause of this type is that the tissue structure of the cervical spine has just started to degenerate, the intervertebral space and intervertebral joints become unstable, and the pressure inside the fibrous ring increases, pulling the sinus vertebral nerve at the periphery of the fibrous ring, which reflexly causes pain and muscle spasm in the head, neck and shoulder. The most commonly involved neuromuscles in this type are: 1. The external branch of this nerve starts from the cervical 1-5 nerve root and innervates the trapezius and sternocleidomastoid muscles. Cervical spondylosis is usually preceded by radicular involvement of the paraspinal nerve, and muscle spasm is secondary. 2. The anterior oblique muscle starts from the node on the anterior side of the cervical 3-6 transverse process and ends obliquely downward at the upper edge of the first rib. The muscle spasm and hypertrophy occur due to damage, which compresses or stimulates the cervical nerve root, subclavian artery and brachial nerve, manifesting as neck, shoulder and arm pain and vascular compression symptoms. It mostly develops at night or in the morning, and sometimes can be relieved by itself.
1.Diagnostic criteria.
1) Clinical features: complaints of pain in the neck, often appearing in the early morning when waking up. It is accompanied by corresponding pressure points (cervical paraspinal muscles, T1-T7 paraspinal or oblique muscles, sternocleidomastoid muscle pressure pain, supraspinatus and infraspinatus muscles also have pressure pain) and neck stiffness in the form of sloping neck. The pain is usually persistent and aching or drilling pain, and the pain may involve the neck, shoulder and upper back.
2) Imaging changes: straightening of the cervical curvature or mild trapezoidal changes on X-ray lateral radiographs, MR imaging showing disc degeneration or posterior protrusion signs.
3) Excluding other disorders: mainly excluding cervical sprain, frozen shoulder, rheumatic myofibrositis and other non-cervical origin of neck and shoulder pain.
2. Treatment principles.
1) Avoid and eliminate various triggering factors: pay attention to sleep and working position, avoid long-term neck bending, head and neck trauma, strain and cold stimulation.
2) Non-surgical therapy is the main treatment, physical therapy, massage, external use of neck circumference, light weight (1-1.5kg) traction therapy, etc. can make the symptoms relieved. In the acute stage, interspinous and paraspinous nerve block therapy is more effective.
(B) Neurogenic cervical spondylosis
1.Overview: intervertebral joint degeneration involving the cervical nerve roots, neck, shoulder and arm pain with sensory and motor disorders in the innervated area of the nerve roots is called neurogenic cervical spondylosis. It occurs in the cervical 4-5, cervical 5-6 and cervical 6-7 intervertebral spaces. It is more common clinically and accounts for 50%-60% of cervical spondylosis. According to the different clinical manifestations, neurogenic cervical spondylosis can be divided into three subtypes: radicular pain type, numbness type and atrophy type.
2. Clinical manifestations: (1) Root pain type Mostly disc herniation, intervertebral joint injury nerve root edema, aseptic inflammation and muscle spasm. The field involves motor, sensory and vegetative nerve fibers in the nerve roots.1. Symptoms The lesion is located above cervical 4, the pain is mainly manifested in the cervical from distribution area; the lesion is located in cervical 5-thoracic 1, the pain is mainly manifested in the brachial from nerve distribution area. At the beginning of the disease, only the posterior branch of the spinal nerve is showing radical pressure symptoms, such as severe pain in the muscles of the back of the neck and restriction of neck movement, and radiating pain in the arm appears 1-2 days later. It can be triggered by coughing and sneezing. 2. Signs 1) Restriction of neck movement with obvious directionality, and the pain increases when turning the neck to the healthy side. (2) There can be pressure pain behind the ear, in the shoulder arm, the internal superior scapula, the paravertebral muscle and the trapezius muscle. Striated or nodular reactions may be palpated in the paravertebral area. (3) Positive nerve root distraction test and pressure top test. (4) Sensory hypersensitivity in the innervated area of the nerve root at the beginning of the disease; when the nerve root has been compressed for a long time, the sensation in the innervated area is reduced; (5) Check the tendon reflexes of the brachialis and triceps muscle. In the early stage of the disease, the tendon reflex is active; in the middle and late stage of the disease, the tendon reflex is weakened or disappeared. (6) In mild cases of nerve root compression, the strength of the affected muscles is reduced, and in severe cases, muscle atrophy occurs.
× Due to the cross innervation of nerve roots, the involvement of one nerve root can appear as changes in the muscles innervated by multiple nerve roots, but there will not be complete paralysis. This is the point of differentiation between radicular and follower and stem nerve damage.
