Part I Overview
Cervical spondylosis is a common and prevalent disease with a prevalence of about 3.8%-17.6% and a male to female ratio of about 6:1.
The Second National Symposium on Cervical Spondylosis (Qingdao, 1992) defined cervical spondylosis as a degenerative change of the cervical disc and its secondary pathological changes involving the surrounding tissue structures (nerve roots, spinal cord, vertebral artery, sympathetic nerve, etc.), with corresponding clinical manifestations. Degenerative changes of the cervical spine without clinical manifestations are called cervical degenerative changes.
With the increase in the number of people engaged in the modern way of working with their heads down, such as the widespread use of computers and air conditioners, the chances of people flexing their necks and suffering from wind, cold and dampness are increasing, resulting in the increasing prevalence of cervical spondylosis, and the trend of younger age of onset.
Part II Classification of cervical spondylosis
According to the different tissues and structures involved, cervical spondylosis is divided into: cervical type (also called soft tissue type), nerve root type, spinal cord type, sympathetic type, vertebral artery type, and other types (at present, it mainly refers to esophageal compression type). If two or more types exist at the same time, it is called “mixed type”.
I. Cervical cervical spondylosis
Cervical cervical spondylosis is caused by acute or chronic injury to the neck muscles, ligaments and joint capsule, degeneration of the intervertebral disc, instability of the vertebral body, misalignment of small joints, etc. On the basis of wind and cold attack, cold, fatigue, improper sleeping posture or inappropriate pillow height, the cervical spine is over-extended or over-flexed, and certain muscles, ligaments and nerves in the neck are strained or compressed. It mostly develops at night or in the morning, and has the tendency of natural remission and recurrent attacks. 30-40 years old women are more common.
Nerve root type cervical spondylosis
Neurogenic cervical spondylosis is caused by irritation and compression of cervical nerve roots in the spinal canal or intervertebral foramen due to disc degeneration, herniation, segmental instability, osteophytes or bone superfluous formation. It has the highest incidence among all types, accounting for about 60-70%, and is the most common type in clinical practice. Mostly unilateral and single-root onset, but there are also bilateral and multi-root onset cases. It is most common in people aged 30-50 years and usually has a slow onset, but there are also cases with acute onset. There are more males than females by a factor of one.
C. Spinal cord type cervical spondylosis
The incidence of spinal cord cervical spondylosis accounts for 12-20% of cervical spondylosis and has a high disability rate because it can cause limb paralysis. It usually starts slowly and is more common in middle-aged people aged 40-60. When combined with developmental cervical spinal stenosis, the average age of onset is younger than that of patients without spinal stenosis. Most patients have no history of cervical trauma.
IV. Sympathetic cervical spondylosis
Sympathetic nerve dysfunction arises due to factors such as disc degeneration and segmental instability, which cause stimulation of sympathetic nerve endings around the cervical spine. Sympathetic cervical spondylosis has a wide range of symptoms, most of which are sympathetic excitation symptoms and a few are sympathetic inhibition symptoms. Since the surface of the vertebral artery is rich in sympathetic nerve fibers, when sympathetic nerve dysfunction occurs, the vertebral artery is often involved, resulting in abnormal diastolic function of the vertebral artery. Therefore, sympathetic cervical spondylosis is often accompanied by inadequate blood supply to the vertebrobasilar system along with symptoms of several systems in the body.
V. Vertebral artery type cervical spondylosis
In normal people, when the head is tilted or twisted to one side, the vertebral artery on the same side is squeezed and the blood flow of the vertebral artery is reduced, but the vertebral artery on the opposite side can compensate, thus ensuring that the blood flow of the vertebrobasilar artery is not greatly affected. When segmental instability and narrowing of the intervertebral space occur in the cervical spine, the vertebral artery can be distorted and compressed; the vertebral artery can be directly compressed by the vertebral margins and the bony bulge at the hook vertebral joint, or the sympathetic nerve fibers around the vertebral artery can be stimulated, resulting in spasm of the vertebral artery and instantaneous changes in vertebral artery blood flow, leading to inadequate blood supply to the vertebrobasilar system, and therefore no symptoms outside the vertebral artery system.
