I. Definition and diagnostic principles of cervical spondylosis
The definition of cervical spondylosis encompasses three basic elements
1. degeneration of the cervical intervertebral discs or degeneration of the intervertebral joints.
2, involvement of its surrounding tissue structures.
3, the appearance of the corresponding clinical manifestations. These three elements are interrelated and one is indispensable.
Therefore, to establish the diagnosis of cervical spondylosis, the following diagnostic principles must be met.
1. clinical manifestations (i.e. clinical symptoms and signs) of cervical spondylosis are present.
2, imaging shows degenerative changes in the cervical intervertebral discs or intervertebral joints.
3, the imaging signs can explain the clinical manifestations.
According to this diagnostic principle, two biases in the diagnosis of cervical spondylosis should be avoided: first, the diagnosis of cervical spondylosis should not be made solely on the basis of the presence of degenerative changes in the cervical spine on the imaging signs. Because 80% of people over 55 years of age have degenerative changes in the cervical spine, but most of them do not have clinical manifestations, it is inappropriate to diagnose cervical spondylosis based on imaging findings alone. Secondly, the diagnosis should not be made only on the basis of clinical manifestations without the necessary imaging examinations to confirm degenerative changes in the corresponding cervical spine, because without degenerative changes in the cervical spine there is no basis for the development of cervical spondylosis. In addition, many clinical manifestations of cervical spondylosis can also exist in diseases other than cervical spondylosis, for example, numbness and weakness of the upper limbs can be caused by thoracic outlet syndrome; dizziness can also be caused by cerebrovascular disease, hypertensive disease, and otologic disease; spastic incomplete paralysis of the extremities can also be caused by intraspinal occupying disease, spinal cavernous disease, and amyotrophic lateral sclerosis. Therefore, the diagnostic principle emphasizes that the imaging signs can explain the clinical manifestations.
II. Staging of cervical spondylosis
There is no agreement on the typology of cervical spondylosis at home and abroad. According to the discussion at the 1992 symposium on cervical spondylosis in China, cervical spondylosis was classified from the three basic elements included in the definition of cervical spondylosis, namely, cervical, radicular, spinal, vertebral artery, sympathetic and other types according to the different clinical manifestations arising from the involvement of different tissue structures. The basis of each type is as follows.
1, cervical type: there are cervical symptoms and pressure points; the cervical spine has curvature changes and instability on X-ray; other disorders of the neck (such as drop pillow, frozen shoulder, myofasciitis, etc.) should be excluded.
2.Neurogenic type: there are radicular symptoms and signs consistent with the lesion segment; positive pressure neck test or brachial plexus pull test; imaging is consistent with clinical manifestations; no significant efficacy of painful point closure; thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, etc. can be excluded.
3, spinal cord type: there are signs and symptoms of cervical spinal cord damage; imaging has cervical spinal stenosis, cervical degenerative changes; should exclude amyotrophic lateral sclerosis, intra-vertebral canal tumor, spinal cord injury, multiple peripheral neuritis, etc.
4.Vertebral artery type: cervical vertigo, history of sudden collapse, positive neck rotation test, cervical segmental instability or crooked vertebral joint hyperplasia on X-ray, mostly accompanied by sympathetic nerve symptoms, ophthalmogenic and otogenic vertigo should be excluded, except for insufficiency of blood supply to vertebral artery segment I and III, intracranial lesions, neurosis, etc. Vertebral arteriogram should be performed to confirm the diagnosis. This type is very controversial and should be further studied.
5, sympathetic type: manifested as dizziness, blurred vision, tinnitus, hand numbness, tachycardia, precordial pain and a series of symptoms of plant nerve disorders, cervical intersegmental instability or degenerative changes on X-ray, vertebral arteriography is not abnormal, and cardiovascular and cerebrovascular diseases should be excluded. The basis of this type is also more controversial.
6, other types: refers to the cervical vertebrae anterior bird’s mouth-like osteophytes compressing the esophagus causing swallowing difficulties and confirmed by barium esophageal fluoroscopy, etc.
III. Pathogenesis of cervical spondylosis
The pathogenesis of cervical spondylosis is not well understood. The cervical spine is located between the more fixed thoracic spine and the head with a certain weight, which is highly mobile and prone to strain. It is generally believed that the pathogenesis of cervical spondylosis is the result of a combination of factors. Degenerative degeneration of the cervical disc and secondary intervertebral joint degeneration are the basis for the pathogenesis of this disease. In the process of cervical spine degeneration, the intervertebral disc is changed first, and then the intervertebral joints are involved, generally in the order of C5 to C6, C6 to C7, and C4 to C5. According to the current understanding, the pathogenesis of the disease is summarized as follows.