(7) The muscle tone of the involved muscles is increased at the early stage of the disease and decreased in the middle and late stages of the disease.
(B) Numbness type
1. Symptoms There is usually no pain or a slight soreness and swelling, highlighted by numbness in the involved area. (The lesion in cervical 5-6 shows numbness in the shoulder, arm and upper chest and back; the lesion in cervical 7-thoracic 1 is mainly numbness in the forearm and hand).
2.Signs
(1) Nerve root traction test or head tilt test may show radioactive numbness.
(2) Sensory impairment of the dermatomes innervated by the affected nerve roots.
(3) Numbness or soreness may appear when the affected paravertebral muscle or nerve root is pressed.
(4) X-ray examination Most small joint disorders, hyperplasia, and displacement.
3.Diagnosis
1) With more typical symptoms (pain, numbness) and its scope is consistent with the area innervated by the cervical spinal nerve.
2)The cervical compression test and upper limb pull test are mostly positive.
3) X-rays can show abnormalities such as changes in cervical curvature, nodal irregularities and spur formation, and MR imaging clearly shows the local pathological anatomy, including nucleus pulposus protrusion and prolapse, and the site and extent of spinal nerve root involvement.
4) The clinical manifestations are consistent with the abnormal imaging findings at the segmental level.
5) Substantial cervical skeletal lesions (tuberculosis, tumor, etc.), thoracic outlet syndrome, carpal tunnel syndrome, ulnar nerve, radial nerve and median nerve injury, periarthritis of the shoulder, tennis elbow and biceps tendinitis and other disorders with upper extremity pain should be excluded.
4.Treatment principles
1) Non-surgical therapy Various targeted non-surgical therapies have obvious efficacy, among which continuous (or intermittent) traction of head and neck, cervical braking and correction of poor posture have certain efficacy, and the application of nerve block therapy in the acute stage has obvious effect. In cases of nucleus pulposus protrusion and prolapse, the clinical manifestations are consistent with the imaging of the spinal nerve root involvement in the segment, and ozone and collagenase lysis therapy can be considered if regular non-surgical therapy is ineffective for more than 3 months.
2) Surgical treatment Surgery can be considered for anyone with progressive muscle atrophy and neurological dysfunction. For those with vertebral segment instability or root canal stenosis, internal fixation of the intervertebral interface can also be used at the same time to open up the vertebral segment and fix the fusion. Although the posterior cervical approach to decompression through incision of small joints is effective, it has been gradually abandoned because of the postoperative tendency to cause angular deformity of the cervical spine.
5.Prognosis
1) Most of the cases caused by simple cervical nucleus pulposus protrusion have a good prognosis, and there are few recurrences after cure.
2) Those whose nucleus pulposus has formed adhesions are prone to residual symptoms.
3) For those who are caused by hyperplasia of the hook vertebral joint, the prognosis is more satisfactory with early and timely treatment. If the disease is longer and subarachnoid adhesions have formed at the root canal, the symptoms are less satisfactory due to prolongation.
4) Patients with extensive osteophytes are not only complicated to treat, but also have a poorer prognosis.
(C) Atrophic type
This type is rare and has a poor prognosis. Initially, the affected muscles are weak, and then muscle atrophy occurs, with the involvement of the large and small interosseous muscles being the most common.
(C) Spinal cord type cervical spondylosis
1. Overview: Cervical spinal cord compression and spinal cord blood supply disorders caused by degeneration of the small joints and intervertebral discs of the cervical spine and the associated spinal cord-related myelopathy are called spinal cord cervical spondylosis. The onset of this disease is insidious, and it is not easy to diagnose and treat early. Late neurological damage is irreversible, and there will be limb dysfunction.
2.Pathogenesis
(I) Bone structure abnormalities
(1) Developmental spinal stenosis Under normal circumstances, there is a certain gap around the spinal cord, so that the spinal cord has a certain buffer space in the spinal canal, but developmental spinal stenosis reduces this space, so that the spinal cord is compressed by the protrusions in the spinal canal. 12CM or less is relative stenosis, and 10 or less is absolute stenosis.
(2) Bone formation As the peripheral tear of the degenerated fibrous ring separates it from the vertebral body edge, so that the nucleus pulposus moves forward under pressure and squeezes the anterior longitudinal ligament, generating excessive tension and stimulating the formation of new bone. As the intervertebral disc degenerates, the cells of the annulus fibrosus proliferate and give rise to chondrocytes, some of which proliferate beyond the edge of the intervertebral disc and give rise to endochondral bone formation.
(b) Soft tissue abnormalities of the spinal canal include disc degeneration, ossification of the posterior longitudinal ligament and calcification of the ligamentum flavum.
