[Abstract] OBJECTIVE: To investigate the clinical treatment results of patients with sympathetic cervical spondylosis who took conservative treatment. METHODS: The treatment results of 60 patients with sympathetic neuropathic cervical spondylosis treated by conservative treatment mainly by manipulation during the 10-year period from July 2002 to July 2011 were reviewed, and the changes of vertebral artery blood flow in patients before and after treatment, as well as the comparison of self-symptoms before and after treatment, were compared to evaluate this treatment method. RESULTS: Most patients’ clinical symptoms disappeared and cerebral blood supply improved after treatment in all patients, with an overall effective rate of 93.3%. CONCLUSION: Conservative treatment based on manipulation has a good therapeutic effect on sympathetic cervical spondylosis.
[Keywords]: cervical spondylosis; sympathetic nerve symptoms; massage; effect.
The Conservative Treatment of the Cervical Spondylosis Accompanied by Sympathetic Symptoms/Wang Xisan1,Chen Mingyu2,Liu Cheng1,et al.
1. Department of the Orthopaedics, Nanshan Affiliated Hospital of Guangdong Medical College,Shenzhen,Guangdong 518052,China.
2. Department of the Ultrasonography, Nanshan Affiliated Hospital of Guangdong Medical College,Shenzhen,Guangdong 518052,China.
[Abstract] Objective:To investigate the clinical treating results of the patients of the cervical spondylosis accompanied by sympathetic symptoms Method:A retrospective study was performed on 60 patients with sympathetic cervical spondylosis who was treated with the conservative method especially with sympathetic symptoms. We compared the voloume of the vertebral artery, self-feeling We compared the voloume of the vertebral artery, self-feeling symptoms before and after the treatment,and we evaluated this method.Result:The clinical symptoms of the most of the patients were disappeared after The clinical symptoms of the most of the patients were disappeared after the treatment,and the voloume of the brain blood was improved,the totally effective rate was 93.3%.Conclusion:The conservative method especially with the massage has the very effective results Conclusion:The conservative method especially with the massage has the very effective results in treating the sympathetic cervical spondylosis.
[Key words] Cervical spondylosis; sympathetic symptoms;massage;result
At present, cervical spondylosis has become one of the most common diseases in orthopedic outpatient clinics. With the continuous improvement of the material standard of living in society, as well as the changes in the industrial structure of society and the increasing number of computer workers, the incidence of sympathetic cervical spondylosis is increasing, and its age distribution is also becoming wider. Its clinical manifestations vary, but it affects patients more, and in serious cases, it can lead to insomnia and forgetfulness, neurasthenia, and even loss of working ability. During the 10-year period from July 2002 to July 2011, I treated 60 cases of sympathetic cervical spondylosis by manipulation and achieved good therapeutic results, which are reported below.
1 Data and methods
1.1 General information
All 60 patients were outpatients of our hospital from July 2002 to July 2011, including 28 males and 32 females, aged 16-75 years old, average 38.6 years old, with an average duration of 1-8 weeks, average 2.4 weeks, including 2 adolescents, 53 young adults and 5 elderly people over 60 years old. 57 patients had a history of long-term ambulatory work, study or long-term Fifty-seven patients had a history of long-term ambulatory work, study or long-term computer use. All patients were excluded from other organ pathologies with similar symptoms to sympathetic cervical spondylosis, such as glaucoma, Meniere’s syndrome and some neurological diseases.
1.2 Diagnostic method
1.2.1 Clinical characteristics are: patients have many complaints, but few objective symptoms and a variety of manifestations. Their clinical symptoms are mainly manifested as sympathetic nerve stimulation symptoms: I. Sympathetic excitation symptoms, which are more common, are mainly manifested as: (1) head symptoms: manifested as headache or migraine, the site of headache is mainly located in the occipital region, unilateral or bilateral temporal region, partly in the frontal region, and may be accompanied by muscle pain in the neck and shoulder region. Most of them are accompanied by dizziness, and a few severe cases are accompanied by nausea and vomiting. Patients often complain of mental confusion, grogginess, memory loss, insomnia and forgetfulness, and some seriously affect their life and work; (2) eye symptoms: blurred or double vision, orbital swelling and pain, dry eyes; (3) cardiovascular symptoms: episodic tachycardia or palpitations, similar to coronary heart disease, often accompanied by phasic hypertension; (4) ear symptoms: hearing loss or tinnitus; (2) sympathetic nerve suppression Symptoms: bradycardia, decreased blood pressure, etc., but are rare. All patients had no obvious positive signs, individual patients had pressure pain in the soft tissues of the neck and shoulder, very few combined with weakly positive Hoffman’s sign unilaterally or bilaterally, and only two cases showed positive signs without spinal cord compression.
