Cervical spondylosis seriously affects the normal work and life of human beings, and neurogenic cervical spondylosis accounts for a larger proportion of all types of cervical spondylosis. As the understanding of neurogenic cervical spondylosis continues to deepen, the standardization of diagnosis and treatment of this disease has become more and more important. In 2010, the Beijing Municipal Commission of Science and Technology established a project on the standardization of diagnosis and treatment of neurogenic cervical spondylosis in the key project of “Research on diagnosis and treatment standardization and rehabilitation technology of common orthopedic diseases”, and this consensus was completed under the funding of this project.
The process of forming this consensus: the draft was formed on the basis of extensive search of high-quality related literature at home and abroad in recent years and reference to the existing diagnosis and treatment norms of cervical spondylosis in China, while the modified Delphi method was applied to collect experts’ feedback and to obtain relevant data for trial implementation in the hospitals where the expert group members are located; the expert group conducted several in-depth discussions around the draft content, feedback and relevant data obtained from trial implementation, and continuously revised and improved the draft. The consensus was finally formed after 3 years of continuous revision and improvement.
This consensus aims to provide clinical workers in China with guidance that is suitable for our national conditions and meets the requirements of standardized treatment.
I. Overview
Neurogenic cervical spondylosis refers to the symptoms and signs of radicular compression or irritation due to degenerative changes in the cervical discs and intervertebral joints involving the cervical nerve roots of the corresponding segments. The pathological features of degenerative changes are mainly degenerative protrusion of the cervical intervertebral disc, formation of osteophytes at the posterior edge of the vertebral body of the corresponding segment or osteophytes of the hook vertebral joint. Its onset is mostly unilateral, but can also be bilateral, mostly seen in people aged 40 to 60 years old, with a slow onset and a high incidence in people with poor posture such as long-term desk work, motor vehicle drivers and prolonged head bowing. The natural history of most patients is self-limiting, and the symptoms can be relieved by themselves.
Clinical manifestations
(A) Symptoms
1. The characteristic symptoms are unilateral or bilateral numbness and (or) radiating pain in the upper limbs along the nerve root innervation area.
2. Neck pain and stiffness are often the earliest symptoms, and may be accompanied by pain in the shoulder, medial edge of the scapula or chest and back, which may be aggravated by neck activity, coughing, sneezing and deep breathing.
3.There may be a popping sensation when the neck is moved.
4.Self-perceived heaviness and weakness of the upper limbs, sometimes holding objects falling down.
5.Symptoms of vasomotor nerve may be present (such as swelling sensation in the hand), and muscle atrophy and muscle bundle tremor may be present in the advanced stage.
(II) Physical signs
1.Sensory changes in the area innervated by the affected nerve roots, weakened muscle strength, weakened or disappeared muscle pressure pain and tendon reflexes, and no obvious effect of pain point closure.
2, neck stiffness, restricted movement, tension in the affected neck muscles, pressure pain in the muscles of the spinous process, paraspinal process and the affected back, pressure pain in the intervertebral foramen and increased pain in the upper limbs.
3, brachial plexus pull test: one hand to support the neck to do confrontation, the other hand will be the affected limb abduction, reverse pull, if the affected upper limb radiating pain or numbness is positive.
4.Cervical compression test/intervertebral foraminal squeeze test: the patient’s head is slightly tilted back or inclined to the affected side, and the head is compressed downward with the hand, and the radiating pain of the affected upper limb is positive.
5.Neck pulling test: if the head is pulled upward and the neck and arm pain is relieved, the test is positive.
6.Head percussion test: Place one hand flat on the patient’s head and the other hand lightly percuss the back of the hand. Discomfort and pain in the neck or pain and soreness in the upper limbs (one or both sides) are considered positive.
7. Locate the signs and symptoms of nerve damage caused by nerve root compression (mainly in the intervertebral foramen area) (Table 1).
(C) auxiliary examinations
1. X-ray.
Narrowing of the vertebral space in the diseased segment, osteophytes or formation of bone superfluous at the upper and lower edges of the vertebral body and the hook vertebral joint; cervical spine sequence changes can be seen in lateral films; cervical instability can be seen in hyperextension and hyperflexion lateral films; cervical intervertebral foramina osteophytes or narrowing can be seen in double oblique films.
2.MRI.