1, mechanical compression theory: divided into two kinds of factors: static compression and dynamic compression. From the static compression factors, intervertebral disc degeneration may begin at the age of 20, and degenerative changes in the cervical intervertebral disc occur after the age of 30, and with its cumulative injury, the degeneration can be aggravated resulting in degeneration, swelling, and fracture of the intervertebral disc’s fibrous ring, resulting in the formation of fissures, leading to disc bulging or protrusion, and the ability of the fibrous ring to resist stretching and other decreases, narrowing the intervertebral space, and abnormal activity between the vertebral bodies, so that the upper and lower vertebral bodies These bones and the protruding discs protrude into the spinal canal and compress the spinal cord or nerve roots, producing the corresponding symptoms. Research at Peking University Third Hospital has demonstrated that such compression can also block cerebrospinal fluid circulation, and the spinal cord has been found to be tolerant to chronic compression, for example, spinal cord injury has been shown to occur in animal experiments with a spinal canal encroachment rate of 60% or more. In terms of dynamic compression factors, the spinal cord changes with the change in morphology of the spinal canal in extension and flexion during cervical spine extension and flexion activities. When the cervical spine is flexed, the spinal cord is elongated, the transverse area is reduced, and the spinal cord becomes thinner; when the cervical spine is supinated, the spinal cord is compressed axially, and the transverse area increases. In cervical extension, the transverse area of the spinal canal decreases by 11% to 17%, while the transverse area of the spinal cord increases by 9% to 17%. If there are already static compression factors, such as herniated or bulging discs on the ventral side of the spinal cord, bone redundancy on the posterior edge of the vertebral body, and thickened ligamentum flavum on the dorsal side of the spinal cord, combined with dynamic factors, further damage to the spinal cord or nerve roots can occur, so that cervical flexion and extension activities may also be a dynamic factor in spinal cord damage. From this point of view, in the case of particularly severe bone redundancy, the repeated micro trauma caused by excessive cervical spine activity may be more noteworthy than simple compression.
2. Cervical instability: As mentioned above, cervical degeneration causes intersegmental instability of the cervical spine, and the spinal cord rubs repeatedly on the bone flab at the posterior edge of the vertebral body during cervical flexion and extension activities, and the accumulation of micro trauma to the spinal cord leads to pathological damage to the spinal cord. In addition, instability caused by cervical degeneration, increased mobility of the intervertebral joints can cause spasm of the lateral spinal arteries and their branches, and also stimulate the cervical sympathetic nerves to reflexly cause arterial spasm, resulting in poor local blood supply to the spinal cord. The cervical sympathetic nerve comes from the upper part of the spinal cord, and its terminal nerve fibers are distributed to the head, neck, and upper extremities, as well as to the thoracic and abdominal viscera. The cervical sympathetic nerves are distributed directly to the heart and through the traffic branches to the pharynx. Sympathetic nerves around the internal carotid artery accompany the arterial branches to the eye, and sympathetic nerves around the vertebral artery enter the skull and accompany the vagus artery to the inner ear. Sympathetic nerves also distribute to the spinal membrane, spinal cord, circumferential portion of the annulus fibrosus, and ligaments and joints of the cervical spine. Therefore, cervical instability may stimulate the sympathetic nerves in the neck, causing a series of symptoms of disorders of the vegetative nervous system such as blurred vision, tinnitus, balance disorders, tachycardia or bradycardia, and finger swelling. In clinical practice, many patients with cervical instability can have their symptoms temporarily relieved through measures such as cervical collar braking and bed rest; surgical treatment can achieve more satisfactory results by removing the discs of the degenerated unstable segments plus bone graft fusion. This also shows the role of cervical instability in the pathogenesis of cervical spondylosis.
3, cervical spinal cord blood circulation disorders: it was recognized early that blood supply factors may be involved in the pathogenesis of cervical spondylosis. Researchers have noted that the spinal cord flattens and turns white in color during surgery in the cervical flexion position; they also found that when a herniated cervical disc compresses the spinal cord, the spinal cord compression damage area is basically the same as the anterior spinal artery blood supply area, and speculated that the herniated disc compresses the anterior spinal artery and its branches causing ischemic damage to the spinal cord. When the cervical spine is flexed, the tension of the spinal cord increases, and the ventral side of the spinal cord becomes flattened by the extrusion of the posterior edge of the vertebral body and the anterior and posterior diameters become smaller, while the lateral side of the spinal cord is subjected to indirect stress that increases the transverse diameter, which may strain the branches of the transverse course of the middle sulcus artery of the spinal cord, causing ischemia in the anterior 2/3 of the spinal cord, including the large part of the gray matter, which compresses the small veins inside it and aggravates the local blood supply deficiency. If there is a protruding disc or bone superfluous compression on the ventral side of the spinal cord and a thick yellow ligament extrusion on the dorsal side of the spinal cord, coupled with intersegmental instability of the cervical spine, the cervical spinal cord is affected by the “clamping mechanism” when the cervical spine is extended and flexed, making the local blood supply to the spinal cord more susceptible to interference. In addition, if the cervical spine is unstable, it stimulates the cervical sympathetic nerve and causes arterial vasospasm, which also affects the blood supply to the spinal cord.