1.2.2 Ancillary examinations: (1) Imaging: All patients underwent frontal and lateral X-ray examinations of the cervical spine and MRI examinations of the cervical spine before and after treatment to exclude cervical disc herniation. Among all 60 patients, the physiological curvature of the lateral X-ray image was changed in 50 patients, the physiological curvature was retroflexed in 15 patients, and the physiological curvature was straightened in 35 patients. In 8 of these patients, lateral cervical hyperflexion-hyperextension radiographs showed anterior-posterior slippage of ≥2.0 mm at the posterior edge of the adjacent vertebral body, and in 10 patients, segmental angulation was >11°. MRI of all patients showed no obvious cervical disc herniation; (2) Blood flow examination: vertebral artery blood flow values were measured between the 5th and 6th transverse foramina of the cervical segment of the vertebral artery with American ACUSON S2000 high-frequency color Doppler ultrasound before and after treatment, respectively, before and 2 weeks after treatment.
1.3 Treatment methods.
1.3.1 Correct psychological and behavioral guidance Most patients with sympathetic cervical spondylosis have a heavy psychological burden because of their serious clinical manifestations. Before treatment, patients should be explained the condition in detail to relieve their mental pressure, and they should be instructed to maintain good habits in their daily work and life, and to participate in physical exercise appropriately, such as swimming, running and playing badminton.
1.3.2 Medication For patients with dizziness as the main symptom, Chinese patent medicines can be used appropriately to perform blood activation and blood stasis treatment; for patients with pain, non-steroidal anti-inflammatory and analgesic drugs can be used at the same time.
1.3.3 Manual therapy Chinese medicine manual massage is the most effective method among non-surgical methods to treat sympathetic cervical spondylosis, and has good therapeutic effect. Firstly, the soft tissues on both sides of the cervical collar are pinched with the thumb and the middle finger symmetrically for 5 min, then the thumb is used to pinch the cervical collar muscles and the spinous process on both sides of the radical convexity for 3 min, then the shoulder is pinched for 5 min, and the neck and shoulder are treated by rolling for 7 min, and the middle clip or the posterior edge of the trapezius muscle, the scapularis muscle, the collar ligament, etc. are treated by massage. The last cervical spine extraction and extension: the patient is sitting, the operator opens one hand, holds the patient’s occiput with the tiger mouth area, the other forearm holds the patient’s chin, tells the patient to relax completely, and then extracts the cervical spine upward with force, if the patient can relax completely, in general, you can hear the sound of the neck, the technique is over. Each massage time of 20 minutes, once a day, 2 weeks as a course of treatment, two weeks later to review the brain ultrasound.
1.3.4 Cervical traction For patients who do not have neck pain and mobility disorders, they can be given occipito-mandibular belt to perform routine seated cervical traction, traction weight starts from 10Kg, and the weight can be increased appropriately for those who tolerate it, but generally not more than 15Kg, and those who do not adapt to it can be adjusted to the adapted weight for 20 minutes each time.
Cervical spine massage once or twice a day, cervical traction twice a day is the best, in addition to some other electrotherapy, such as infrared, microwave, acupuncture and other treatment can also be appropriate. All patients were treated for 3 days to 2 weeks, with a follow-up period of six months.
2. Treatment results
Cured clinical symptoms: clinical symptoms disappeared, no recurrence within six months, cervical physiological bending returned to normal (Figure 1), no obvious instability performance, vertebral artery flow velocity results significantly improved, a total of 40 cases, accounting for 66.7%; effective: clinical symptoms basically disappeared, cervical physiological bending partially returned to normal, cervical instability mildly improved, vertebral artery flow velocity results have improved, but there will be discomfort in case of exertion or long-term bad posture The symptoms disappeared after rest or appropriate exercise, 10 cases, accounting for 16.7%; improved: the symptoms partially disappeared or were relieved to some extent, the cervical physiological curvature did not improve significantly, the vertebral artery flow velocity results improved, but the condition is prone to recurrence and requires repeated treatment, 6 cases, accounting for 10%; invalid: no improvement or no significant improvement in symptoms before and after treatment, no change in the cervical physiological curvature, no change in the vertebral artery There was no change in cervical physiological curvature and vertebral artery flow velocity, accounting for 6.7% of the total of 4 cases, and the effective rate was 93.3%. All patients showed significant changes in mean flow velocity values after treatment compared with those before treatment. Statistical analysis: In the analysis of peak flow velocity, end-diastolic flow velocity, mean flow velocity, resistance index and pulsatility index, the commonly used analysis method was the own pre-post paired t-test. The test level a=0.05, and P<0.05 was considered a significant difference. The specific results are shown in Table 1.