Degeneration and protrusion of the intervertebral disc, thickening of the posterior longitudinal ligament and ligamentum flavum, osteophytes or bone superfluous formation of the posterior edge of the vertebral body and the hook vertebral joint, compression of the nerve roots and part of the dural sac on one or both sides, and local high signal changes of the spinal cord may be accompanied.
3.CT.
It can show the posterior edge of the vertebral body of the diseased segment, osteophytes or bone superfluous formation of the hook vertebral joint, and whether there is ossification of the posterior longitudinal ligament.
4.Electromyography (EMG).
For patients with MRI suggestive of multi-segmental lesions, it helps to clarify the responsible nerve segment; and helps to differentiate it from other neuropathies.
III. Diagnosis
1, Presence of localized radicular compression manifestations, typical radicular symptoms and signs, and the scope is consistent with the area innervated by cervical spinal nerve roots.
2. Positive brachial plexus pull test or cervical compression test.
3.X-ray and CT examination suggest the formation of osteophytes or osteophytes around the nerve roots due to degenerative changes in the cervical spine, or the manifestation of intervertebral foraminal stenosis; MRI examination suggests the compression of nerve roots.
4. Excluding the disorders of upper limb pain such as frozen shoulder, thoracic outlet syndrome, tennis elbow and substantial lesions of cervical vertebrae (such as TB, tumor, etc.).
It should be noted and emphasized that the diagnosis of neurogenic cervical spondylosis requires the mutual conformity of clinical symptoms, signs and auxiliary examination results to be established; the possibility of C4 neurogenic cervical spondylosis should be considered when neck pain is accompanied or not accompanied by bilateral upper limb radicular symptoms.
IV. Differential diagnosis
(A) Disorders with pain and numbness in the neck, shoulder and/or upper limbs
1. Myofasciitis of the neck and shoulder, periarthritis of the shoulder.
It is a chronic strain disease, related to prolonged poor posture and age; it manifests as non-specific shoulder and arm pain, which can be identified by careful physical examination, radicular pain and sensory abnormalities.
2. Thoracic outlet syndrome.
Due to the compression of cervical plexus nerve roots by cervical ribs, fasciculations, anterior oblique muscles or compression of C8 and T1 nerve roots by subclavian vessels, the vascular murmur at the lower cervical spine and X-ray showing cervical ribs help to diagnose this disease.
3. Progressive myasthenia gravis.
Progressive, symmetric, predominantly proximal flaccid paralysis and muscle atrophy characterized by lower motor neuron disease, and with a certain degree of heredity; muscle atrophy mostly from the small muscles of the hand, tendon reflexes disappeared, can be accompanied by evoked back “muscle tremor” performance, but no sensory impairment; sternocleidomastoid electromyography can help diagnose.
4, ulnar neuritis.
The manifestation is numbness of the ring finger, little finger and intrinsic hand muscle atrophy, there may be a history of elbow trauma; pressure pain at the elbow nerve sulcus, positive ulnar canal Tinel’s sign, sometimes the cord-like degeneration of the ulnar nerve can be touched, and there is no forearm numbness.
5. External epicondylitis of the humerus.
Also known as “tennis elbow”, localized pain over the elbow, aggravated by exertion; mostly with a history of repeated elbow flexion and extension, rotational exertional strain, positive pressure pain at the humeral epicondyle, positive Mills sign.
6. Carpal tunnel syndrome.
The carpal tunnel is caused by the decrease in volume or increase in pressure in the carpal tunnel, which causes pressure on the median nerve in the tunnel; the main manifestation is numbness and pain in the 3-4 fingers on the radial side, thumb abduction, weakness of the opposite palm, and inflexibility of movement; positive Tinel’s sign of the carpal tunnel and positive Phalen’s sign.
7. Angina pectoris.
There may be severe pain in the back of the shoulder, often accompanied by pain in the precordial region and shortness of breath manifested by chest tightness, while there are obvious changes in the electrocardiogram, and taking nitroglycerin-type drugs can relieve the symptoms.
(II) Other types of cervical spondylosis
1. Cervical cervical spondylosis.
Pain in the occipital area and neck and shoulder, restricted head and neck movement, cervical muscle tension, mostly without upper limb symptoms; X-ray examination shows cervical spine sequence changes and degenerative changes.
2.Spinal cord type cervical spondylosis.
Upper limb weakness and inflexibility, lower limb weakness, gait instability, severe cases with urinary and fecal dysfunction, hyperactive tendon reflexes of the limbs, increased muscle tone, positive pathological signs, MRI examination suggests obvious cervical degenerative spinal cord compression.
