Cervical spondylosis, also known as cervical spine syndrome, is a slowly progressive degenerative disease of the cervical spine, mostly seen in middle-aged and elderly people, but can also develop in adolescents. It is mainly due to the degeneration and protrusion of cervical discs, resulting in secondary changes in the surrounding tissues and structures, and causing a series of clinical manifestations.
I. Classification
Cervical spondylosis is generally divided into four types, each with its own characteristics. Clinicians should be able to determine the type of cervical spondylosis to which they belong through symptoms, signs and X-rays.
Generally, it can be divided into cervical type, nerve root type, vertebral artery type, sympathetic nerve type, spinal cord type, and esophageal type.
(I) Cervical type
It is the milder type of cervical spondylosis, dominated by cervical symptoms, in the beginning stage of cervical degeneration, and has a good prognosis. It is due to the dehydration of the nucleus pulposus and the fibrous ring of the intervertebral disc, degeneration with reduced tension, which in turn causes loosening and instability of the vertebral space, and the symptoms are often suddenly aggravated in the morning after rising, overwork, improper posture and cold stimulation.
1, symptoms: repeatedly fallen pillow, manifested as neck pain, swelling and discomfort and protective cervical muscle spasm. There is limited neck movement or forced position, transient upper limb numbness, abnormal sensation, etc.
2.Signs: cervical muscle tension, stiffness, pain when moving the neck with a smaller range of motion, pressure pain in one or both oblique muscles.
3.X-ray: the physiological curvature of the cervical spine changes to straightening or even reversion.
(II) Nerve root type
Common type, cervical spine hyperplasia, disc herniation, small joint hyperplasia, compression or stimulation of the nerve root, resulting in edema, inflammation, adhesion of the nerve root, and a series of clinical symptoms caused by the cervical 5-6 and cervical 6-7 gap.
1, symptoms: cervical stiffness and discomfort, neck, shoulder and arm pain can occur along the nerve root down the string and the arm has electric shock-like, pinprick-like numbness.
2.Signs: cervical spine movement is limited, cervical spine transverse process spine, supraspinal fossa, intra-superior and inferior scapular angle pressure pain, nerve root innervation area sensory and motor impairment, grip strength is weakened, pressure top test, brachial plexus pull test, head down test, head up test may be positive.
3.X-ray: abnormal physiological curvature of the cervical spine can be seen in ortho, lateral and left-right oblique positions, osteophytes on the anterior and posterior edges of the cone, narrowing of the intervertebral space, small joint hyperplasia, calcification of the anterior longitudinal ligament and collateral ligament, hyperplasia of the hook vertebral joint and narrowing of the intervertebral foramen.
(C) Vertebral artery type
Insufficient blood supply to the vertebral basilar artery caused by spasm or stenosis of the vertebral artery caused by hyperplasia of the hook vertebral joint, instability of the vertebral joint, loosening and displacement of the posterior joint, and stimulation or compression of the vertebral artery.
1, symptoms: headache, dizziness, cerebral ischemia is manifested as vertigo, nausea, vomiting, deafness, blurred vision and even sudden collapse when the head is turned to a certain orientation. When the head is in another orientation, or has fallen to the ground, it quickly improves.
2.Signs: positive rotation test, positive head-down and head-up test.
3.Imaging examination
(1) X-ray plain film: abnormal cervical physiological curvature, hyperplasia of the hook vertebral joint, narrow intervertebral foramen.
(2)Cerebral hemogram: abnormal
(3)Vertebral arteriogram: there may be compressive distortion, thinning or obstruction of the vertebral artery
(4) Magnetic resonance angiography may also show the travel path of the vertebral artery and its changes.
(D) Sympathetic nerve type
It is a symptom of cervical sympathetic nerve stimulation due to cervical conus minor joint hyperplasia and calcification of the posterior longitudinal ligament. It often coexists with inadequate blood supply to the vertebrobasilar artery because of the sympathetic nerve network around the cervical vertebral artery.
1. Symptoms: dizziness, headache, migraine, occipital or neck pain, blurred vision, cold limbs, tinnitus, deafness, etc.
2.Signs: tachycardia or bradycardia, unstable high and low blood pressure, low or tilted head test may induce symptoms or aggravate.
3.X-ray: degenerative changes of cervical spine
(E) Spinal cord type
It is the most serious type of cervical spondylosis, but the incidence is low, the onset is insidious, the symptoms are complicated, and it is often missed and misdiagnosed. Symptoms arise from developmental spinal stenosis, hyperplasia at the posterior edge of the cervical spine, and intervertebral disc lesions (bulge, protrusion, prolapse) compressing the spinal cord.
