Although this type of cervical spondylosis is rare, its symptoms are serious and it develops in an insidious and aggressive manner, so it is easy to be misdiagnosed as other diseases and delay treatment. It is called spinal cord cervical spondylosis because it mainly compresses or stimulates the spinal cord and the accompanying blood vessels, resulting in sensory, motor, reflex and bowel dysfunction of the spinal nerves. Many patients do not recognize the seriousness of the disease, and some are treated in neurology or massage and physiotherapy departments, while some patients suffer serious consequences, even paralysis, due to failure to treat or mis-treatment. It should be paid enough attention, and its differential diagnosis is especially important. Xia Jianlong, Department of Orthopedics and Traumatology, Jiangsu Provincial Hospital of Traditional Chinese Medicine
I. Spinal cord tumor
Patients have pain or numbness in the neck, shoulder, arm and fingers, with damage to lower motor neurons in the ipsilateral upper limb and damage to upper motor neurons in the lower limb. The symptoms gradually develop to the contralateral lower limb and finally reach the contralateral upper limb. Sensory loss and motor deficits below the plane of compression begin as Brown_Sequard syndrome and eventually progress to the phenomenon of transverse spinal cord damage. It is characterized by.
(i) X-ray plain film showing enlarged intervertebral foramina and destruction of the vertebral body or arch.
(ii) Spinal iodine oil imaging with an inverted cup shape at the site of obstruction and a negative Queckenstedt test for spinal puncture.
③In cases of complete obstruction, the cerebrospinal fluid is yellow, easily coagulated, and has an increased protein content.
II. ossification of the posterior longitudinal ligament
Because ossification of the posterior longitudinal ligament narrowed the spinal canal and affected the blood circulation of the spinal cord. In severe cases, it can compress the spinal cord and cause paralysis. Myelogram and CT and MRI are very helpful for its diagnosis.
Occipital foramen magnum tumor
Its symptoms are posterior occipital pain, spastic paralysis of ipsilateral upper limb, and development to lower limb, ipsilateral lower limb and contralateral upper limb. There is atrophy of hand and forearm muscles. Sometimes sensory changes may occur. It is characterized by (i) myelography, where the obstruction is high and the iodine oil is difficult to reach the cranial cavity. ②Symptoms of cranial recess cerebral nerve may appear. ③Late stage may cause elevated cerebral pressure with fundus edema and signs of meningeal irritation.
IV. Spinal cord adhesion arachnoiditis
The manifestations are neurological symptoms of the sensory (anterior) and motor (posterior) roots of the spinal nerve, or symptoms of the conduction tract of the spinal cord. queeckenstedt test with incomplete or complete obstruction. There is no certain value for the increase in cell count and protein. It is characterized by difficulty in passing iodine oil through the subarachnoid space during myelography, with wax tear-like changes.
V. Spinal cavernous disease
(1) Overview: This disease and medullary cavitation are both chronic degenerative lesions, characterized by intramedullary cavity formation and gliosis, which progresses slowly and affects the upper extremities in a segmental distribution in the early stage, and when the cavity gradually expands, the long conduction tracts in the white matter of the spinal cord can also be involved due to the increasing pressure or gliosis, which can be clinically confused with cervical spondylosis. It occurs in the cervicothoracic segment and sometimes feels pain in the arm. Its characteristics are: (1) it occurs in young people, mostly 20-30 years old. The pain sensation is separated from other deep and superficial sensations, and the loss of temperature sensation is obvious.
(2) Differentiation points.
When the lesion spreads to the anterior joint, there may be bilateral loss of pain and temperature sensation in the hand, ulnar side of the forearm and part of the neck and chest, while touch and deep sensation are basically normal, which is called sensory dissociative disorder. Patients with cervical spondylosis do not have this phenomenon.
②Dystrophic disorder: As nociceptive disorder can not only cause local ulcers and burns, thickening of subcutaneous tissues and sweating dysfunction, but also excessive hyperplasia and abrasive changes in the joints and even hyper-limited activities without pain, which is called Charcot joint. It should be distinguished from those caused by spinal consumption.
VI. Primary lateral sclerosis
This is a neurological disease of unknown origin, which manifests as bilateral damage to the pyramidal tract, increased muscle tone, loss of superficial reflexes, and muscle atrophy when the motor tract of the corticospinal cord is invaded.
It is characterized by.
①No sensory impairment.
②Queckenstedt test was clear.
(iii) No obstruction on myelogram. If the lesion affects the cortical medullary tract, pseudo-medullary palsy (pseudobulbar palsy) may appear.
VII. Amyotrophic lateral sclerosis
(1) Overview: This disease is a type of motor neuron disorder, a disease with unexplained damage to the motor nuclei of the brainstem, corticospinal tracts and anterior horn cells of the spinal cord. Its etiology is still unknown. The onset of the disease is slow and occurs in the cervical expansion of middle-aged people. The disease has no effective treatment and has a poor prognosis. Surgery may aggravate the disease or cause death, while patients with spinal cord cervical spondylosis require early surgery.
① Muscular atrophic paralysis of the upper limbs, with small muscles evident and eagle-claw shaped hands.