3. Sympathetic cervical spondylosis.
Cervical vertigo and associated with postural changes, along with a variety of symptoms such as palpitations, unstable blood pressure or blurred vision; cervical intervertebral instability manifestations are seen on X-ray examination.
(C) Substantial lesions of cervical vertebrae
1, cervical spine tuberculosis.
Previous history of unexplained fever, night sweats, weakness, weight loss and other toxic symptoms, pain at night or persistent pain is obvious, imaging examination can be seen intervertebral destruction as the main manifestation, can form a posterior convex deformity or cervical spine lesions poor segmental sequence.
2.Cervical spine tumor.
Neck pain, persistent and progressive aggravation performance, may be accompanied by motor and sensory disorders. The imaging examination can see the destruction of vertebral body bone, and the tumor tissue can be compressed into the spinal canal.
V. Evaluation criteria
It is necessary to quantitatively evaluate the clinical condition of patients with neurogenic cervical spondylosis before and after treatment. The commonly used scoring criteria include VAS pain score, NDI cervical dysfunction index, and Odom clinical efficacy assessment criteria.
VI. Treatment and prevention
(I) Non-surgical treatment principles
It is suitable for those with clear diagnosis, mild symptoms or short presentation time, and is the basis of surgical treatment.
1. Neck braking.
When the symptoms are mild or standing activities, the neck should be braked with a neck brace; when the symptoms are severe or when resting in a lying position, it is recommended to brake in a flat hard bed and use a low hard pillow, and during the treatment period, the patient should lie in bed as much as possible and reduce the sitting time and neck flexion, the time limit is 1~3 weeks.
2.Physical therapy (selectively recommended).
Continuous occipito-mandibular band traction, acupuncture treatment, infrared spectrum irradiation, etc. to improve symptoms.
3.Medication.
Helps to reduce symptoms caused by neurogenic cervical spondylosis in the acute stage, with a recommended time limit of 2 weeks. Main drugs: (1) non-steroidal anti-inflammatory analgesics (NSAIDs), COX-2 inhibitors, opioid analgesics; (2) neurotrophic drugs; (3) muscle relaxants (selectively recommended); (4) dehydration drugs (selectively recommended); (5) steroids (selectively recommended); (6) blood circulation and blood stasis herbal medicines (selectively recommended).
4.Psychotherapy.
For the longer duration of the disease should be taken seriously, and antidepressant treatment should be given if necessary.
(II) Surgical treatment
1. Indications for surgery.
(1) obvious neck and shoulder pain, pain and numbness radiating to one or both upper extremities for more than 8 weeks after conservative treatment has failed, or the patient clearly requests; (2) numbness and pain of neck and shoulder pain and upper extremities repeatedly for more than half a year, seriously affecting work and life, and recently aggravated; (3) obvious upper extremity radiated pain and numbness, and accompanied by muscle atrophy and muscle strength loss on one side, imaging examination shows that the lesion segment cervical (3) there is obvious upper limb radiated pain, numbness, with one side of muscle atrophy and muscle loss, imaging examination shows that the lesion segment cervical disc protrusion or vertebral body posterior edge, hook joint bone superfluous formation compression nerve root or dural sac, or lesion segment obvious intervertebral instability.
2. Contraindications to surgery.
(1) those with serious medical diseases; (2) those who are too old and weak to tolerate surgery; (3) those with psychiatric disorders or menopausal neurosis; (4) those with severe extensive muscle atrophy of the limbs and spinal cord dysfunction.
3.Surgical methods.
(1) Anterior cervical open surgery: including anterior cervical interbody decompression + fusion, anterior cervical sub-total vertebral body dissection + fusion, anterior cervical interbody decompression + dynamic non-fusion implantation, anterior cervical interbody decompression + artificial cervical disc implantation. (2) Posterior cervical open surgery: including cervical laminectomy and decompression, cervical expanded laminoplasty and decompression + nerve root canal decompression, and local nerve root decompression. (3) Minimally invasive percutaneous surgery: including percutaneous minimally invasive cervical disc radiofrequency ablation and percutaneous minimally invasive cervical disc laser decompression.
(C) Prevention
1.Avoid or correct bad posture.
2.Moderate physical exercise and functional training (such as back tension band structure exercise, etc.).