1.Disease introduction
Cervical spondylosis refers to degenerative changes in the cervical disc tissue and its secondary pathological changes involving the surrounding tissue structures (nerve roots, spinal cord, vertebral artery, sympathetic nerve, etc.), with corresponding clinical manifestations. Degenerative changes of the cervical spine without clinical manifestations are called cervical degenerative changes. In 2011, the North American Spine Society (NASS) published the Guidelines for the Treatment of Degenerative Neurogenic Cervical Spondylosis, which aims to provide evidence-based research recommendations on key issues in the treatment of degenerative neurogenic cervical spondylosis. The European Spine Journal published the article “Lack of uniform diagnostic criteria for neurogenic cervical spondylosis” in 2012, and in 1992, the definition, typology, diagnostic criteria and treatment principles of cervical spondylosis in China were clarified at the Second National Symposium on Cervical Spondylosis. On this basis, the first “Guidelines for the Diagnosis, Treatment and Rehabilitation of Cervical Spondylosis” in China was released in June 2007. The Guide classifies cervical spondylosis into: cervical type, nerve root type, spinal cord type, sympathetic type, vertebral artery type, and other types (at present, it mainly refers to the esophageal compression type) according to the different tissues and structures involved. If two or more types exist at the same time, it is called “mixed type”.
2.Diagnostic criteria
(1)Domestic diagnostic criteria
Cervical spondylosis is one of the common and frequent diseases of middle and old people. Cervical spondylosis refers to the clinical symptoms and signs manifested by cervical spinal lesions in general. Currently, the latest diagnostic criteria for cervical spondylosis are
The diagnosis can be confirmed if the clinical manifestations are consistent with what is seen in the imaging.
In cases with typical clinical manifestations of cervical spondylosis and normal imaging, attention should be paid to the exclusion of other diseases before diagnosing cervical spondylosis.
If there is only abnormal imaging but no clinical symptoms of cervical spondylosis, cervical spondylosis should not be diagnosed.
In addition to the above criteria, the diagnostic criteria for each type of cervical spondylosis are as follows
I. Cervical type.
1.Subjective complaints of abnormal sensations such as head, neck and shoulder pain, accompanied by corresponding pressure pain points.
2. The cervical spine shows changes in curvature or intervertebral joint instability on X-ray film.
3. Other disorders of the neck should be excluded (drop pillow, frozen shoulder, rheumatic myofibrositis, neurasthenia and other neck and shoulder pain not caused by degenerative disc degeneration).
Second, nerve root type.
1.With more typical radicular symptoms (numbness and pain), and the scope is consistent with the area innervated by the cervical spinal nerve.
2.The presence of pressure points in the neck and shoulder, positive head press test, brachial plexus pull test, rotational squeeze test and other tests. The skin sensation of the upper limbs is abnormal, and the tendon reflexes are enhanced or weakened, and hand muscle atrophy is seen in severe cases.
3. The imaging findings are consistent with the clinical manifestations.
4. Exclude the disorders caused by extra-cervical spine lesions (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, biceps tenosynovitis, etc.) with upper limb pain as the main cause.
Third, spinal cord type.
1. Clinical manifestations of cervical spinal cord damage such as weakness and numbness of the limbs, bundle chest feeling, trembling of the hands and feet, etc. In severe cases, urinary and fecal incontinence, paralysis, etc. may occur.
2. Depending on the location and degree of spinal cord compression, different signs such as abnormal tendon reflexes, weakened physiological reflexes, positive pathological reflexes, and positive flexion and extension tests may occur. And there may be abnormal sensation at the level of the corresponding segment.
3.X-ray shows osteophytes at the posterior edge of the vertebral body, spinal canal stenosis, narrowing of the spinal space and other manifestations. Imaging confirms the presence of spinal cord compression.
4, except for amyotrophic lateral sclerosis, spinal cord tumor, spinal cord injury, secondary adhesive arachnoiditis, multiple peripheral neuritis.
IV. Vertebral artery type.
The diagnosis of vertebral artery type cervical spondylosis is a problem to be studied.
1, there may be episodes of vertigo (sometimes accompanied by nausea and vomiting), tinnitus, deafness and other symptoms of insufficient blood supply to the vertebrobasilar artery, characterized by the appearance and disappearance of symptoms mostly related to the position of the head.
2.Cervical spine rotation test may be positive, and low head and head tilt test may also induce vertigo.
3.X-ray film shows segmental instability or hook vertebral joint hyperplasia. Vertebral artery CTA or vertebral arteriogram shows bending and torsion of vertebral artery.