In conclusion, the pathogenesis of cervical spondylosis is more complex, and the role of compression and instability in the pathogenesis is more studied, while the factors of impaired spinal cord blood supply may also have some relationship with compression or instability. Through clinical practice, such as discectomy and intervertebral implant fusion in the surgical treatment of cervical spondylosis and enlarged spinal canal plasty, good therapeutic results have been achieved, and the above pathogenesis has received some support. However, there are still many aspects of the pathogenesis of cervical spondylosis that are not well understood and need to be further studied in depth.
IV. Non-surgical treatment of cervical spondylosis
The treatment methods of cervical spondylosis can be divided into two categories: non-surgical treatment and surgical treatment. At present, for the treatment of cervical spondylosis, most medical experts advocate non-surgical treatment, and only a few cases need surgical treatment. Non-surgical treatment is a comprehensive therapy combining Chinese and Western medicine, which includes cervical traction, physical therapy, massage and massage, acupuncture, medication, rest, collar or neck brace and medical sports exercise, etc. One or two to three of these methods can be used according to different situations and applied simultaneously or alternately. They are introduced as follows
1.Massage and massage therapy
This is one of the methods of treatment of cervical spondylosis in Chinese medicine, and is also a more effective treatment measure for cervical spondylosis. It is the therapeutic effect is to relieve the tension and spasm of the neck and shoulder muscles, restore the cervical spine activities, release the nerve roots and soft tissue adhesions to relieve the symptoms, widen the vertebral space, expand the intervertebral foramen, rectify the vertebral body slippage to release the neurovascular stimulation and compression, promote local blood circulation and receive the effect of relaxation and activation, relief of spasm and analgesia. It can be roughly divided into two categories; one is the traditional massage and tui-na manipulation; the other is the rotational repositioning technique and the lifting end shaking technique. But the treatment of manipulation should be operated under the guidance of an experienced specialist to prevent accidents.
2.Cervical spine traction therapy
This is a more effective and widely used treatment method for cervical spondylosis, which is applicable to all kinds of cervical spondylosis and effective for early cases. Its therapeutic effect is to restrict cervical spine activities, which is conducive to the decreasing of tissue congestion and edema; to release the muscle spasm of the neck, thus reducing the pressure on the intervertebral disc; to increase the large vertebral space and intervertebral foramen, so that the stimulation and compression of the nerve roots can be eased and the vertebral artery distorted between the transverse foramina can be stretched; to hold open the embedded synovial membrane of the small joint; to buffer the pressure of the intervertebral disc tissue to the periphery, and to facilitate the outward protrusion of the decongestion of the annulus fibrosus
Traction method: Usually the occipito-mandibular band traction method is used, both seated and horizontal, and intermittent traction is used for mild patients, 1-3 times a day for half an hour to an hour each time. In severe cases, continuous traction is feasible, with 6-8 hours of traction per day. The traction weight can start from 3-4 kg and gradually increase to 5-6 kg. Later, the traction weight and traction time can be adjusted appropriately according to the patient’s gender, age, physical strength, neck muscle development and the patient’s response to traction treatment. Course of treatment: small weight traction 30 times for a course of treatment, if effective, can continue traction 1-2 courses or longer, between two courses of treatment should rest 7-10 days, traction generally requires mild forward flexion of the neck about 20 degrees, but it is best to the patient’s conscious symptoms to reduce the appropriate position, do not have to force a specific position
3.Physiotherapy.
In the treatment of cervical spondylosis, physical therapy can play a variety of roles and is also a more effective and commonly used treatment method. It is generally believed that in the acute stage, the iontophoresis, ultrasound, ultraviolet light or intermittent current, etc. are feasible; after pain reduction, ultrasound, iodine iontophoresis, induction electricity or other heat therapy are used.
4.Drug treatment
Drugs in the treatment of this disease, especially Chinese medicine can play a major role in the treatment of the cause, Western medicine is only to relieve symptoms, can choose to apply painkillers, sedatives, vitamins (such as B1, B12, Veloxan), vasodilators, etc., on the relief of symptoms have a certain effect.
