Definition of cervical spondylosis With the increase in per capita life expectancy and the increasing tension of modern life, as well as the increasing level of disease awareness, it is now recognized that the incidence of cervical spondylosis exceeds that of lumbar and leg pain and is currently the most common disease in neurological and surgical clinics.
The incidence of cervical spondylosis, foreign surveys show that 25% of people around 50 years of age are suffering or have suffered from cervical spondylosis, and 50% at the age of 60, while the incidence after the age of 70 is more than 80%. The incidence may be higher in China.
From an occupational point of view, desk workers are most common, and if they work more than 4 hours a day, the incidence of cervical spondylosis increases exponentially every 3 years as the working life increases.
Cervical spondylosis is a group of symptoms and signs caused by degenerative degeneration of the cervical disc itself and its secondary changes that irritate or compress the adjacent tissues.
A brief review of the anatomy.
The cervical spine consists of 7 vertebrae, the first, second and seventh cervical vertebrae are called special cervical vertebrae because of their special morphology: atlas, pivot and rongeur respectively; the third to sixth cervical vertebrae are called common cervical vertebrae because of their similar morphology, they are located in the center of the physiological forward flexion of the cervical spine and are subject to the greatest stress and thus are the most susceptible to degeneration and are the most frequent sites of cervical spondylosis.
The bony component of the common cervical spine can form three important skeletal structures, which are the front vertebral body, which is the back tail, bifurcated, and becomes the spinous process, and the two sides are the vertebral plates, which enclose the spinal canal, with transverse foramina on both sides and intervertebral foramina formed between the upper and lower vertebral bodies. The vertebral canal contains the cervical spinal cord, the transverse foramen has the vertebral artery running through it, and the spinal nerve roots pass through the intervertebral foramen.
So what connects the cervical vertebrae to each other? This is the second anatomical structure that we break down, the intervertebral disc. The intervertebral disc is the main connecting structure between the vertebrae, and its height accounts for 1/4 of the entire cervical spine. The first intervertebral disc consists of the upper and lower cartilage plates, the nucleus pulposus in the middle and the surrounding fibrous ring. In addition to connecting the vertebral bodies, the cervical intervertebral disc also serves as a hub to participate in the flexion, rotation, and posterior extension of the cervical spine and plays a role in slowing down the concussion during cervical spine activities.
Etiology and pathology of cervical spondylosis.
Having understood the anatomy of the cervical spine and intervertebral discs in the definition, we now analyze the degenerative degeneration of the cervical discs described in the definition. Cervical disc degeneration is the most fundamental cause of cervical spondylosis. In normal intervertebral discs, dehydration and water absorption dysfunction of the nucleus pulposus begins to occur after the age of 20 years, the semipermeable membrane of the cartilage plate degenerates, the annulus fibrosus degenerates and ruptures, and the intervertebral disc thus bulges, protrudes, and even prolapses. This is the process of cervical intervertebral disc degeneration.
What are the secondary changes caused by cervical disc degeneration?
First, the bulging and protrusion of the disc lifts the periosteum and ligament, and bleeding occurs under the periosteum, leading to the formation of a ligamentous disc hematoma; the hematoma gradually mechanizes plus stresses stimulate the formation of a bone spur, which is an important concept in degenerative bone and joint disease.
Secondly, the height of the intervertebral disc changes after degeneration, and the intervertebral joints become loose and unstable, leading to hyperplastic degeneration of the small joints and significant narrowing of the gaps in the joints due to hyperplastic degeneration.
The adjacent tissues stimulated or compressed by the above pathological changes include the nerve roots, cervical spinal cord, and vertebral artery mentioned in the previous anatomy. Therefore, clinically, cervical spondylosis commonly includes nerve root type, spinal cord type, and vertebral artery type.