(2) Spastic paralysis of the lower limbs with active or hyperactive tendon reflexes.
③ When the lesion progresses to the brainstem, death may occur due to medullary paralysis.
(2) Differentiation points.
① Age characteristics: Patients with spinal cord type cervical spondylosis are mostly above 45 to 50 years old, while the disease has an early onset, often starting around 40 years old in younger people or even around 30 years old.
②Sensory impairment: this disease is generally no sensory impairment, only some cases can have complaints of sensory abnormalities; while in patients with cervical spondylosis when the spinal cord is compressed with motor disorders, they are accompanied by symptoms and signs of sensory impairment.
③Speed of onset: cervical spondylosis has a slow onset and is often accompanied by certain triggers, while this disease has a sudden onset without any cause, often starting with muscle weakness and developing rapidly.
Myasthenia gravis: Although the disease can occur in any part of the body, the upper limbs are the first to develop, especially in the small muscles of the hands. The large and small interphalangeal muscles and earthworm muscles atrophy, metacarpal space depression, hands can be hawk claw-shaped and rapidly develop to the elbow and shoulder of the forearm, and even cause muscle weakness and atrophy of the neck, so such cases should be routinely examined sternocleidomastoid, scapularis and neck muscles to determine whether there are signs of atrophy. Because cervical spondylosis is more common in cervical 5-6, cervical 6-7 and cervical 4-5, the level of muscle involvement rarely exceeds that of the shoulder.
(5) Autonomic symptoms: This symptom is rarely seen in this disease but is often encountered in patients with spinal cord-type cervical spondylosis.
(6) Dysphonia: When lateral sclerosis affects the medulla oblongata (which may appear at the beginning of the disease but mostly in the later stages of the disease), dysphonia may appear and affect the masticatory muscles and swallowing action, while patients with spinal cord cervical spondylosis do not have this symptom, and only when the lesion affects the vertebral artery do they have mild dysphonia.
(7) Sagittal diameter of the spinal canal: it is mostly normal in this disease, while patients with spinal cord cervical spondylosis show more obvious stenosis signs.
(8) Cerebrospinal fluid examination: Patients with cervical spondylosis tend to have incomplete obstruction and abnormal biochemical examination of cerebrospinal fluid, while patients with this disease tend to be normal.
⑨ Myelography: all patients with this disease are negative, while patients with cervical spondylosis have positive findings.
⑩Other: including electromyographic signs, muscle biopsy, and CT and MRI examinations that are unique to each stage of the disease can help in the differential diagnosis of the disease and spinal cervical spondylosis.
The prognosis of this disease is poor, and there are no effective measures to stop the progression of this disease, and most of them die of various complications or respiratory disorders several years to more than ten years after the onset of the disease.
Ataxia
The disease has obvious heredity, and depending on the characteristics of the lesion, it is divided into juvenile spinal ataxia (also known as Friedreich’s ataxia), spinal cerebellar ataxia, cerebellar ataxia and peripheral ataxia, and there are many subtypes.
It is not difficult to differentiate this disease from spinal cord cervical spondylosis. The key is to have a clear understanding of this disease and to pay attention to the presence of symptoms such as limb ataxia, nystagmus and limb hypotonia during the physical examination of the patient to help determine the disease.
9. Skull base depression
(1) Overview: In recent years, this disease is not rare because there is no specific treatment, and patients often seek treatment between the outpatient clinics of various hospitals. Because it can cause spinal cord compression symptoms, it should be differentiated from spinal cord cervical spondylosis.
(2) Differentiation points: The main basis: this disease is a congenital malformation, with its inherent clinical characteristics.
①Short neck appearance: mainly due to the concavity of the upper cervical spine into the skull.
② Marker measurement abnormalities: the following two are commonly used clinically.
A. Skull base angle: the angle formed by the pterygoid saddle and slope is 132°, if it exceeds 145°, it is flat skull base.
B. Hard palate – occipital foramen line: also known as Chamberlain line, that is, the line from the posterior edge of the hard palate to the posterior superior edge of the occipital foramen under normal circumstances, the tip of the odontoid process of the cardinal vertebrae is lower than this line, if it is higher than this line, it is a flat skull base.
③Other: patients with this disease have an early age of onset, starting from 20 to 30 years old; clinically, it is mostly manifested as spastic paralysis of the limbs, and its location is higher and heavier than that of patients with spinal cervical spondylosis; it is mostly accompanied by painful oblique neck deformity and other deformities of the cervical skeleton; intracranial symptoms may appear if the disease causes increased intracranial pressure at a later stage.
Ten, multiple sclerosis
(1) Overview: This disease is a kind of central nerve demyelination disorder whose etiology is not well understood, and it can be easily confused with spinal cervical spondylosis because of the presence of cone bundle symptoms and sensory disorders.
Although this disease is rare in China, it is not rare. It can cause sensory disorders and spastic paralysis of the limbs similar to spinal cervical spondylosis, so it should be considered in the diagnosis. There is no special treatment for this disease. Surgery can aggravate the disease and even cause accidents, so do not misdiagnose.
(2) Differentiation points: mainly based on the following five points for differentiation.