4.More often accompanied by sympathetic symptoms.
5.Except ophthalmogenic and otogenic vertigo.
6. Exclude the insufficiency of basilar artery supply caused by the compression of vertebral artery segment I (the segment of vertebral artery before entering the transverse foramen of cervical 6) and vertebral artery segment III (the segment of vertebral artery before exiting the cervical spine into the skull).
V. Sympathetic type.
Clinical manifestations are a series of sympathetic symptoms such as migraine, dizziness, blurred vision, tinnitus, hand numbness, tachycardia, pain in the precordial region, etc. There is instability or degeneration on x-ray and negative vertebral arteriogram.
VI. Other types.
Cervical vertebral body anterior bird’s beak-like hyperplasia compressing the esophagus causing dysphagia (confirmed by barium esophagogram), etc.
(II) Foreign diagnostic criteria
There is a lack of specific description of diagnostic criteria for cervical spondylosis in authoritative journals and websites in North America and Europe. The National Institutes of Health (NIH) defines cervical spondylosis as a condition of chronic wear and tear of the cervical spine, often resulting in chronic pain in the neck. This chronic wear includes the interbody tissues of the cervical vertebrae and the cervical interbody joints, and may be accompanied by abnormal bone growth or bone growth at the vertebral margins. In the long term, these changes can produce clinical symptoms by compressing one or more nerve roots and, in severe cases, the spinal cord.
Interpretation of diagnostic criteria
(1) Cervical cervical spondylosis is caused by acute or chronic injury to the cervical muscles, ligaments and joint capsule, degeneration of the intervertebral disc, instability of the vertebral body, misalignment of the small joints, etc. The body is attacked by wind and cold, cold, fatigue, improper sleep posture or inappropriate pillow height, which causes the cervical spine to be over-extended or over-flexed, and certain muscles, ligaments and nerves in the cervical area are stretched or compressed. It mostly develops at night or in the morning, and has the tendency of natural remission and recurrent attacks. 30-40 years old women are more common.
(2) Neurogenic cervical spondylosis is caused by irritation and compression of cervical nerve roots in the spinal canal or intervertebral foramen due to disc degeneration, herniation, segmental instability, osteophytes or bone redundancy formation. It has the highest incidence among all types, accounting for about 60-70%, and is the most common type in clinical practice. Mostly unilateral and single-root onset, but there are also bilateral and multi-root onset cases. It is most common in people aged 30-50 years and usually has a slow onset, but there are also cases with acute onset. The onset of the disease is usually slow, but there are cases of acute onset.
(3) The incidence of spinal cord cervical spondylosis accounts for 12-20% of cervical spondylosis and has a high disability rate because it can cause limb paralysis. It usually starts slowly and is more common in middle-aged people aged 40-60. When combined with developmental cervical spinal stenosis, the average age of onset is younger than that of patients without spinal stenosis. Most patients have no history of cervical trauma.
(4) Sympathetic cervical spondylosis, due to factors such as disc degeneration and segmental instability, thus causing stimulation of sympathetic nerve endings around the cervical spine and producing sympathetic nerve dysfunction. Sympathetic cervical spondylosis has a wide range of symptoms, most of which are sympathetic excitation symptoms and a few are sympathetic inhibition symptoms. Since the surface of the vertebral artery is rich in sympathetic nerve fibers, when sympathetic nerve dysfunction occurs, the vertebral artery is often involved, resulting in abnormal diastolic function of the vertebral artery. Therefore, sympathetic cervical spondylosis is often associated with inadequate blood supply to the vertebrobasilar system along with symptoms of several systems in the body.
(5) In vertebral artery type cervical spondylosis, when the head is tilted or twisted to one side in normal people, the vertebral artery on the same side is squeezed and the blood flow of the vertebral artery is reduced, but the vertebral artery on the opposite side can compensate, thus ensuring that the blood flow of the vertebrobasilar artery is not greatly affected. When segmental instability and narrowing of the intervertebral space occur in the cervical spine, the vertebral artery can be distorted and compressed; the vertebral artery can be compressed directly by the vertebral edges and the bony bulge at the hook vertebral joint, or the sympathetic nerve fibers around the vertebral artery can be stimulated, causing spasm of the vertebral artery and instantaneous changes in the vertebral blood flow, resulting in inadequate blood supply to the vertebrobasilar system and symptoms, and therefore not accompanied by symptoms outside the vertebral artery system.