The concept of cervical spondylosis is relatively ambiguous internationally, and the recognition of the disease is only a matter of recent decades. 1946 Bclast was named cervical syndrome because of the variety of symptoms and signs that appeared after the discovery of cervical spine lesions. Later, it was gradually recognized internationally and also called cervical spine syndrome in China is mostly called cervical spondylosis and defined as: those who irritate or compress the adjacent tissues due to cervical disc degeneration itself and its secondary changes and cause various symptoms and signs are called cervical spondylosis.
At present, the following classification methods are mostly used in China: cervical type, root type, spinal cord type, vertebral artery type, esophageal compression type and mixed type.
I. Cervical cervical spondylosis
This type is caused by degenerative changes of cervical vertebrae and is the most common in clinical practice, with mild symptoms.
1.Pathogenesis
At the early stage of cervical degeneration, the main manifestation is dehydration of the nucleus pulposus and the fibrous ring, degeneration and tension reduction, which in turn causes secondary loosening and instability of the vertebral space. It is often aggravated in the morning after waking up, overworking, postural disorders and cold stimulation. The destabilization of the vertebral joint does not public cause local imbalance of the cervical spine and defensive spasm of the cervical muscles, and at the same time directly stimulates the sinus – vertebral nerve endings distributed in the posterior longitudinal ligament and the root cuffs on both sides, resulting in cervical symptoms. At this time, I showed local pain, neck discomfort and restricted movement. In a few cases, there may be transient upper extremity symptoms due to reflex action, the scope of which is consistent with the affected vertebral segment. When the body establishes a new balance in the neck through compensation and adjustment, the above symptoms will gradually disappear.
2.Clinical characteristics
(1) Mostly in young adults, but for those with wide sagittal diameter of the spinal canal, the first onset may occur after 45 years of age.
(2) In addition to morning sickness (associated with high pillows or improper sleep posture), it is also common after prolonged head-down work or study, which indicates a direct correlation with increased pressure in the intervertebral disc space.
(3) The common symptoms are mainly neck pain and discomfort, especially patients often complain that they do not know what position to put their head and neck. About half of the patients have limited neck movement or are forced into a position, and individual cases may have transient sensory abnormalities in the upper extremities.
(4) The examination shows that the patient is mostly in “military upright position” (i.e., the neck is straight, and the physiological curvature is reduced or disappeared), and there can be pressure pain in the spine and interspinous process of the affected node, which is generally mild.
3.Imaging changes
In addition to the straightening or loss of cervical physiological curvature on X ray, the gap of the affected segment shows loosening (mild trapezoidal changes) in about one-third of cases on power lateral radiographs, and MR imaging shows early degeneration of the nucleus pulposus, and posterior protrusion of the nucleus pulposus can be found in a few cases.
4.Diagnostic criteria
(1) The patient complains of abnormal sensation such as pain in the neck, shoulder and occipital area with corresponding pressure points and stiffness of the neck.
(2) X-rays show changes in cervical curvature, lateral power films show intervertebral joint instability and loosening (mild trapezoidal changes), MR imaging shows disc degeneration or posterior protrusion.
(3) The main diseases that must be excluded are neck injury, shoulder periarthritis, rheumatic myofibrositis, neurasthenia and other painful neck and shoulder diseases not caused by intervertebral disc degeneration.
5.Treatment principles
(1) Non-surgical therapy is the main treatment. Various therapies are effective, such as self-traction, physiotherapy massage, herbal topical application, external application of cervical perimeter and intermittent or continuous cervical traction can relieve the symptoms, among which light and heavy traction (1-3Kg) is the most effective.
(2) Avoid and eliminate various triggering factors. Attention should be paid to sleep and work position, avoiding long-term neck flexion, head and neck trauma, strain and cold stimulation.
(3) Surgical treatment. Generally, surgery is not required, but if the symptoms persist, non-surgical treatment is ineffective and has seriously affected the quality of life, vertebral fusion can be used as appropriate; the efficacy is more satisfactory, but attention should be paid to safety and avoid complications.