Symptoms: Symptoms vary depending on the location and degree of spinal cord compression, often starting with tightness in the lower extremities, numbness, difficulty walking, inability to walk fast, feet seemingly stepping on cotton, and a feeling of girdling in the chest or waist. Then there is numbness of one or both upper limbs, weakened hand grip, easy to hold objects falling, muscle atrophy, and in severe cases, quadriplegia (spastic paralysis) and urinary and fecal incontinence.
2.Signs: muscle atrophy, increased muscle tone, biceps, triceps, radial reflex, knee reflex, hyperactive Achilles reflex, positive pathological reflexes such as Hoffman, Babinski, ankle clonus.
3.X-ray plain film: osteophytes at the posterior edge of the cervical spine, narrowing of the spinal space, ossification of the posterior longitudinal ligament, etc. MRI examination: abnormal cervical curvature, vertebral body posterior margin hyperplasia, disc bulging, protrusion, prolapse, dural sac or spinal cord compression and deformation, and high signal in the spinal cord seen in a few TW2 images (suggesting focal ischemia or edema in the spinal cord).
(vi) Esophageal type
It is due to the stimulation or compression of the esophagus by the bone flab in front of the conus, causing mechanical compression by esophageal spasm and causing dysphagia.
1, symptoms: early difficulty in eating hard food, tingling, burning sensation, gradually affected to eat soft food also have difficulties.
2.Signs: difficulty in swallowing, aggravated when the neck is tilted up and reduced when the neck is flexed.
3.X-rays: Bone flab in front of the cone is obvious. Barium meal imaging: posterior esophageal compression and esophageal stricture.
II. Rehabilitation assessment
(I) Routine examination
1.Medical history
2.Symptoms: With the different subtypes of multi-type cervical spondylosis, there can be different symptoms.
3.Signs: With different subtypes of cervical spondylosis, there may be different signs and so on.
(II) Physical examination
1. Pressure top test. (also known as Spurling test), is the compression of the intervertebral foramen, triggering the appearance or aggravation of symptoms.
2, brachial plexus pull test. Positive if the patient has pain and numbness in the upper limbs.
3. Neck pulling test. That is, the intervertebral foramen separation test, the upper limb numbness and pain symptom reduction is positive.
4. Forward flexion and rotation test. If there is pain in the cervical spine, it is positive. It suggests degenerative changes in the small joints of the cervical spine.
5. Neck rotation test. Positive if the patient has dizziness. It is used to check vertebral artery type cervical spondylosis.
6. Head down test. Positive if the above symptoms are present.
7. Head tilt test. Significant for the diagnosis of different types of cervical spondylosis
(C) Special examination
1.X-ray plain film examination, which is an important basis for the diagnosis of cervical spondylosis.
2.CT examination, to understand disc protrusion, posterior longitudinal ligament calcification, spinal canal stenosis, transverse foramen size, etc. It is important for the diagnosis of ossification of the posterior longitudinal ligament.
3, MRI examination, to understand the degree of disc protrusion (bulging, protrusion, prolapse), dural sac and spinal cord compression, ischemia and edema foci in the medulla, whether cerebrospinal fluid interruption, nerve root compression, ligamentum flavum hypertrophy, spinal canal stenosis, etc.
4.Electromyography examination. It can identify neurogenic or myogenic muscle atrophy, and is meaningful for the diagnosis of nerve root type and spinal cord type.
5, cerebral hemogram examination. It is helpful for the diagnosis of sympathetic nerve type and vertebral artery type cervical spondylosis.
III. Rehabilitation treatment
Rehabilitation treatment of cervical spondylosis can achieve the purpose of reducing or eliminating symptoms. Its specific treatment methods include cervical spine traction, physical factor therapy and exercise therapy.
Patients with cervical spondylosis should usually be treated mainly by non-surgical therapy, but patients with obvious symptoms of spinal cord type and other types of patients with serious conditions that have been ineffective for a long time or have recurrent attacks need to consider surgical treatment.
1.The purpose of rehabilitation treatment
To reduce or eliminate symptoms and signs, and restore normal physiological function and working ability as much as possible.
The specific objectives are as follows.
(1) To reduce the pressure and stimulation of cervical nerve roots, dural sac, vertebral artery and sympathetic nerve.
(2) Release the adhesions and edema of the nerve roots.
(3) Relieve spasm of cervical, shoulder and arm muscles.