5.Warm compress
This treatment can improve blood circulation, relieve muscle spasm, eliminate swelling to reduce symptoms, and help stabilize the affected vertebrae after manipulative treatment. This method can be used hot towels and hot water bags local external compresses, preferably with Chinese herbal fumigation formula to hot compress. The local temperature should be maintained at about 50-60 degrees Celsius during treatment, and the hot compress time should be 15-20 minutes each time, twice a day. Too high a temperature or too long a time can cause peripheral vasodilation and aggravate the symptoms. Acute stage patients with severe pain symptoms should not be warm compress treatment
6.Bed rest
Bed rest can reduce the weight bearing of the cervical spine and the tension of its surrounding tissues, so that the nerve compression and reactive edema can be reduced, thus accelerating the relief of symptoms. Since the lower limbs of cervical spondylosis patients are mostly unaffected and move freely, so patients and even doctors often ignore the problem of rest, so it is very important to emphasize this point.
7.Functional exercise
In the acute stage, it is appropriate for the patient to rest when the pain symptoms are heavy, and only after the symptoms are reduced and the displaced affected vertebrae are more stable, the patient can start functional exercise of the neck and shoulder and back, and the range of neck activities should be small when exercising, and the force should not be too violent.
8.Other
The treatment of cervical spondylosis also includes closed therapy, acupuncture, electroacupuncture, ear acupuncture, magnetic therapy, collar and neck brace protection and other medical measures, which are also effective in improving the symptoms.
V. Surgical treatment of cervical spondylosis
Surgery for cervical spondylosis is complicated and involves certain risks, so the indications for surgery should be strictly controlled. If a patient is contraindicated for surgery, surgical treatment is not an option. The pathological mechanism and clinical manifestations of cervical spondylosis are complex, and appropriate surgical methods should be selected according to different conditions.
For all types of cervical spondylosis other than the spinal cord type, non-surgical conservative treatment should be preferred because the vast majority of patients can be significantly relieved or cured by non-surgical treatment, while surgical treatment is mainly for patients with more serious symptoms, who have recurrent attacks because strict non-surgical conservative treatment is ineffective or the efficacy is not consolidated.
Selection of indications for surgery
1, cervical cervical spondylosis requires surgery: in principle, cervical cervical spondylosis does not require surgery, but only in rare cases where long-term non-surgical treatment is ineffective and seriously affects normal life or workers, surgery can be considered. Since orthopedic experts still have some differences in the understanding of cervical cervical spondylosis and myofasciitis of the collar and back muscles, surgery for cervical cervical spondylosis should be very cautious.
2, neurogenic cervical spondylosis requiring surgery: in principle, non-surgical treatment should be taken first for neurogenic cervical spondylosis, and the vast majority of patients do not need surgery.
Spinal cord cervical spondylosis requires surgery: Spinal cord cervical spondylosis accounts for 5%-10% of cervical spondylosis, which is based on the basic pathology of intervertebral disc degeneration, followed by the formation of a bulge containing vertebral redundancy, which constitutes the main compression of the spinal cord or the blood vessels innervating the spinal cord, resulting in different degrees of spinal cord dysfunction, causing a serious decline in the quality of life of patients or even life-threatening, and is a serious danger to human health. It is a serious health hazard. Since the symptoms of this disease are serious and progressively aggravated, once the diagnosis and treatment are delayed, it often develops into irreversible neurological damage, so if the diagnosis is clear, surgery should be actively taken.
4, vertebral artery type cervical spondylosis requiring surgery: The majority of vertebral artery type cervical spondylosis should be preferred to non-surgical conservative therapy, while surgery can be considered for those with the following conditions.
5, sympathetic cervical spondylosis requiring surgery: sympathetic cervical spondylosis, the vast majority of conservative treatment can have good results. Surgery can be considered only if the symptoms seriously affect the patient’s life, the non-surgical treatment is ineffective, the symptoms are significantly reduced by cervical sympathetic nerve closure or cervical high epidural closure test, and the segmental instability or disc bulge is confirmed. However, since sympathetic cervical spondylosis is difficult to distinguish from neurosis and menopausal syndrome, and some patients may even have psychosomatic factors that exaggerate the symptoms, the indications for surgery should be strictly controlled, and surgical treatment should be very cautious.
6, other types of surgical treatment: other types of cervical spondylosis, such as the protruding bone superfluous to the anterior edge of the vertebral body compression and stimulation of the esophagus caused by swallowing difficulties, by non-surgical treatment is ineffective, you can surgically remove the protruding bone superfluous to the anterior edge of the vertebral body, so as to release the compression of the esophagus.