Cervical spondylosis fractionated cervical spondylosis is a degenerative change presented by the cervical spine, and although the most frequent incidence is in cervical 5-6 and cervical 6–7, most of the intervertebral discs are often involved at the same time. The pathological manifestations are degeneration of the intervertebral disc, reduced elasticity and convexity in all directions, thus narrowing the intervertebral space; followed by a series of lesions such as bone spurs on the anterior and posterior edges of the vertebral body, bone spurs in the hook vertebral joint, changes in the relationship between small joints, vertebral subluxation, narrowing of the upper and lower diameter and anterior and posterior diameter of the intervertebral foramen, hypertrophy, degeneration, calcification and ossification of the ligamentum flavum, degeneration, chondrosis and ossification of the collar ligament. The posterior spur of the vertebral body, the posteriorly elevated fibrous ring, the posterior longitudinal ligament and the mixed protrusions of edema, fibrosis, chondrosis and calcification of the surrounding tissues are the main causes of cervical nerve and cervical spinal cord compression. This is especially true in the presence of a congenitally small transverse diameter of the spinal canal (<12 mm). In addition, lateral irritation or compression of the vertebral artery traveling within the transverse foramen by the herniation can produce a series of phenomena of inadequate blood supply to the vertebral artery. Sympathetic symptoms can occur when sympathetic nerve fibers inside and outside the spinal canal are stimulated. The spinal cord can also undergo a series of changes, such as dysfunction, lateral cord degeneration and cavity formation, due to adhesion of the dura to the protrusion, abrasion by bone spurs or compression by the ligamentum flavum, resulting in impaired blood flow.
The cervical vertebrae and joints are the most active and have the largest range of motion in the entire spine, but they are the weakest and vulnerable to injury leading to degeneration and compression of the cervical medulla, nerves, vertebral arteries and sympathetic nerves, causing pain in the neck, shoulders, kidneys and upper limbs, movement disorders, sensory disorders, vertigo, blurred vision, transient impaired consciousness and many other clinical symptoms, which we call cervical spondylosis. The incidence of cervical spondylosis is high, accounting for about 7% of clinical patients. It seriously affects people’s work and life.
Cervical spondylosis is divided into four types.
1, nerve root type: due to degeneration of the small intervertebral joint, hook joint hyperplasia or disc protrusion, compression of the cervical nerve root, causing pain in the neck, shoulder and one upper limb, stiffness of the neck, restricted movement, clear pressure points with radiating pain, sensation of the upper limb, motor dysfunction, and different clinical manifestations depending on the nerve under compression.
2, spinal cord type: due to cervical vertebral body posterior edge osteophytes, posterior longitudinal ligament calcification, intervertebral disc protrusion, vertebral plate or yellow ligament hypertrophy and compression of the spinal cord, causing spinal cord symptoms. It is also divided into central type and central paracentral type. The central type is characterized by unstable gait, numbness and weakness of the extremities, high muscle tone, spasm or even ankylosis (mostly in the extensor and adductor muscles), and hyperactive tendon reflexes. There is no neck pain or sensory disturbance. The paracentral type shows ipsilateral motor and contralateral sensory dysfunction, i.e. sensory-motor separation, accompanied by ipsilateral upper limb neurological symptoms, which is the same as the performance of neurogenic cervical spondylosis.
3. Sympathetic type: hyperplasia or cervical disc protrusion at the intervertebral foramen or transverse foramen, which compresses the sympathetic nerve and causes a series of sympathetic symptoms, the manifestations of which, such as eye: eyelid weakness, blurred vision, dilated pupil, pain behind the eye and lacrimation, etc. Head: cervical dizziness, nausea and vomiting, pain in the head and occiput. Cardiac symptoms: rapid or slowed heartbeat, pain in the precordial region, often mistaken for a coronary heart attack. Sweating disorder: excessive or little sweating on one side of the head, face, neck, hands and feet. In addition, it is often accompanied by tinnitus, deafness, and balance disorders.
4, vertebral artery type: due to the stimulation of hyperplasia or protrusion, compression of vertebral artery, spasm of vertebral artery in the cervical segment or mechanical compression causes a series of symptoms caused by the reduction of blood circulation supplying brain tissue, which manifests as cervical vertigo, nausea, tinnitus, deafness, blurred vision, headache, transient impaired consciousness and even sudden collapse. The above symptoms are mostly induced when the neck is moved to a certain position.
In addition to the above four types, it is common for different symptoms of the above four types to occur at the same time in clinical practice, which we call mixed type.
Treatment of cervical spondylosis Treatment of cervical spondylosis includes surgical treatment and non-surgical treatment.