6.Prognosis
Most of the cases are good, as long as attention is paid to protecting the neck and avoiding various triggering factors, the majority of cases can be cured, but if the neck load and various triggering factors are continued, the course of the disease may be prolonged or further developed.
Second, nerve root type cervical spondylosis
The incidence of this type is second only to the former and is more common clinically, mainly manifesting as sensory, motor and reflex disorders consistent with the spinal nerve subdivision.
1.Pathogenesis
It is mainly due to the protrusion or prolapse of the nucleus pulposus, osteophytes or traumatic arthritis of the posterior small joints, formation of bone spurs in the hook vertebral joints, and the loosening and displacement of the three adjacent joints (intervertebral joints, hook vertebral joints and posterior small joints), which can cause irritation and compression of the spinal nerve roots. In addition, narrowing of the root canal, adhesive arachnoiditis at the root cuff, and adjacent inflammation and tumors can cause similar symptoms.
Because of the complex pathogenesis of this type, the symptoms and clinical signs vary depending on the location and degree of optic nerve root involvement, such as more pronounced muscle strength changes if the anterior root is predominantly compressed, and more severe sensory disturbances if the posterior root is predominant. This is mainly due to the fact that in the narrow root canal, multiple tissues are densely packed together and there is no room for retraction. Therefore, when the anterior side of the spinal nerve root is compressed, the posterior side of the root canal is also compressed at the same time. Both sensory and motor disorders are mostly present at the same time. However, because the sensory nerve fibers are more sensitive, the sensory abnormalities are manifested earlier.
The mechanisms that cause various clinical symptoms are threefold.
(a) It is the compression, pulling and local secondary reactive edema of the spinal nerve roots by various compression-causing objects, which manifests as radicular symptoms at this time.
Second, it is the manifestation of cervical symptoms through the terminal sinus-vertebral nerve branches on the dural sac wall at the root cuff.
Third, it is the symptoms arising from the imbalance of the internal and external balance of the cervical spine on the basis of the first two, resulting in the local ligaments, muscles and joint capsule of the vertebral joint suffering from the implication of the tissue.
2.Clinical characteristics
(1) Cervical symptoms: vary in severity depending on the cause of radicular compression. If it is mainly caused by the herniated nucleus pulposus, it is mostly accompanied by obvious neck pain, paravertebral pressure pain, direct pressure pain or percussion pain of cervical spinous process or interspinous process, especially in the acute stage.
(2) Radicular pain: It is the most common, and its scope is consistent with the distribution area of the spinal nerve root of the involved vertebral segment. In this case, it must be distinguished from dry pain (mainly radial nerve trunk, ulnar nerve trunk and median nerve trunk) and plexiform pain (mainly cervical plexus, brachial plexus and axillary from). Accompanying with radicular pain are other sensory disorders distributed by this nerve, among which numbness, fingertip hypersensitivity and skin sensory loss are common.
(3) Radicular dysesthesia: It is obvious in those who have first compression of the anterior root, and the muscle tone is increased in the early stage, but soon weakens and the muscle atrophy. The involvement is limited to the muscle group innervated by the spinal nerve, and is most obvious in the hand with the interosseous and interosseous muscles. It should also be distinguished from dry and plexiform muscular atrophy, and should be distinguished from the muscle strength changes caused by spinal cord lesions.
(4) Tendon reflex changes: the reflex arcs involved in the spinal nerve roots are abnormal. In the early stage, the reflexes are active, but in the middle and late stages, they are diminished or disappeared. When examining the reflexes, they should be compared with the contralateral side.
(5) Special tests: Most of the pull tests that increase the tension of spinal nerve roots are positive, especially in the acute phase and posterior root compression. The negative cervical extrusion test is mostly seen in cases with nucleus pulposus herniation, nucleus pulposus prolapse and vertebral joint instability, while most of those due to crooked vertebral joint hyperplasia are less severe, and those due to intracanal occupying lesions are mostly negative.