Figure 1: a The physiological curvature of the cervical spine in the lower cervical segment disappeared; b cervical instability was seen in the hyperflexion position; c the physiological curvature of the cervical spine became smaller in the hyperextension position; d the physiological curvature of the cervical segment improved after treatment compared with that before treatment.
Table 1 Comparison of vertebral artery blood flow measurement data before and after treatment for sympathetic cervical spondylosis
Before treatment
After treatment
Peak flow velocity Vs
35..25±6.19①
44.24±11.12
End-diastolic flow velocity Vd
13.82±5.22②
20.29±4.22
Mean flow velocity Vm
22..24±7.13③
31..24±4.24
Resistance index RI
0.61±0.09④
0.54±0.06
Pulsatility index PI
0.96±0.27 ⑤
0.79±0.21
①: p0.05; ②: p0.05; ③: p0.05; ④: p0.05; ⑤: p0.05.
3. Discussion
3.1 Diagnosis of sympathetic cervical spondylosis and the possible pathogenesis
With the progress of science and technology, the continuous development of electronic technology, the increasing number of IT workers and the popularity of computers and some electronic products in the home, there are more and more patients with sympathetic cervical spondylosis with dizziness, insomnia and forgetfulness as the main symptoms in outpatient clinics.
The diagnosis of sympathetic cervical spondylosis is difficult and there is no unified diagnostic standard, and the exact pathogenesis has not been recognized. Previous studies have suggested that irritation of cervical nerve roots [1] and obstruction of cervical reflexes [2] can cause sympathetic cervical spondylosis. Currently, it is more accepted that cervical sympathetic nerve dysfunction caused by any cause is a group of symptoms mainly vertigo, nausea, vomiting, insomnia and amnesia. It has been suggested that the sympathetic nerves in the wall of the vertebral artery are stimulated by hyperplasia of the hook vertebral joint, thus reflexively causing inadequate blood supply to the vertebrobasilar artery [3], but anatomical studies have shown that the hook vertebral joint is more than 0.5 cm away from the transverse foramen [4], and few hyperplasias can compress the vertebral artery. It has been found that cervical segmental instability and changes in vertebral artery blood flow are one of the causes of vertigo attacks [5]. Qian et al [6] found that the incidence of cervical instability was 21.8% in those without sympathetic symptoms and 55.9% in those with sympathetic symptoms, and it can be inferred that this part of patients may be due to cervical instability stimulating the sympathetic ganglia in the neck. The increased excitability of the sympathetic ganglion after stimulation causes reflex spasm of the vertebral artery, which leads to insufficient blood supply to the vertebrobasilar artery and produces symptoms. However, it is also observed that patients without cervical instability also have sympathetic symptoms, and their symptoms improve significantly after anterior surgical decompression [7]. Yu Tengbo et al [3] found that when the sympathetic ganglion is stimulated, the effect on the vertebrobasilar blood flow system is mainly to reduce its blood flow, thus causing vertebrobasilar ischemia. Physiologically, the sympathetic action on the vasculature is mainly achieved by the constrictive effect of chemical transmitters released from the postganglionic fibers that bind to receptors in the vascular wall.
In the past, it was thought that vertebrobasilar artery ischemia was caused by mechanical compression such as bony redundancy, but there is now much evidence that the size of bony redundancy is not proportional to the degree of cerebral ischemia. For patients with abnormal vertebral artery travel and vascular torsion, clinical symptoms are significantly reduced or disappeared after sympathetic stripping of the vertebral artery or cervical spine stability reconstruction [7, 8], and clinically many doctors adopt cervical stellate ganglion closure treatment Therefore, a large amount of evidence proves that cervical sympathetic nerve is the main cause of vertebrobasilar artery ischemia, rather than the mechanical compression theory as previously thought.
3.2 Treatment of sympathetic cervical spondylosis
Currently, the treatment of sympathetic cervical spondylosis is mainly conservative and surgical. Conservative treatment mainly includes acupuncture, traction, massage, Chinese herbal medicine, stellate ganglion block and other methods; surgical treatment mainly includes the following ways: (1) sympathectomy; (2) sympathectomy around the vertebral artery; (3) cervical discectomy intervertebral implant fusion; (4) cervical osteotomy; (5) vertebral artery decompression and so on. Clinically, most patients can achieve satisfactory treatment results through conservative treatment and do not need surgical treatment. Liang Lei et al [10] considered that only the following cases are suitable for surgical treatment: (1) neurological symptoms and signs caused by cervical spinal cord compression; (2) more than three sympathetic symptoms such as dizziness; (3) imaging regardless of the presence of cervical instability or hook joint hyperplasia, but should have changes in the physiological curvature of the cervical spine, degenerative protrusion of the cervical shoulder disc, hypertrophy of the posterior longitudinal ligament of the cervical spine, and other changes, with the dural sac and (4) conservative treatment such as cervical braking, medicine, traction and physiotherapy for more than 3 months, but no significant improvement in symptoms or relapse after short-term improvement; (5) exclusion of neurology, otorhinolaryngology, cardiology, neurosis and menopausal syndrome, etc.