Part III Clinical manifestations of cervical spondylosis
I. Cervical cervical spondylosis.
1, cervical straightness and pain, there may be pain and stiffness in the whole shoulder and back, and the head cannot be nodded, tilted, and head-turning activities, and the posture is oblique neck. When the neck needs to be turned, the trunk must be turned at the same time, and the symptoms of dizziness may also appear.
2. A few patients may have reflex shoulder, arm and hand pain, swelling and numbness, and the symptoms do not worsen when coughing or sneezing.
3.Clinical examination: In the acute stage, the cervical spine activity is absolutely limited, and the range of motion of the cervical spine in all directions is nearly zero. There is pressure pain in the cervical paraspinal muscles, thoracic 1 to thoracic 7 paraspinal or rhomboid muscles, sternocleidomastoid muscles, and there may also be pressure pain in the supraspinatus and infraspinatus muscles. If there is secondary spasm of the anterior oblique muscle, the spastic muscle can be found on the medial side of the sternocleidomastoid muscle, which is equivalent to the level of the transverse process of cervical 3 to cervical 6, and with slight pressure, radiating pain can appear in the shoulder, arm and hand.
Second, nerve root type cervical spondylosis
1. Neck pain and neck stiffness are often the earliest symptoms. Some patients also have pain in the shoulder and the medial edge of the scapula.
2.Radiation pain or numbness in the upper extremities. This pain and numbness radiates along the course and innervation area of the affected nerve root and is characteristic, hence the term root-type pain. The pain or numbness can be episodic or persistent. Sometimes there is a clear relationship between the appearance and relief of symptoms and the position and posture of the patient’s neck. Neck movement, coughing, sneezing, exertion and deep breathing can cause aggravation of symptoms.
3. The affected upper extremity feels heavy, has reduced grip strength, and sometimes appears to hold objects falling down. There may be vasomotor nerve symptoms, such as swelling of the hand. Muscle atrophy can occur in the late stage.
4. Clinical examination: neck stiffness and restricted movement. Tension in the affected neck muscles, pressure pain in the spinous process, paraspinal process, medial edge of the scapula and muscles innervated by the affected nerve roots. The presence of pressure pain in the intervertebral foramina with radiating pain or numbness in the upper extremities, or aggravation of existing symptoms, has localizing significance. A positive intervertebral foramen compression test and a positive brachial plexus nerve pull test are indicated. Careful and comprehensive neurological examination can help localize the diagnosis.
C. Spinal cord type cervical spondylosis
1. Most patients first experience numbness and heaviness in one or both lower limbs, and then gradually experience difficulty in walking, tightening of various groups of muscles in the lower limbs, slow lifting and inability to walk fast. Then, when going up and down the stairs, it is necessary to hold the handrail with the upper limb in order to ascend the steps. In severe cases, the gait is unstable and walking is difficult. Patients have the feeling of stepping on cotton in both feet. Some patients start insidiously, often trying to catch a bus that is about to leave, but suddenly find that the legs cannot walk fast.
2. Numbness and pain in one or both upper limbs, weakness and inflexibility in both hands, difficulty in completing fine movements such as writing, fastening, holding chopsticks, etc., and easy to drop objects. In severe cases, the patient cannot even eat by himself.
Patients often feel a belt-like binding sensation in the chest, abdomen, or both lower limbs, called “belt sensation”. At the same time, there may be burning and cold sensation in the lower extremities.
4. Some patients have bladder and rectal dysfunction. Such as weak urination, frequent urination, urgent urination, incomplete urination, urinary incontinence or urinary retention and other urinary disorders, constipation. Sexual function is reduced.
Further development of the disease, the patient must be crutched or assisted by others to walk, until the emergence of spastic paralysis of both lower limbs, bedridden, unable to take care of themselves.
