Part I Preface
Cervical spondylosis is a common and frequent disease.
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 tissues (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.
Cervical cervical spondylosis is caused by acute or chronic injury to the muscles, ligaments and joint capsule of the neck, degeneration of the intervertebral disc, instability of the vertebral body, misalignment of small joints, etc. The body is attacked by wind and cold, cold, fatigue, improper sleeping posture or inappropriate pillow height, which makes the cervical spine over-extend or over-flex, 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.
II. Neurogenic 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 redundancy 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, single-root onset, but there are also bilateral, multi-root onset. It is usually seen in people aged 30 to 50 years old, and usually has a slow onset, but there are also cases of acute onset. It is more common in males than females.
III. Spinal cord 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 between 40 and 60 years old. 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 occurs 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 associated with inadequate blood supply to the vertebrobasilar system in addition to symptoms of multiple systems.
V. Vertebral artery type cervical spondylosis
In normal individuals, when the head is tilted or twisted to one side, the vertebral artery on the same side is compressed, reducing the blood flow to the vertebral artery, but the vertebral artery on the opposite side can compensate, thus ensuring that the blood flow to the vertebrobasilar artery is not greatly affected. When there is segmental instability and narrowing of the intervertebral space 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 of the hook vertebral joint, or the sympathetic nerve fibers around the vertebral artery can be stimulated, causing spasm of the vertebral artery and instantaneous changes in vertebral artery blood flow, resulting in inadequate blood supply to the vertebrobasilar artery.
Therefore, symptoms are not associated with symptoms outside the vertebral artery system.
Part III. Clinical manifestations of cervical spondylosis
I. Cervical spondylosis Cervical cervical spondylosis
1. The neck is tense and painful, and there may be painful stiffness in the whole shoulder and back, and the head cannot be nodded, tilted, or turned, and the posture is oblique. When the neck needs to be turned, the trunk must be turned at the same time, and the symptoms of dizziness may also appear.
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 paravertebral muscles, thoracic 1 to thoracic 7 paravertebral or oblique muscles, and sternocleidomastoid muscles, and there may also be pressure pain in the supraspinatus and infraspinatus muscles. If there is secondary anterior oblique muscle spasm, the spastic muscle can be found in the medial aspect 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 in the shoulder, arm and hand can occur.
II. Nerve root type cervical spondylosis
1. Neck pain and neck stiffness are often the first symptoms to appear. Some patients also have pain in the shoulder and the medial edge of the scapula.
2. Radiating 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 may appear 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 crush test and a positive brachial plexus nerve pull test are indicated. Careful and thorough neurological examination helps to localize the diagnosis.
III. Spinal cord type cervical spondylosis
1. Most patients first experience numbness and heaviness in one or both lower extremities, followed by gradual difficulty in walking, tightness of various groups of muscles in the lower extremities, 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. In some patients, the onset of the disease is insidious, often trying to catch a bus that is about to leave, but suddenly find that the legs can not 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. If the disease develops further, the patient can only walk with the help of crutches or others, until there is spastic paralysis of both lower limbs, bedridden and 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 mostly normal, muscle strength is decreased, and grip strength of both hands is decreased. Tendon reflexes are active or hyperactive, including biceps, triceps, radial membrane, knee tendon and Achilles tendon reflexes; 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 extremities. Superficial reflexes such as abdominal wall reflex and testicular reflex are weak or absent. If the tendon reflexes of the upper extremity are weak or absent, 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 teariness, 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 and even vomiting, bloating, diarrhea, indigestion, belching and foreign body sensation in the throat.
4.Cardiovascular symptoms: palpitations, chest tightness, heart rate changes, arrhythmias, blood pressure changes, etc.
5, face or a limb sweating, no sweating, chills or fever, sometimes pain, numbness, but not according to the distribution of nerve segments or travel. 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：Normal neck movement, soft tissue pressure pain between the spinous processes of the cervical vertebrae or around the small joints of the paravertebrae. Sometimes it may 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. It is sometimes accompanied by nausea, vomiting, tinnitus or hearing loss. These symptoms are related to the change of neck position.
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.