3.Imaging changes
MR imaging can show disc degeneration, posterior protrusion of the nucleus pulposus and even protrusion into the root canal or spinal canal and mostly to the affected side.
4.Diagnostic criteria
(1) With typical radicular symptoms (numbness, pain, etc.) and its scope is consistent with the area innervated by the cervical spinal nerve.
(2) pressure neck test and upper limb pulling test are mostly positive, painful point closure is not significant, but the test is required for those with a clear diagnosis.
(3) abnormalities such as changes in cervical curvature, vertebral joint instability and bone spur formation can be seen on X-ray plain films, and MR imaging can clearly show the local pathological anatomy, including the protrusion and prolapse of the nucleus pulposus and the site and extent of spinal nerve root involvement.
(4) The clinical manifestations are consistent with the abnormalities seen on imaging.
(5) The cervical skeletal changes (such as tuberculosis and tumor), thoracic outlet syndrome, carpal tunnel syndrome, ulnar nerve, radial nerve and median nerve injury, periarthritis of the shoulder, tennis elbow and biceps tenosynovitis, and other disorders with upper extremity pain should be excluded.
5.Treatment principles
(1) Non-surgical therapy: Various non-surgical therapies with thorium have obvious effects, especially continuous or intermittent traction of the head and neck, cervical braking and correction of poor body position are more important. Manual massage is also effective, but should be strictly prevented from accidental occurrence.
(2) Indications for surgery: Surgery can be considered in the following cases: those who have been ineffective for more than 3 months with regular non-surgical treatment, and whose clinical manifestations, imaging and neurological localization are consistent; those with progressive muscle atrophy and severe pain; those whose work, study and life are affected by recurrent attacks despite the effectiveness of non-surgical treatment.
The procedure is not only effective, but also has little effect on the stability of the cervical spine. For those with vertebral segment instability or root canal stenosis, internal fixation of the intersegmental interface can also be used at the same time to prop up the vertebral segment and fix the fusion. The posterior cervical approach is effective but has been gradually abandoned because of the postoperative tendency to cause angular deformity of the cervical spine.
6.Prognosis
(1) The prognosis is good in most cases due to simple cervical nucleus pulposus protrusion, and recurrence is rare after cure.
(2) Those whose nucleus pulposus prolapse has formed adhesions are prone to residual symptoms.
(3) For those caused by hyperplasia of the hook vertebral joint, the prognosis is more satisfactory with early and timely treatment. If the disease is of long duration and subarachnoid adhesions have formed at the root canal, the prognosis is less satisfactory due to prolonged symptoms.
(4) In cases of radicular pain caused by extensive osteophytes, the treatment is not only complicated, but also has a poor prognosis.
3.Spinal cord type cervical spondylosis
This type is less common than the previous two types, but because of the seriousness of symptoms and the development of “trapped invasion”, it is easy to be misdiagnosed as other disorders and delay the treatment. Therefore, it is called cervical spondylosis.
1.Pathogenesis
(1) Congenital factors: mainly refers to the developmental stenosis of the cervical spinal canal, and scholars at home and abroad have confirmed that the sagittal diameter of the cervical spinal canal is the main factor constituting the early onset and development of excitatory spinal cord cervical spondylosis. From the etiological point of view, it is the pathological-anatomical basis for other etiologies in this type. Unless the size of the occupying lesion is too large, the incidence of a large spinal canal is significantly lower than that of a narrow one, and even if symptoms appear, they are mostly mild and easily cured.
(2) Dynamic factors: mainly refers to instability and loosening of the vertebral segments, expansion and invagination of the posterior longitudinal ligament, posterior protrusion of the nucleus pulposus, anterior protrusion of the ligamentum flavum, and other factors that may protrude into the spinal canal and cause pressure on the spinal cord that can be eliminated or reduced by postural changes.
(3) Mechanical factors: refers to osteophytes, bone spur formation, nucleus pulposus prolapse, especially those who have formed adhesions that cannot be returned, and those who have adhesions in the subarachnoid space. Most of these factors are the main causes of sustained compression of the spinal cord on the basis of the former.