(4) Enhance the strength of the neck muscles and maintain the stability of the cervical spine. However, it is impossible for rehabilitation treatment to eliminate cervical disc degeneration and cervical spine osteophytes
2.Treatment methods
(1) Cervical traction
(1) Cervical traction can release the spasm of cervical muscles and relax the cervical muscles; restore the normal line of the cervical intervertebral joints; increase the size of the intervertebral foramen and release the nerve root irritation and compression; enlarge the vertebral space and reduce the pressure in the cervical intervertebral disc, which is favorable to the retraction of the bulging disc and the retraction of the protruding disc; stretch the distorted vertebral artery; and pull away the embedded small joint synovium.
The traction method is commonly used in the occipito-mandibular band traction method, in the sitting or lying position. The patient’s comfort should be used to adjust the angle.
Traction time of 10-30 minutes is appropriate.
Mode: continuous traction method, interval traction method.
Weight: can start from 6kg before the intra-vertebral space pressure changes, and gradually increase the weight to 12-15kg.
Angle Upper cervical spine, 0°-5°C4-5, 5°-10°C5-610°-15°, C6-7 15-20°, C7-120°-30°
③CautionThe angle, time and weight of traction are three important factors that determine the effectiveness of traction. The results of force test show that when the traction angle is small, the maximum stress position is close; when the traction angle increases, the maximum stress position shifts downward, so the traction angle should be selected according to the lesion site determined by X-ray. The dose of cervical traction should be decided according to the condition. Also should pay attention to the overall condition of the patient, such as good health, young, the dose can be larger, such as frail, elderly, traction time should be shorter, the weight should also be lighter. The patient’s reaction should be understood during the cervical traction process, and if there is discomfort or aggravation of symptoms, the treatment should be stopped in time to find the cause or change the treatment. Contraindications: Traction is not recommended for those with severe spinal cord compression, poor physical condition, or aggravation of symptoms after traction. Traction should not be used temporarily or cautiously for the acute phase of nerve root type and sympathetic type, spinal cord type dural compression or mild spinal cord compression.
(2) Physical factor therapy
①Ultra-short wave therapy: electrodes are placed on both sides of the back of the neck or electrodes are placed on the back of the neck and the forearm of the affected limb, with no heat for 12-15 minutes each time in the acute stage, and micro heat for 15-20 minutes each time in the chronic stage, with 10-15 times as a course of treatment. It is mostly used for patients with nerve root type (acute) and spinal cord type (spinal edema). This method can improve local blood circulation, subside edema, reduce nerve root irritation, and have a better pain relief effect.
②thermal therapy: infrared, wax therapy, Chinese herbal medicine hot compress, etc. can be used.
③Medium frequency electrotherapy: electrodes are often placed on both sides of the back of the neck, the size of the electricity is tolerated by the patient, different prescriptions can be selected according to different conditions, 20 minutes each time, this method is applicable to various types of cervical spondylosis.
④ Direct current ionization therapy: use various Chinese and Western drugs such as glacial acetic acid, potassium iodide, VitB12, wei ling xian, safflower, etc. placed at the back of the neck, connect the anode or cathode according to the performance of the drug, and place the other electrode on the affected forearm, and apply to various cervical spondylosis for 20 minutes each time with electricity.
⑤ Ultrasound: the sound head is placed at the back of the neck and the back of the shoulder on the affected side. Contact mobile method output power 0.8-1.5W/cm2, each time 10-15 minutes, once a day 15-20 times for a course of treatment. Other commonly used are magnetic thermal oscillation method, laser, interferential electrotherapy, etc.
(3) Exercise therapy
Neck medical exercises, passive active exercise therapy, etc., can enhance the muscle strength of the neck, shoulder and back muscles and correct poor posture.
(4) Joint loosening manipulation therapy Passive activity therapy is carried out through manipulation such as pushing and pulling and rotation of the cervical spine and small joints of the cervical spine by the operator in order to improve joint function and relieve pain.
(5) Traditional treatment Acupuncture and massage therapy: The main function is to unblock the meridians, reduce pain and limb numbness; relieve muscle tension and spasm, widen the intervertebral space and enlarge the intervertebral foramen; rectify synovial inlay and small joint subluxation; improve joint range of motion and release nerve root adhesions, etc.
(6) Drug treatment Relieve muscle tension; anti-inflammatory and pain relief; nourish nerves; improve vascular function; and mediate autonomic function.
(7) Neck orthoses The commonly used orthoses are
①soft type girth
②rigid adjustable neck brace
(3) strut type cervical orthosis. Provide support for the cervical spine, protect and limit the movement of the cervical spine. It is suitable for patients with acute attack or heavy symptoms, and the treatment effect is not consolidated, and should not be used for too long, so as not to cause adverse consequences such as muscle atrophy and joint stiffness of the neck and back.
3.Rehab education guidance
(1)Avoid injury
(2)Pay attention to keep warm
(3)Suitable pillow
(4)Working posture