5. Clinical examination: There are no signs in the neck. The upper extremities or trunk have segmental distribution of superficial sensory disorders, deep sensation is normal, muscle strength is reduced, and grip strength of both hands is reduced. The muscle tone of the extremities is increased, and there may be a sense of folding knife; tendon reflexes are active or hyperactive: including biceps, triceps, radial membrane, knee tendon, Achilles reflex; patellar clonus and ankle clonus are positive. Positive pathological reflexes: such as Hoffmann’s sign, Rossolimo’s sign, Barbinski’s sign and Chacdack’s sign in the upper limbs. Superficial reflexes such as abdominal wall reflex and tic reflex were diminished or absent. If the tendon reflexes of the upper extremity are diminished or absent, it suggests that the lesion is at the level of that nerve segment.
IV. Sympathetic cervical spondylosis
1. Head symptoms: such as dizziness or vertigo, headache or migraine, head sinking, occipital pain, poor sleep, memory loss, difficulty in concentration, etc. Occasionally, people may fall down due to dizziness.
2. Eye, ear, nose and throat symptoms: eye swelling, dryness or tearfulness, vision changes, blurred vision, fog in front of the eyes, etc.; tinnitus, ear blockage, hearing loss; nasal congestion, “allergic rhinitis”, foreign body sensation in the throat, dry mouth, vocal cord fatigue, etc.; taste changes, etc.
3, gastrointestinal symptoms: nausea or even vomiting, bloating, diarrhea, indigestion, belching, and foreign body sensation in the throat, etc.
4.Cardiovascular symptoms: palpitations, chest tightness, heart rate changes, arrhythmias, blood pressure changes, etc.
5. Excessive sweating, no sweating, chills or fever on the face or a certain limb, sometimes pain and numbness but not according to the distribution of nerve segments or travels.
The above symptoms are often clearly related to neck activities, aggravated when sitting or standing, and alleviated or disappeared when lying down. It is obvious when there are many neck activities, prolonged head bowing, long working hours in front of computer or exertion, and improves after rest.
6.Clinical examination: the neck activity is normal, and the soft tissue around the interspinous process of the cervical spine or the paravertebral small joints is painful. Sometimes it may also be accompanied by changes in heart rate, heart rhythm, blood pressure, etc.
V. Vertebral artery type cervical spondylosis
1. Episodic vertigo with diplopia accompanied by nystagmus. Sometimes it is accompanied by nausea, vomiting, tinnitus or hearing loss. These symptoms are related to the change in the position of the neck.
2.Sudden weakness of lower limbs and sudden collapse, but consciousness, mostly occurs when the head and neck are in a certain position.
3. Occasionally, there is numbness and abnormal sensation in the limbs. Transient paralysis and episodic coma may occur.
Part IV Diagnostic criteria of cervical spondylosis
I. Clinical diagnostic criteria
1.Cervical type: with typical history of falling pillow and the above-mentioned cervical symptoms and signs; imaging examination may be normal or only have physiological curvature change or mild spinal space narrowing, with little bone formation.
2, neurogenic type: symptoms (numbness, pain) and signs of radicular distribution; positive intervertebral foramen squeeze test or/and brachial plexus pull test; imaging findings are basically consistent with clinical manifestations; pain due to extra-cervical pathology (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, biceps long head tenosynovitis, etc.) is excluded.
3, spinal cord type: clinical manifestations of cervical spinal cord damage; imaging shows cervical degenerative changes, cervical spinal stenosis, and confirms the presence of cervical spinal cord compression consistent with clinical manifestations; except for progressive amyotrophic lateral sclerosis, spinal cord tumor, spinal cord injury, secondary adhesive arachnoiditis, multiple peripheral neuritis, etc.
4, sympathetic type: diagnosis is more difficult, and there is a lack of objective diagnostic indicators. Clinical manifestations of sympathetic nerve dysfunction and imaging show segmental instability of the cervical spine are present. In some patients with atypical symptoms, if the symptoms are reduced after planetary ganglion closure or high cervical epidural closure, it will help the diagnosis. Vertigo due to other causes besides.
