Diagnosis of spinal cervical spondylosis
Cervical spondylotic myeloDathy (CSM) is one of the most common types of degenerative cervical spondylosis, and CSM is a common health hazard in middle-aged and elderly people. Since Brain reported a large group of cervical spine cases in 1952 and classified them into spinal and neurogenic types, the understanding of this disease has gradually increased. The symptoms of this disease are severe. Once treatment is delayed, irreversible neurological damage often occurs. In recent years, with the development of CT, MRI and other imaging techniques, research on the natural history, etiology and pathogenesis of CSM and continuous observation of a large number of clinical cases, the diagnosis of this disease has made great progress. Liu Yishan, Department of Integrative Orthopedic Treatment, Air Force General Hospital
1.Definition of CSM: The cervical disc degeneration itself and secondary pathological changes stimulate or compress the spinal cord and cause various neurological symptoms and signs, and its diagnosis is based on clinical manifestations, physical examination and imaging examination.
2, clinical manifestations of CSM: early stage may have neck pain, weakness and numbness of upper limbs, reduced fine motor function of hands, such as: difficulty in writing, tying buttons, difficulty in rapid gait and unstable gait of lower limbs, a feeling of stepping on cotton, and pain is a more common symptom. It is characterized by aggravation during sleep and relief during the day. The anterior spinal cord compression manifests as motor dysfunction, and because of the order of arrangement of nerve fibers innervating the cervicothoracic lumbosacral in the dermatomal spinal cord from inside to outside, the motor impairment after spinal cord compression is first in the lower extremities and then in the upper extremities, manifesting as weakness of the lower extremities, clumsy gait, trembling, etc. It gradually develops into increased muscle tone, easy to fall, and spastic paralysis in the late stage. Lateral posterior spinal cord compression shows sensory impairment, generally numbness in the lower extremities first, and gradually progresses upward without obvious sensory planes. However, there are also CSM with upper limb muscle atrophy as the main manifestation without sensory impairment, and this type should be distinguished from motor neuron disease.
CSM is usually preceded by loss of fine motor movements and unsteady gait before the appearance of pathological reflexes. It is worth mentioning that Hoflmann’s sign can be an important sign for early diagnosis of CSM if the patient elicits Hoffmann’s sign in the posterior extension of the head and neck. Although a positive Hoffmann’s sign can occur in normal individuals, a negative sign at rest and a positive sign at motion undoubtedly has important clinical significance. In addition, unilateral or bilateral ankle clonus has important clinical significance for CSM.
4. Imaging examination of CSM: MRl has obvious advantages among all imaging examinations, which can directly reflect the site of CSM, the degree of degenerative lesions in the involved stage and the relationship between adjacent tissues, and has important values for the diagnosis, differential diagnosis, treatment selection and prognosis of CSM. Therefore, when CSM is clinically suspected, it is best to perform MRI examination to make early diagnosis.
The current diagnostic criteria for CSM are: (1) clinical manifestations of spinal cord damage. (2) MRI confirms the compression of the spinal cord by the bone. (3) Excluding tumor, motor neuron disease, peripheral neuritis and other diseases.
Patients with conservative treatment of CSM should be followed up with MRI at an interval of 3 months to understand the state of the spinal cord and adjust the treatment plan in a timely manner according to the treatment content, effect and residual symptoms, and in conjunction with clinical practice.
Conservative treatment of spinal cord cervical spondylosis
In the treatment of cervical spondylotic myelopathy (CSM), which is one of the common types of degenerative cervical spondylosis and the most serious among the six types of cervical spondylosis, Rowland believes that the effect of surgery is not yet proven to be better than that of conservative treatment, and Zhao Dinglin and Ni Wencai believe that conservative methods At present, the treatment of CSM is still based on conservative comprehensive treatment, especially for patients with mild symptoms, and the specific treatment plan according to clinical results is as follows.