(C) the mechanism of spinal cord damage
1, the theory of compression, the onset of which is caused by two factors ① static factors, including spinal stenosis, disc herniation, posterior longitudinal ligament calcification, vertebral body posterior edge and intervertebral joint redundancy and ligamentum flavum hypertrophy, etc. ②Dynamic factors include degeneration, excessive motion caused by cervical instability.
2.Diagnostic criteria
The diagnosis of this type is mainly based on.
(1) Clinical manifestations of spinal cord compression, with the conus fasciculus sign being the main feature. The order of arrangement of the pyramidal tracts in the medulla is cervical, upper extremity, thoracic, lumbar, lower extremity and sacral nerve fibers in the order of inward and outward, which are divided into the following three types depending on the location of nerve fiber involvement.
Central type (also called upper limb type): It is because the deep part of the pyramidal bundle is involved first, because the nerve fiber bundle is close to the central canal, so it is called central type; the symptoms start from the upper limb first, and then spread to the lower limb. The pathological changes are mainly due to compression or stimulation of the sulcus arteriosus; if one side is compressed, the symptoms appear on one side; if both sides are compressed, the symptoms appear on both sides.
② Peripheral type (also known as lower limb type): refers to the pressure first acting on the surface of the cone bundle and the lower limbs first appear symptoms, when the pressure continues to increase and deep fibers, then the symptoms extend to the upper limbs, but the degree is still heavier than the lower limbs. The mechanism is mainly the result of direct compression of the anterior wall of the dural sac by the anterior canal bone or the prolapsed nucleus pulposus.
(3) Anterior central vascular type (also known as extremity type): that is, the upper and lower extremities at the same time. This is mainly caused by the involvement of the anterior central artery of the spinal cord, which causes ischemia in the anterior part of the spinal cord through the innervation area of this vessel and produces symptoms. This type is characterized by rapid onset of disease and rapid healing with treatment; non-surgical treatment is effective. The above three types can be divided into mild, moderate and severe according to the severity of symptoms. Mild refers to the early stage of symptoms, although there are symptoms, but can still adhere to work; moderate refers to those who have lost the ability to work, but can still take care of their own personal life; such as bed rest, can not go to the ground and lose the ability to take care of their own life, then belong to the severe degree. Generally speaking, if the pressure-causing substances are removed early, there is still hope for recovery in severe cases. However, if the spinal cord continues to develop until degeneration or even cavity formation occurs, it is difficult to reverse the function of the spinal cord.
(2) Numbness of the limbs This is mainly due to the involvement of the thalamic tract of the spinal cord. The order of the fibers of this bundle is similar to the former, from the inside out to the cervical, upper extremity, thoracic, lumbar, lower extremity and sacral nerve fibers. Therefore, the location and typing of symptoms are consistent with the former. The distribution of nociceptive and thermo-sensory fibers in the thalamic tract of the spinal cord is different from that of tactile fibers, and therefore the degree of compression varies, i.e. nociceptive and thermo-sensory deficits are obvious, while tactile sensation may be completely normal. This kind of dissociative sensory disorder is easily confused with spinal cord cavitation and should be distinguished clinically.
(3) Reflex disorder The main manifestations are.
① Abnormal physiological reflexes: Depending on the segment of the spinal cord affected by the lesion, there are corresponding changes in each physiological reflex, including the biceps, triceps and radial reflexes of the upper limbs, and the knee reflex and Achilles reflex of the lower limbs, which are mostly hyperactive or active. In addition, the abdominal wall reflex, testicular reflex and anal reflex may be weakened or disappear.
(2) Presence of pathological reflexes: Hoffmann’s sign and palmar chin reflex have the highest positive rate; ankle clonus, patellar clonus and Babinski’s sign may appear in the later stage of the disease.
(4) Defecation and urinary dysfunction Most of them appear in the later stage. At first, urinary urgency, poor emptying, urinary frequency and constipation are common, and gradually urinary retention or urinary and fecal incontinence appear.
(5) Imaging examinations may show various imaging findings such as sagittal narrowing of the spinal canal, vertebral segment instability (trapezoidal changes), osteophytes (bone spur formation), dural sac compression signs and spinal cord signal abnormalities.
(6) Other disorders should be excluded, including amyotrophic lateral sclerosis, spinal cord cavitation, spinal cord consumption, skull base depression, polyneuritis, spinal cord tumor, secondary adhesive spinal arachnoiditis, ataxia, and multiple sclerosis. Note that cases of coexistence of two or more disorders are often found clinically.
(7) Other tests such as cerebrospinal fluid aspiration, electromyography and evoked potentials can be used to assist in the diagnosis and differential diagnosis.
