Cervical spondylosis is a relatively common degenerative disease of the spine. With the development of spinal surgery in China, this disease is gradually becoming better understood, but there are still cases of underdiagnosis and misdiagnosis, which affect the effectiveness of the treatment of the disease. Cervical spondylosis is diagnosed when degenerative changes in the cervical disc involve the surrounding tissues and structures and present with corresponding clinical manifestations. Degenerative changes in the cervical disc are a process that every individual must undergo as they age, but there are differences between individuals that may be related to congenital or developmental abnormalities of the cervical spine, or more likely due to the motion of the cervical spine. Degenerative changes in the cervical spine are evaluated primarily by imaging, which has continued to advance. Degenerative changes such as narrowing of the intervertebral space, formation of bone fragments, and intervertebral instability can be observed on X-ray plain films; herniated discs and bone fragments can be observed on CT; and MRI, in addition to the above, allows earlier observation of signal changes due to water loss within the disc. Degenerative changes involving the surrounding spinal cord, nerve roots, vertebral arteries, and sympathetic nerves can be confirmed by imaging; clinical manifestations need to be determined by careful history taking and rigorous physical examination by the physician. Once these data are collected, the doctor needs to analyze whether there is an inevitable connection between the degenerative changes of the cervical spine and the clinical manifestations, and only when this connection is confirmed can the diagnosis of cervical spondylosis be clarified. The real difficulty lies in establishing this connection, and the misdiagnosis of other diseases as cervical spondylosis that occurs in clinical diagnosis is mainly due to the doctor’s mistake in linking the two. The following is a summary of common clinical misdiagnoses. I. Attribution of neck symptoms to cervical spondylosis “A disease in the neck is cervical spondylosis” is the understanding of most patients about cervical spondylosis, and this understanding is also found among many specialized physicians. If the symptoms in the neck are not caused by degenerative changes affecting the spinal cord, nerve roots, vertebral arteries, or sympathetic nerves, cervical spondylosis cannot be diagnosed. Therefore, it is crucial to understand the definition of cervical spondylosis correctly. Most symptoms in the neck should be attributed to cervical strain, cervical myofasciitis, supraspinous ligamentitis, osteoarthritis, rare conditions including ankylosing spondylitis, rheumatoid arthritis, and intervertebral discitis, and more serious conditions including tuberculosis, septic infection, and tumors. Neurogenic cervical spondylosis may present with only neck pain and other symptoms of the neck. Nerve root involvement is seen primarily at the C2-4 level. The site of pain is identified and distributed according to the corresponding dermatome, and a nerve root stimulation test may be positive. Second, diagnosing degenerative changes in the cervical spine as cervical spondylosis Once degenerative changes in the cervical spine are identified on imaging, some radiologists diagnose it as cervical spondylosis, expanding the scope of cervical spondylosis. Most degenerative changes in the cervical spine do not have any symptoms and obviously cannot be diagnosed as cervical spondylosis. A subset of people exhibit symptoms in the neck, most of which are osteoarthritis or sensory pain, except for the neurogenic cervical spondylosis mentioned above, which also cannot be diagnosed as cervical spondylosis. The diagnosis of cervical spondylosis can only be made in those cases where the degeneration and neurological symptoms are fully compatible. (a) Cerebrovascular disease misdiagnosed as cervical spondylosis: The high incidence of cervical spondylosis is between 50 and 60 years old, and cerebrovascular disease is also very common in this age group. The two are often confused, and because awareness of cerebrovascular disease is more widespread, it is far more common to misdiagnose cervical spondylosis as cerebrovascular disease than vice versa. The presence or absence of cranial nerve damage in the clinical presentation is key in the differential diagnosis. Imaging of the brain and spinal cord is important. Consultation with orthopedic and neurologist is necessary. The possibility of a combination of the two exists. (ii) Peripheral nerve entrapment misdiagnosed as cervical spondylosis: thoracic outlet syndrome, elbow tunnel syndrome, carpal tunnel syndrome. Confusion often occurs between these disorders and neurogenic cervical spondylosis. In addition to the clinical manifestations of the latter two that can help to differentiate them, neurophysiological examination is very helpful. Thoracic outlet syndrome is mainly identified by clinical manifestations and imaging examinations of the cervical spine. Since thoracic outlet syndrome is a rare disease, it is not easily diagnosed if there is a lack of knowledge about it. (iii) Other external pressure diseases of the cervical spine are misdiagnosed as cervical spondylosis: tumor, tuberculosis, and septic infection. The