1, traction treatment to remove the dynamic injury factors of CSM, i.e. dynamic spinal stenosis, remove cervical muscle spasm, reduce nerve root edema and reduce intervertebral disc pressure, etc. The time, angle and traction force of cervical traction are very important. traction time: total quantitative l5～20 min, including continuous traction l0～i5 min, intermittent 5 min, in intermittent traction, intermittent traction is 20s, intermittent 10s. continuous traction force is equivalent to 15%-20% of its body weight, intermittent traction force is 10% of its body weight, traction force can start from small amount, gradually increase the weight. The angle of traction should be determined according to the onset site. Many scholars believe that cervical braking can help in the treatment of CSM. Braking can reduce the swelling and inflammatory reaction of the nerve tissue caused by the irritation of the nerve roots by the bone flab during spinal activity. It increases the available space due to the already impaired spinal cord and nerve roots. Traction therapy was performed on 128 cases of spinal cord-type cervical spondylosis, resulting in an overall efficiency of 97.7%. 87 cases of light CSM were observed through cervical braking and traction therapy, and it was found that patients with cervical degeneration, cervical disc herniation and spinal stenosis had varying degrees of symptom recovery after conservative treatment. The scores increased (P>0.05). The scores of patients with posterior longitudinal ligament calcification and ligamentum flavum lesions decreased (P>0.05), where the treatment satisfaction rate was highest for cervical disc herniation and exceeded that of posterior longitudinal ligament calcification and spinal stenosis (P<0.01). This indicates that there can be better functional recovery for light CSM through conservative treatment.
2, improve microcirculation treatment, early improvement of emblem circulation is significant, because the early stage of cervical medullary injury is winless changes, is reversible changes, timely improvement of microcirculation, can make CSM patients quickly improve symptoms, shorten the treatment period, and can make a part of CSM patients cervical medullary softening foci smaller.
(1) Low molecular dextrose 250ml plus Chuanxiongzin hydrochloride injection 160 mg VD, 1 time/d for 10d.
(2) Kaiser 10µg, 1 time/d for 10d.
(3) Haematopoietin Injection 0.5g, 1 time/d for 10d.
(4) Langshangxin injection Li 180mg, 1 time/d, for 10d.
3.Chinese herbal medicine chasing percussion 2 times / d, 20min each time.
(4) Closed treatment for the swollen small cervical joint capsule 1 time/week. Recipe: 2% lidocaine 2 ml dexamethasone 2 mg
5.Ultra-short wave treatment of the neck, once a day, 20 min each time, 10d for a course of treatment.
30 cases of spinal cord type cervical spondylosis were treated with ultrashort wave with manipulation, and the results showed that the total effective rate was 93.3%.
6.Manipulation treatment, several major manipulations currently used in clinical practice.
(1) spinal fixed-point rotational reset method once or twice a week; (2) tui-na manipulation with tendon division and tendon management as the main method; (3) small oblique moving method; (4) swinging method.
The following are the evidence for the treatment of CSM: (1) people with grade C or D or grade 2, 3 or 4 physical disability according to the American Spinal Cord Injury Association ASIA damage classification or 4D classification. (2) Degeneration and injury resulting in bulging cervical discs and mild hyperplasia at the posterior edge of the corresponding intervertebral space, but imaging shows that the stress point of spinal cord compression is a cervical disc herniation. (3) If the cervical MRl spinal cord signal is not obviously abnormal, but the multi-segmental cervical disc herniation with obvious hyperplasia and degeneration of the corresponding intervertebral space, and the dural sac is deformed by compression in the form of bead-like changes, if the stress point of extrusion is mainly the cervical disc rather than bony extrusion, and in accordance with (1) and (3) above.
For obvious osteophytes protruding into the spinal canal, and posterior longitudinal ligament ossification and yellow ligament hypertrophy, small joint hyperplasia and many other factors causing obvious spinal canal narrowing and extrusion of the dural sac, imaging shows that the stress point of spinal cord compression is mainly bony factors is contraindicated for manipulative treatment.
7.Other treatment
The results of 44 cases of CSM treated with ultraviolet irradiation and oxygenated self-blood transfusion now show significant effect in l4 cases and effective in 30 cases, but there is no change in the pathological reflexes, considering that the clinical manifestations are relieved by improving the microcirculatory function of tissues and organs, thus improving the function of spinal nerves.