3.Treatment principles
(1) Non-surgical treatment
It is still the basic treatment for this type (the specific method is the same as before), especially the early central type (upper limb type) and the anterior central vascular type (limb type), about nearly half of the cases can obtain more obvious results. However, the disease should be closely observed during the procedure, and any rough manipulation and maneuvers should be avoided. Once the condition worsens, surgery should be performed early to prevent degeneration of the spinal cord.
(2) Surgical treatment
(1) Selection of surgical cases If.
(1) acute progressive cervical spinal cord compression symptoms are obvious and confirmed by clinical examination or other special examinations (magnetic resonance, CT scan, etc.), surgery should be performed as soon as possible.
(ii) those with a long duration of disease, with symptoms that continue to worsen and with a clear diagnosis
③ Although the symptoms of spinal cord compression are moderate or mild, they are not improved by non-surgical treatment for more than 1-2 courses and affect workers.
(2) Surgical approach and operation style The most effective surgical approach and operation style will be selected depending on the condition, patient’s general condition, operator’s technique and operation habit.
①Surgical approach: for those with cone bundle compression symptoms, the anterior approach should be adopted in principle. For those with sensory disorders and cervical spinal stenosis, the posterior cervical approach is the main approach. For those with both symptoms, depending on the operator’s habit, the anterior or posterior approach should be chosen first, and the need for another approach for decompression should be decided after l to 3 months according to the recovery situation.
②Surgical procedure: for herniated or prolapsed nucleus pulposus, nucleus pulposus removal is performed first, followed by internal fixation, bone graft fusion, or artificial disc implantation as appropriate. For those with spinal cord compression due to bone spurs, accidents may occur by dropping the spinal cord as appropriate.
4.Prognosis
The prognosis is better if the disc is herniated or prolapsed, and there are few recurrences after healing if protection can be paid attention to; the central type responds faster to various treatments and the prognosis is more satisfactory; the sagittal diameter of the spinal canal is obviously narrow with large
The prognosis is worse for those with a significantly narrow sagittal diameter of the spinal canal with large bone spurs or calcification of the posterior longitudinal ligament; the prognosis is worst for those with a disease duration of more than one year and severe disease, especially those with degeneration of the spinal cord; the prognosis is also worse for the elderly, especially those with serious systemic disorders or poor function of major organs (heart, liver, kidney, etc.); the first two should be treated with caution when choosing surgical treatment, and special care is needed when operating.
(D) Vertebral artery type cervical spondylosis
1.Overview
Its incidence is similar to the former, because most of them are caused by vertebral joint instability and are easily cured or improved by non-surgical treatment, so fewer people are hospitalized and operated on. This type is easily confused with a variety of disorders, and the diagnosis is often difficult to confirm before imaging of the vertebral artery. The diagnosis is often a controversial issue among the departments concerned.
2.Pathogenesis
The disease is a syndrome in which the vertebral-basilar artery supply is inadequately supplied with blood due to various mechanical and dynamic factors causing irritation or compression of the vertebral artery, resulting in narrowing and folding of the vessel.
3.Diagnostic criteria
Mainly based on the following points.
(1) Those who have signs of vertebrobasilar ischemia (mainly vertigo) and/or a history of sudden collapse.
(2) Positive rotational cervical provocation test.
(3) Radiographs showing intervertebral joint instability or osteophytes of the hook vertebral joint.
(4) generally have more pronounced sympathetic symptoms.
(5) Excluding ophthalmogenic and otogenic vertigo.
(6) Insufficient blood supply to the basilar artery due to compression of the first segment of the vertebral artery (the vertebral artery before entering the transverse foramen of the 6th cervical vertebra) is excluded.
(7) Excluding neurosis and intracranial tumors.
(8) The diagnosis of this disease, especially the preoperative localization, should be based on MR, DSA or vertebral arteriography; transcranial Doppler, vertebral arteriogram and cerebral hemogram may have reference value.
4.Treatment principles
(1) Non-surgical treatment is the basic treatment for this type, and more than 90% of cases can be treated, especially those caused by cervical instability, and most of them can be cured without leaving sequelae.
(2) Surgical treatment Surgery should be considered only in the following three cases.
(1) Obvious cervical vertigo or sudden collapse with at least 2 episodes.
(2) The non-surgical treatment is ineffective and it affects normal life and workers.
(3) Those who are confirmed by vascular digital subtraction, vertebral artery angiography or MRA.
5.Prognosis
The prognosis of this disease is mostly good, especially if it is caused by vertebral joint instability. The prognosis of cases with severe symptoms treated by surgery is also satisfactory.