3.3 Effectiveness and mechanism of conservative therapy for sympathetic cervical spondylosis
Since the clinical manifestations of sympathetic cervical spondylosis are complex and the etiology and pathogenesis are still unclear, there are great differences in treatment, and it is difficult to decide whether to choose surgical treatment or conservative treatment. At present, it is reported that many doctors choose surgical treatment and have achieved better results, but they usually adopt conservative treatment before surgery, such as the use of anti-inflammatory and analgesic drugs and blood-activating drugs, cervical traction, manual massage [11], hot compresses of Chinese herbs, and functional exercises of the neck. However, because of the high risk, high cost, long treatment time, and heavy psychological burden of patients, only patients with more severe symptoms, recurrent attacks, and longer duration are suitable for surgical treatment.
In this group of cases, the patients we selected basically satisfied the following conditions: (1) symptoms were mainly dizziness, which could be accompanied by nausea, vomiting, headache, insomnia and forgetfulness; (2) no manifestations of neurogenic cervical spondylosis, no manifestations of cervical disc herniation, such as weakness of limbs and unstable walking, and most patients had negative Hoffman’s sign; (3) imaging manifestations: X-ray examination The lateral image may be accompanied by straightening of cervical physiological curvature or retroflexion, and there may be intervertebral instability of one or more segments in hyperextension and hyperflexion, and instability is generally more common in hyperflexion; there is no manifestation of cervical disc herniation on MRI; (4) exclude other medical conditions. We generally did not give the patients anti-inflammatory and analgesic drugs, individual patients were given oral Chinese medicine to activate blood circulation and remove blood stasis, some patients were given cervical traction, and all patients were given Chinese medicine manipulation massage. In this group of cases, it was considered that most of the patients were suffering from cervical muscle strain, change in the physiological curvature of the cervical spine, and cervical instability, thus stimulating the sympathetic ganglion in the neck and causing increased excitability of the sympathetic nerve, resulting in spasm of the vertebral artery and causing changes in the blood flow rate and flow of the vertebrobasilar artery, which in turn produced a series of symptoms. Some patients have osteophytes in combination with cervical instability, and some patients are considered to have no cervical instability or change in physiological curvature, but due to degeneration of the cervical discs, they can also stimulate the sympathetic ganglion and cause the corresponding symptoms. We believe that both cervical spine physiological curvature alteration, cervical spine instability, and cervical disc degeneration and osteophytes occur on the pathological basis of cervical muscle strain. The cervical spine itself acts as a bony scaffold, but its stability is maintained by the various muscles of the neck. Chronic fatigue of the neck muscles caused by various reasons slowly weakens their strength, thus their elasticity decreases, contraction force decreases, and therefore cannot produce normal tension, which leads to changes in the physiological curvature of the cervical spine, cervical instability, which in turn leads to cervical disc degeneration and symptoms. The manipulation massage has the effect of relaxing the tendons and blood, activating the meridians and relieving pain [12], in which the holding, rolling, kneading and plucking techniques can effectively relieve the cervical muscle spasm, expand the local capillaries, accelerate the blood circulation, improve the blood supply and oxygen supply to the muscles, promote the rapid repair of the muscles, enhance their vitality, increase their stability to the cervical spine, and reduce the stimulation to the sympathetic ganglion, so as to achieve the therapeutic purpose. And instantaneous large-weight traction can correct the disordered small joints and skewed spinous processes, adjust the physiological curvature of the cervical spine, restore the normal anatomical relationship and physiological balance of the cervical spine, and reduce the stimulation of the sympathetic ganglion.
In conclusion, through systematic conservative treatment methods, it can effectively restore the vitality of cervical muscles and strengthen their maintenance of cervical spine stability, effectively reduce or eliminate the stimulation of sympathetic nerves caused by the change of cervical physiological curvature or cervical spine instability, and further control the excitability of sympathetic nerves and improve the blood supply to the brain, so as to achieve the treatment purpose. The method is simple, practical and convenient, and has low risk and good efficacy. The effective rate of this group of cases was as high as 93.3%, and one of the four patients who were ineffective was considered to be caused by psychological factors, thus this treatment method is worthy to be widely promoted in the clinic.
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