① Prevalent age: mostly between 20 and 40 years old, more women than men.
(2) Psychiatric symptoms: there are varying degrees of psychiatric symptoms, often euphoric emotionally impulsive.
③Dysarthria: If the lesion affects the cerebellum, dysphonia or even vocal cord paralysis may occur.
(iv) Cerebral neurological symptoms: the optic nerve is mostly involved, but other cerebral nerves may also be affected.
⑤ Ataxia symptoms: may appear when the lesion affects the cerebellum.
Peripheral neuritis
(1) Overview: The disease is a peripheral neuropathy caused by toxic infection and post-infection metaplasia, mainly manifesting as symmetrical or asymmetrical (rare) limb motor, sensory and autonomic dysfunction. It can be single or multiple, and those with acute onset due to viral infection or autoimmune deficiency are called acute polyneuritis (Guillain-Barre syndrome).
(2) Differentiation points: The main basis is the symmetrical symptomatic features of the disease, including.
(1) Symmetric motor disorders: usually manifest as symmetric flaccid, incomplete paralysis with emphasis on the distal extremities, which is different from asymmetric spastic paralysis in cervical spondylosis.
(2) Symmetrical sensory disorders: Bilateral symmetrical glove-sock-like hypesthesia of the upper or lower extremities may occur, which is rare in patients with cervical spondylosis.
(③) Symmetric autonomic dysfunction: The main manifestations are vasodilatory sweating and trophic changes in the hands and feet.
In addition, other relevant examinations such as X-ray, MRI and CT can also be referred to the medical history. Myelography is generally not required for non-specific conditions.
XII. Secondary adhesive spinal arachnoiditis
(1) Overview: In recent years, it has been found that this disease is increasing. In addition to trauma, long-term compression of the spinal cord and spinal nerve roots, it is mostly caused by puncture, intradural or extradural injection, subarachnoid space block and myelography, etc. Therefore, it is mostly a medical factor.
(2) Differentiation points.
(1) Medical history: There is a history of spinal puncture, drug injection or myelography, especially certain irritating contrast agents (which are no longer used by everyone) are more likely to cause.
(ii) radicular irritation symptoms: more obvious, especially those with longer duration of disease often show radicular pain which is more widespread and persistent and may have periods of remission, but intensifies when increasing abdominal pressure.
(iii) Imaging changes: previous iodine oil imaging shows candle tear shadows in the spinal canal on X-ray, mostly scattered on both sides of the root cuff. In addition, MRI technique can show the extent and degree of subarachnoid space adhesions more clearly, which helps to differentiate it from spinal cord type cervical spondylosis, but there are many cases with both.
XIII. Cervical medullary hyperextension injury
(1) Overview: Cervical medullary hyperextension injury, also known as central spinal canal syndrome, is a type of cervical trauma and is easily confused with anterior central spinal artery syndrome caused by hyperextension injury based on cervical spondylosis, which mostly requires conservative therapy first, while the latter requires early surgery.
(2) Differentiation points.
① mechanism of injury: both onset after head and neck trauma, overextension injury is mostly caused by high-speed vehicle emergency braking, due to the role of inertia, the passenger face and jaw, chin suffered a frontal impact, so that the head and neck backward over-extension; at this time has been elongated spinal cord (spinal canal also becomes relatively narrow) is easy to suddenly be embedded in the anterior process of invagination of the ligamentum flavum and the fibrous canal wall in front of the bone caused by the central canal of the spinal cord In patients with anterior central spinal cord syndrome, the spinal cord spasm and stenosis of the anterior central spinal cord artery are caused by the sudden head and neck bending violence based on the bone spur or herniated nucleus pulposus at the posterior edge of the vertebral body, and the symptoms of incomplete blood supply are caused by the impact of the anterior spinal cord on the bony or cartilaginous compressive object.
(2) Motor disorders: Since the pathological changes of hyperextension injury are located around the central canal of the spinal cord, the nerve conduction bundles of the upper extremities are first involved and the upper extremities are paralyzed first, or the upper extremities are heavier than the lower extremities, especially in the hands, while patients with anterior central spinal cord artery syndrome are completely opposite, with paralysis being heavier in the lower extremities and lighter in the upper extremities.
(iii) Sensory impairment: Patients with anterior central spinal cord syndrome have less sensory involvement. In contrast, patients with hyperextension injury not only have obvious symptoms, but also have sensory dissociation, i.e., the disappearance of warmth and pain, and the presence of position and deep sensation, mainly due to the lesion located near the central canal.
④Imaging changes: X-ray plain film of the two have obvious differences hyperextension injury in the lateral observation can be found in the affected section of the intervertebral space in front of the widening and the front shadow of the vertebral body is significantly widened more than one times the normal value, while patients with anterior central spinal artery syndrome due to the formation of bone spurs on the basis of the onset of not only the presence of more bone superfluous, and the canal is generally narrower (wide spinal canal is not easy to develop).
⑤ Other: the presence or absence of soft tissue injury to the face and jaw or the back of the head, as well as the patient’s age and medical history, can be used to differentiate. Myelography is generally not required.