(4) Vascular factors: Spinal cord blood vessels and their blood supply, like the blood vessels in the brain, have a very amazing ability to regulate to maintain the blood supply to the spinal cord in various complex activities, and the blood supply in its party state and abnormal state can differ by about 20 times. If a group of blood vessels suffers from compression or stimulation, spasm, stenosis or even thrombosis can occur, which feeds or interrupts the blood supply to the spinal cord.
In severe cases, irreversible consequences may occur. Clinically representative sites include: quadriplegia caused by compression of the anterior central spinal artery, upper extremity paresis due to ischemia in front of the central canal of the spinal cord caused by compression of the sulcus artery (which may also spread to the lower extremities), spinal cord irritation caused by soft spinal membrane ischemia, and spinal cord degeneration caused by restriction of the great root artery. These factors, which are difficult to detect clinically, actually play an important role in the pathophysiological changes of the spinal cord.
The spinal cord tissue in the bony fiber canal is easily irritated and compressed due to these four factors. In the early stage, the symptoms such as increased muscle tone, hyperreflexia and sensory hypersensitivity appear due to the stimulation of the spinal cord itself or the anterior spinal artery or the sulcus arteriosus on the basis of the spinal stenosis by dynamic factors, and there are large fluctuations. The consequences can be irreversible.
2. Clinical features
(2) Cone bundle sign: It is the main characteristic of spinal cord cervical spondylosis, and its mechanism is due to the direct compression of the cone bundle (corticospinal bundle) by the pressure-causing material or the reduction of local blood supply. Clinically, it starts with weakness of the lower limbs, tightness of the legs and heavy lifting, and gradually develops symptoms such as cotton foot, floating, limping, easy to fall, inability to lift the toes off the ground, clumsy gait and a feeling of chest binding.
On examination, hyperreflexia, ankle and knee clonus, muscle atrophy and other typical symptoms of cone bundle can be found. Most of the abdominal wall reflexes and testicular reflexes are diminished or disappeared, and objects held in the hands tend to fall down (this indicates that the deep part of the cone bundle is involved).
The order of arrangement of the pyramidal events in the medulla, from inside to outside, is cervical, upper extremity, thoracic, lumbar, lower extremity and sacral nerve fibers, depending on the location of the involvement of the bundle fibers can be divided into the following three types.
(1) Central type (upper limb type): It is called central type because the deep part of the pyramidal bundle is involved first and the nerve fiber bundle is near the central canal. The symptoms begin in the upper extremities and then spread to the lower extremities. The pathological changes are mainly due to compression or irritation of the sulcus arteriosus. If one side is compressed, the symptoms appear on one side, and if bilateral compression occurs, the symptoms appear bilaterally.
(2) Peripheral type (lower extremity type): the squeezing pressure acts on the conus fasciculus first and the lower extremity, but the degree is still heavier in the lower extremity. The mechanism of its occurrence 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 (extremity type), that is, the upper 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 healing with treatment and effective non-surgical treatment.
The above three types can be divided into mild, moderate and severe according to the severity of symptoms. Mild refers to the early appearance of symptoms, although there are symptoms, but can still adhere to the work; moderate refers to the loss of work ability, but personal life can still be self-care; such as bed rest, can not go to the ground and lose the ability to take care of themselves, is a severe. Generally speaking, if the pressure-causing substance can be removed early, there is still hope for recovery, but if the spinal cord continues to develop until degeneration or even cavity formation, it will be difficult to reverse the function of the spinal cord.
(2) Body numbness: This is due to the simultaneous involvement of the thalamic tract of the spinal cord. The order of arrangement of fibers in this bundle is similar to the former, from inward to outward, the nerve fibers in the cervical, upper extremity, thoracic, lumbar, lower extremity and sacral areas, so the site of symptoms and their separation are consistent with the former. The pain and temperature sensory fibers in the thalamic tract of the spinal cord also differ, i.e., pain and temperature disturbances 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.