latter two diseases are easier to diagnose. Tumors of the bones and joints of the spine are also easier to distinguish from cervical spondylosis, and confusion is likely to occur with tumors in the spinal canal. Because degeneration is a common condition, tumors in the spinal canal increase the volume of the spinal canal, making it easy for physicians to mistake degeneration for spinal cord compression, which may lead to misdiagnosis if the boundaries of the tumor are not clearly visible on plain MRI. The important differentiation is based on clinical manifestations and enhanced MRI examination. (d) Misdiagnosis of cervical spondylosis due to nerve damage caused by spinal lesions other than the cervical spine: ossification of ligaments in the spinal canal, disc herniation, tumors in other parts of the spine, septic infection. In typical spinal cervical spondylosis, all extremities are dysfunctional, but in many cases only the sensory and motor functions of the lower extremities are dysfunctional, especially in the early stages of spondylosis, which is related to the order of the sensory and motor conduction tracts in the spinal cord and is easily confused with thoracic spinal stenosis. Sometimes cervical spondylosis can also present with intermittent claudication (spinal cord-derived intermittent claudication), which can be easily confused with lumbar spinal stenosis. Posterior longitudinal ligament ossification in the cervical spine is often combined with ossification of ligaments in other parts of the spinal canal, the most common of which is ossification of the yellow ligament of the thoracic spine. Therefore, clinical nerve localization is crucial, and when in any doubt, detailed information about the relevant sites must be obtained. (v) Misdiagnosis of lesions within and outside the spinal cord as cervical spondylosis: confusion may occur between the clinical presentation of cervicothoracic spinal cord cavitation and cervical spondylosis, with clinical separation of pain and temperature sensation being a feature of the former. MRI is the key to differential diagnosis. It is important to note that a poorly defined MRI may lead to a missed diagnosis. When a spinal cavity is found in a segment of the spinal cord, knowledge of the whole spinal cord is mandatory. MRI is an important differential diagnostic aid in spinal cord embolism syndrome, a congenital disorder presenting primarily with lumbosacral nerve damage. It can be diagnosed when low spinal cord and intraspinal lipoma are present. (vi) Neurodegenerative changes misdiagnosed as cervical spondylosis: motor neuron disease, sensory neuron disease, and multiple sclerosis. Motor neuron disease without sensory dysfunction, but also cervical spondylosis without sensory abnormalities exists, when a careful differential diagnosis is required. If neurophysiological examination reveals signs of cranial nerve damage and the patient has dysphagia, hoarseness, and flesh throbbing without diaphoresis, motor neuron disease should be considered. Both sensory neuron disease and multiple sclerosis can be differentiated by clinical manifestations and neurophysiological examination. The differential diagnosis is more difficult when the above diseases do not involve cranial nerves, but degenerative changes resulting in the presence of spinal cord or nerve root compression. (vii) Systemic diseases involving the spinal cord or spinal nerves are misdiagnosed as cervical spondylosis: diabetes mellitus, macrocytic anemia, alcoholism, and paraneoplastic syndrome, all of which can lead to nerve damage, and when these conditions are found, experimental treatment can be helpful in the differential diagnosis. Fourth, the combined presence of multiple diseases is diagnosed only with cervical spondylosis, or other diseases are diagnosed and cervical spondylosis is missed This is a very important and sometimes difficult problem, and the physician must determine the extent to which multiple factors affect the disease in order to determine the sequence of treatment and the overall strategy for treatment. V. Dizziness and vertebral artery stenosis attributed to vertebral artery type cervical spondylosis VI. Confusion with sympathetic type cervical spondylosis Vestibular dysfunction, menopausal syndrome, psychogenic factors, heart disease, hypertension, cerebrovascular disease VII. Differential diagnosis of the two conditions is quite difficult A comprehensive analysis is needed after integrating clinical manifestations, vertebral artery examination, nerve closure, and related departmental examinations. In conclusion, the diagnosis of cervical spondylosis is quite complicated, and one should neither make the mistake of enlargement nor be wary of missing the diagnosis in the diagnosis. The key is to have both an accurate understanding of the definition of cervical spondylosis and abundant knowledge of related diseases in clinical thinking; to take accurate medical history and objective signs, and to make full use of various auxiliary examinations; to make full use of one’s own experience for logical judgment, and to humbly consult relevant departments to help in differential diagnosis. Only when the degenerative changes of the cervical spine correspond exactly to the clinical manifestations can the diagnosis of cervical spondylosis be established with as few mistakes as possible.