Sympathetic cervical spondylosis (CSS) is a disease in which the sympathetic nerves in the neck are stimulated and excited or inhibited by factors such as degenerative degeneration of the cervical spine or trauma, and exhibit a variety of symptoms. Precisely because the clinical manifestations of sympathetic cervical spondylosis are complex and diverse, mostly subjective symptoms and lack of specific objective indicators for diagnosis, the diagnosis of sympathetic cervical spondylosis is more difficult to determine.
1. Symptoms and signs.
In general, sympathetic cervical spondylosis is characterized by patients with many complaints but few objective signs and a wide variety of symptoms. Due to the lack of limb numbness and neck pain common to cervical spondylosis, doctors first think of diseases of the cardiovascular system when they encounter middle-aged and elderly male patients. In the case of middle-aged female patients, the symptoms are attributed to menopausal syndrome or neurosis, thus delaying diagnosis and treatment. The first category is sympathetic excitatory symptoms, which are more common, and the second category is sympathetic inhibitory symptoms, which are less common.
1.1 Sympathetic excitatory symptoms.
① Head symptoms: headache and migraine, the site of pain is mainly located in the occipital region or forehead, and the nature is dull pain. Sometimes it is accompanied by dizziness, which is not aggravated when turning the neck. Patients often complain of mental confusion and drowsiness, and some even have memory loss; some patients also have nausea and vomiting. The symptoms are mostly triggered by overwork and poor sleep.
② Symptoms of the five senses: eye swelling and pain, dryness, blurred vision, or even blindness, dilated pupils and enlarged eye fissures. Throat discomfort or foreign body sensation. Tinnitus, hearing loss or deafness. Slurred pronunciation, or even loss of voice.
(iii) Peripheral vascular symptoms: cold and fearful of cold limbs, there may be little sweating on one limb, tingling sensation or numbness and pain when cold. Local skin temperature is reduced, pain and temperature sensation are normal.
④ Cardiac symptoms: transient tachycardia and elevated blood pressure, arrhythmia, and pain in the precordial region.
⑤ Blood pressure abnormalities: hypertension.
(6) Sweating abnormalities: excessive sweating, mostly on the head, face, neck, hands, feet, and one side of the trunk.
(7) Sphincter symptoms: bladder detrusor diastole, sphincter contraction, difficult or incomplete urination, constipation.
1.2 Sympathetic inhibition symptoms.
① Head symptoms: dizziness and dullness of the head.
② Five sensory symptoms: droopy eyelids, sunken eyes, narrow pupils, lacrimation, nasal congestion, salivation.
③ Peripheral vascular symptoms: redness and swelling of the finger ends, or burning sensation, fear of heat and preference for cold, and burning sensation in the chest and back.
④ Cardiac symptoms: bradycardia.
⑤ Blood pressure abnormalities: hypotension.
(6) Abnormal sweating: no sweating or little sweating, more at night or in the morning.
⑦ Sphincter symptoms: urinary frequency, urinary urgency, or diarrhea.
1.3 Physical signs.
The objective signs of sympathetic cervical spondylosis are few, and stiffness and pressure pains can be found in the sphenoid process, pars transversus muscle and suprascapular region in the neck on general examination. The flexion test and brachial plexus pull test may be positive.
2.Auxiliary examinations.
2.1 Imaging examination.
The imaging changes of sympathetic cervical spondylosis have no obvious features, and general degenerative changes of the cervical spine are common. Cervical spine X-ray examination may reveal different degrees of cervical spine osteophytes, degenerative changes, or narrowing of the vertebral space, vertebral instability, especially C3-4 and C4-5 are the more common vertebral segment instability, and changes such as calcification of the anterior and posterior longitudinal ligaments and straightening of the physiological curvature. However, some patients may not show any abnormalities on x-ray.
2.2 Laboratory tests of sympathetic nerve function.
At present, laboratory tests of sympathetic nerve function are less commonly used in clinical practice and have an auxiliary role in diagnosis.
① Sympathetic vasoconstrictor reflex (SVR) Some scholars use SVR to show sympathetic nervous system activity. The rationale is that performing a deep inspiration excitation test can cause a brief sympathetic response and skin vasoconstriction. Also, some scholars used laser multispectral flowmetry to measure skin blood flow at the ends of two fingers. Data were taken at a frequency of 20 Hz. The ratio of blood flow changes after deep inspiration was calculated using laboratory software.
② Sympathetic skin response (SSR) SSR is used to measure sympathetic nerve activity. It can be used in patients with spinal cord injury, cervical spondylosis, and spinal stenosis to assess abnormalities in their sympathetic nervous system function. However, SSR wave amplitude can be affected by the number of intermediate nerve fibers that are effectively excited. SSR is a valuable test that provides objective information about the sympathetic nervous system. Latency is a stable component of SSR, while wave amplitude is variable and can be adaptively attenuated by frequent stimulation, and the bilateral latency difference and wave amplitude ratio are relatively stable.
③ Muscle sympathetic nerve activity (MSNA) The electrical activity of the peroneal nerve was recorded directly with a tungsten microelectrode in the right N fossa in the supine position.
Sympathetic nerve function was observed using skin blood flow changes. Blood flow changes were recorded in the right ear with a laser multispectral flowmeter. The basic wave, a regular periodic activity of the cutaneous vessels 5-10 times in 1 min, was recorded with a stylus or recorder. It is a reflection of the automatic movement of blood vessels due to sympathetic nerve activity), while blood flow is recorded every 10 s with a digital tracer. Changes in sympathetic nerve activity indirectly cause changes in blood flow through changes in the cyclic activity of the underlying waves.
3. Diagnosis of sympathetic cervical spondylosis.
Sympathetic cervical spondylosis lacks specific auxiliary tests to make a clear diagnosis, and there are no exact criteria for diagnosing sympathetic cervical spondylosis. Cervical spine X-ray is the most important examination means, but some other diagnostic means are needed because the degree of lesion it shows is mostly not parallel to the clinical symptoms. In fact, a significant proportion of outpatients with sympathetic cervical spondylosis with headache, dizziness, blurred vision, tinnitus or tachycardia are misdiagnosed as neurological or internal medicine diseases, which directly affects the treatment outcome. According to current clinical experience, the diagnosis can be based on the following principles.
① Sympathetic excitation symptoms or sympathetic inhibition symptoms.
② Mostly no obvious signs, some patients may have slight discomfort when flexing, extending or rotating the neck.
③ X-ray shows cervical degeneration or narrowing of the intervertebral space and vertebral instability, especially C3 to 4 and C4 to 5 are the more common segments of vertebral segment instability. However, some patients may show no abnormalities on x-ray.
④ Excluding organic lesions of the brain, eyes, ears and heart with symptoms similar to sympathetic cervical spondylosis, such as glaucoma, Meniere’s syndrome, as well as neurosis and menopausal syndrome.
⑤ Laboratory tests of sympathetic nerve function include sympathetic constrictor reflex (SVR), sympathetic skin response (SSR), and muscle sympathetic nerve electrical activity (MSNA), and sympathetic nerve function is observed using changes in skin blood flow as an indicator.
(6) The diagnosis of sympathetic cervical spondylosis is also supported by diagnostic treatments such as cervical stellate ganglion block, high epidural capsular closure and cervical braking, if effective.