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Abstract: Cervical spondylosis is a common clinical disease that usually presents with pain, numbness, and decreased grip strength of both hands in the neck and upper extremities, and is most common in the middle-aged and elderly population. The patient in this case was 69 years old and was admitted to the hospital with cervical disc herniation 6 months ago when he developed the above symptoms. After continuous traction of the cervical spine, as well as drug treatment with ibuprofen extended-release tablets, diclofenac sodium extended-release tablets, aspirin enteric-coated tablets and methylcobalamin tablets, the condition gradually stabilized and the symptoms improved.
Basic information】Female, 69 years old
Disease Type】Cervical spondylosis
Hospital】The First Hospital of China Medical University
Date of consultation】April 2022
Treatment plan】Surgery (cervical traction) + medication (ibuprofen extended-release tablets, diclofenac sodium extended-release tablets, aspirin enteric-coated tablets, methylcobalamin tablets)
Treatment period】3 weeks of inpatient treatment, 1 month of outpatient follow-up
Treatment effect】The condition gradually stabilized and the symptoms improved
I. Initial interview
Patient, female, 69 years old. Six months ago, she developed pain and numbness in the neck and both upper limbs without any obvious cause, accompanied by decreased grip strength in both hands, mainly on the right side. She had no pins and needles pain, no headache, no dizziness, no nausea, no vomiting, no confusion, no abdominal pain, no bilateral numbness in the lower extremities, and took oral Chinese medicine (details unknown) at a local clinic with poor results. Outpatient MRI examination of cervical spine: mild protrusion of C5/6 and C6/7 discs; degenerative changes of cervical spine; partial vacuolation of the pterygoid saddle. The initial diagnosis was “cervical spondylosis”. The patient was admitted to our department for treatment of cervical spondylosis. Since the onset of the disease, the patient had a clear consciousness, was mentally competent, had a good diet, and had no urinary or fecal incontinence.
II. Treatment history
After the patient was admitted to the hospital, the cervical X-ray examination was completed, which showed straightening of the physiological curvature of the cervical spine, sclerosis and hyperplasia at the edges of the fourth to seventh cervical vertebrae, narrowing of the fifth intervertebral space, and striated calcification of the posterior collateral ligament. After communication with the patient, the patient was advised to rest in bed to reduce the load on the neck, considering that the patient was too old to tolerate surgical treatment. At the same time, the patient was given continuous traction on the cervical spine, and was instructed to take ibuprofen extended-release tablets, diclofenac sodium extended-release tablets, and aspirin enteric soluble tablets, which can play an analgesic and anti-inflammatory role, thus relieving the patient’s pain and discomfort. At the same time, the patient was instructed to take methylcobalamin tablets to repair the damaged cervical nerves.
III. Treatment effect
After 1 week of bed rest, the patient’s neck load was reduced and the grip strength of both hands gradually returned to normal. After symptomatic treatment with ibuprofen extended-release tablets, diclofenac sodium extended-release tablets and aspirin enteric-coated tablets, the patient’s pain symptoms in the neck and both upper limbs gradually decreased to disappear. After taking methylcobalamin tablets, the patient’s symptoms of numbness in the neck and upper extremities were also relieved. After 3 weeks of continuous treatment, the patient’s symptoms were significantly improved and he could carry out basic life.
IV. Precautions
After 3 weeks of treatment, the patient’s symptoms of pain and numbness in the neck and both upper limbs were improved, and I was sincerely happy for the patient. However, for elderly patients with cervical spondylosis, there is a greater possibility of recurrence, so the following points should be noted in life, which can effectively prevent disease recurrence: First, elderly patients should pay more attention to rest and avoid overexertion. Pay attention to a comfortable sleeping position when taking a nap and avoid sleeping in a sitting position so as not to induce a recurrence of symptoms related to cervical spondylosis. Second, elderly patients should pay attention to the protection of the neck muscles, daily standing left and right neck rotation, head and neck back to look at the roof and other exercises to stretch the neck muscles, pay attention to the activities should be gentle movements. Third, elderly patients have a higher tendency of recurrence of cervical spondylosis, so they should adhere to regular checkups as prescribed by the doctor, and seek medical treatment promptly if symptoms such as pain and numbness in the neck and both upper limbs appear.
V. Personal insight
Cervical spondylosis occurs in the elderly population and is related to the degeneration of neck tissues as a result of aging, usually manifesting as pain, numbness, loss of grip strength and neck stiffness in the neck and both upper limbs. Once such symptoms appear in the elderly population, they should be seen in a timely manner to avoid the progression of the disease, which may result in adverse consequences such as insomnia and fainting. In this paper, the patient had already developed the above symptoms 6 months ago, and although herbal treatment was carried out during this period (specific details are not available), the disease was not treated fundamentally. It is good that the patient’s disease progressed to a lesser extent and recovered well after treatment in our hospital.