The basic principle of cervical spondylosis treatment is that non-surgical treatment is the most basic method, and more than 70% of cervical spondylosis do not need surgery, but can obtain satisfactory results through non-surgical treatment, and non-surgical treatment is a necessary stage of surgical treatment. For those whose symptoms are not relieved or even aggravated after more than half a year of regular non-surgical treatment, they should be operated in time, instead of delaying the condition by continuing non-surgical treatment.
Non-surgical treatment
1, to choose the appropriate height, special shape of the metacarpal pillow, the use of good sleep posture, lying position, side lying position, should maintain the physiological curve of the cervical spine.
2.Correct and change bad body position. Excessive forward leaning of the upper body makes the physiological curve of the cervical spine change significantly, which is wrong; the correct one should raise the head and chest to maintain the physiological curve of the cervical spine as well as the entire spine. Generally, you should stand up and move around after half an hour or so of operating the computer in this way.
3, neck braking is the most common and important conservative treatment method, currently plastic neck brace is most commonly used. The upper part of the neck brace holds the jaw and occipital bone, the lower part holds the shoulders, and the front chest and back are slightly extended to stop the back and forth movement, so the braking effect is good. In clinical practice, braking with the appropriate type of plastic neck brace can slow down the degeneration of cervical discs and reduce the irritation of nerve roots, thus relieving clinical symptoms.
4, cervical traction, cervical spondylosis is a chronic disease, mainly using small weight continuous traction, the so-called small weight is 20 ~ 30 pounds, generally about 10 kg. Traction mode commonly used are sitting traction and horizontal traction. Sitting traction is to let the patient sit on the backrest chair traction, this method is suitable for light, as well as the work needs can not leave the post of patients, can be carried out in the office or at home. Horizontal traction allows the patient to lie on the bed traction, more comfortable than sitting traction, and has an advantage, in addition to the daytime can be carried out, the night can also be traction, for patients with serious symptoms generally require absolute bed rest 24 hours continuous traction, 2 weeks for a course of treatment, in order to limit cervical activities, so that the neck muscles relaxation, promote mild disc herniation back into the effect.
5, drug treatment is also an important part of non-surgical treatment, should be used under the guidance of a doctor, mainly including four categories: the most commonly used is neurotrophic drugs, such as Microphysical. The second category of drugs that promote degenerative repair, such as chondroitin sulfate tablets. For patients with significant pain symptoms, anti-inflammatory and pain-relieving drugs can be applied for symptomatic management, such as Furtalin tablets and Xilabao. Traditional Chinese medicine in China is unique in activating blood circulation, such as Danshen and Neck Pain Ling.
Surgical treatment Conservative treatment cannot be applied to all patients, and some patients must be treated surgically.
The surgical treatment of cervical spondylosis belongs to the difficult and risky category, which is the treatment feature of the neurosurgery department of the PLA General Hospital. The old generation of neurosurgery department experts, Professor Duan Guosheng, carried out anterior cervical surgery in China as early as in the 1970s, and all anterior cervical surgeries were performed by microsurgery since the 1980s. With the development of internal fixation technology and various implants, progress has been rapid. As a result, the surgical treatment of cervical spondylosis is now very mature and is a routine operation in neurosurgery.
1. Indications for surgery include.
(1) The presence of obvious symptoms of spinal cord and nerve root damage.
(2) Patients with pre-existing cervical spondylosis have a sudden aggravation of symptoms when they are traumatized. Most commonly, a mild neck whipping injury can lead to a rapid deterioration of the condition when a cervical spondylosis patient is riding in a car due to emergency braking, or when a tailgating occurs on a highway, and this situation often requires surgery of a limited duration, or even emergency surgery.
(3) A segment of the cervical spine is obviously unstable, and neck pain is difficult to be relieved by drugs, which is depicted by intractable pain in English, and this condition requires surgery to be internally fixed to stabilize the cervical spine and eliminate symptoms.
2.The purpose of surgical treatment.
(1) Release the spinal cord and nerve root compression, called decompression (Decompression).
(2) Stabilization of the spine.
3, anterior cervical surgery is currently the most common and most mature surgical approach. There are three steps.
(1) the vertebral body of the corresponding segment of the spinal cord compression will be subtotal resection window, through which the spinal canal and nerve root canal decompression is done.
(2) filling the bone defect with an autologous iliac bone graft or artificial allograft bone.
(3) Fixation with an anterior cervical titanium plate to prevent prolapse of the bone graft and to enhance cervical stability.