(1) Otogenic vertigo: vertigo is caused by vestibular dysfunction in the inner ear. For example, Meniere’s syndrome and embolism of the auditory artery in the ear.
(2) Ophthalmogenic vertigo: refractive error, glaucoma and other ophthalmic disorders.
(3) Brain-derived vertigo: inadequate blood supply in vertebrobasilar artery due to atherosclerosis, lacunar cerebral infarction; brain tumor; sequelae of traumatic brain injury, etc.
(4) Vertigo of vascular origin: vertebrobasilar artery insufficiency due to stenosis of V1 and V3 segments of vertebral artery; hypertensive disease, coronary heart disease, pheochromocytoma, etc.
(5) Other causes: diabetes, neurosis, overexertion, long-term sleep deprivation, etc.
(5) Vertebral artery type: previous sudden collapse attack with cervical vertigo; positive spin neck test; imaging shows segmental instability or hook joint hyperplasia; except for other causes of vertigo; positive neck motion test.
II. Imaging and other auxiliary examinations
X-ray examination is an important tool for the diagnosis of cervical spine injury and certain disorders, and is also the most basic and commonly used examination technique for the neck, and is an important examination method that cannot be ignored even under the highly developed conditions of imaging technology.
X-rays provide an imaging basis for determining the severity of injury, treatment selection, and treatment evaluation. The whole cervical spine frontal and lateral radiographs, cervical extension and flexion dynamic lateral radiographs, oblique radiographs, and cervical 1-2 open radiographs and tomography films are often taken when necessary. Orthopantomographs can be seen as acromegaly or transverse hyperplasia of the hook vertebral joint and narrowing of the intervertebral space; lateral films can be seen as poor compliance of the cervical spine, retroflexion, narrowing of the intervertebral space, formation of bone redundancy at the anterior and posterior edges of the vertebral body, osteosclerosis of the upper and lower edges of the vertebral body (motion endplate), and developmental cervical spinal stenosis; hyperflexion and hyperextension lateral positions can have segmental instability; left and right oblique films can be seen as narrowing and distortion of the intervertebral foramen. Sometimes a high-density striated shadow at the posterior edge of the vertebral body can be seen – Ossificationofposteriorlongitudinalligament (OPLL).
Cervical spinal canal measurement (see Figure 1): on a lateral cervical radiograph, the ratio of the midsagittal diameter of the spinal canal to the midsagittal diameter of the vertebral body is diagnosed as developmental cervical spinal stenosis if the ratio is less than or equal to 0.75 on any of the vertebral segments C3 through C6. Segmental instability is important in the diagnosis of sympathetic cervical spondylosis and is measured (see Figure 2): i.e., on a lateral cervical hyperflexion-extension film, the sum of the distance from the point at which the extension of the posterior border of the vertebral body line intersects the inferior border of the slipped vertebral body to the posterior border of the same vertebral body ≥
MRI examination of the neck can clearly show the changes within the spinal canal and the spinal cord, as well as the site and morphological changes of spinal cord compression, which is of great value for the diagnosis of cervical spine injury, cervical spondylosis and tumor. When the cervical intervertebral disc degenerates, its signal intensity also decreases, and the diagnosis of disc herniation can be accurately made in both the sagittal and cross-sectional planes. In the diagnosis of cervical spine diseases, magnetic resonance imaging can not only show the extent and degree of backward compression of the dural sac by cervical spine fractures and disc herniation, but also reflect the pathological changes after spinal cord injury. Intraspinal hemorrhage or substantial damage generally appears as a dark and gray image on T2-weighted images. In contrast, spinal cord edema often appears as a uniformly dense striated or pyknotic signal.
Transcranial color Doppler (TCD), DSA, and MRA can probe basilar artery blood flow and intracranial blood flow in the vertebral artery and presume vertebral artery ischemia, which is an effective means of examining inadequate blood supply to the vertebral artery and is a common test for clinical diagnosis of cervical spondylosis, especially vertebral artery cervical spondylosis. Vertebral arteriogram and vertebral artery “ultrasound” can be helpful in diagnosis.