Cervical spondylosis is a common and frequent disease.
The Second National Symposium on Cervical Spondylosis (Qingdao, 1992) defined cervical spondylosis as a degenerative change of the cervical disc and its secondary pathological changes involving the surrounding tissues (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. With the increase in the number of people engaged in the modern way of working with their heads down, such as the widespread use of computers and air conditioners, the chances of people flexing their necks and suffering from wind, cold and dampness are increasing, resulting in the increasing prevalence of cervical spondylosis, and the trend of younger age of onset. Song Ruipeng, Department of Orthopedics, First Affiliated Hospital of Zhengzhou University
Part II Classification of cervical spondylosis
According to the different tissues and structures involved, cervical spondylosis is divided into : cervical type (also called soft tissue type), nerve root type, spinal cord type, sympathetic type, vertebral artery type, and other types (at present, it mainly refers to esophageal compression type). If two or more types exist at the same time, it is called “mixed type”.
I. Cervical cervical spondylosis.
Cervical cervical spondylosis is caused by acute or chronic injury to the muscles, ligaments and joint capsule of the neck, degeneration of the intervertebral disc, instability of the vertebral body and misalignment of the small joints, etc. The body is attacked by wind and cold, cold, fatigue, improper sleep posture or inappropriate pillow height, which makes the cervical spine over-extend or over-flex, and certain muscles, ligaments and nerves in the neck are strained 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.
II. Neurogenic cervical spondylosis
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, single-root onset, but there are also bilateral, multi-root onset. It is usually seen in people aged 30 to 50 years old, and generally has a slow onset, but there are also cases of acute onset. It is more common in males than females.
III. Spinal cord cervical spondylosis
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 between 40 and 60 years old. 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.
IV. Sympathetic cervical spondylosis
Sympathetic nerve dysfunction occurs due to factors such as disc degeneration and segmental instability, which cause stimulation of sympathetic nerve endings around the cervical spine. 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 in addition to symptoms of multiple systems.
V. Vertebral artery type cervical spondylosis
In normal individuals, when the head is tilted or twisted to one side, the vertebral artery on the same side is compressed, reducing the blood flow to the vertebral artery, but the vertebral artery on the opposite side can compensate, thus ensuring that the blood flow to 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 directly compressed by the vertebral margins and the bony bulge at the hook vertebral joint, or the sympathetic nerve fibers around the vertebral artery can be stimulated, resulting in spasm of the vertebral artery and instantaneous changes in vertebral artery blood flow, leading to inadequate vertebrobasilar blood supply.
Therefore, symptoms are not associated with symptoms outside the vertebral artery system.
Part III. Clinical manifestations of cervical spondylosis
I. Cervical spondylosis Cervical cervical spondylosis
1. Cervical straightness, pain, and painful stiffness of the entire shoulder and back may be present, and the head cannot be nodded, tilted, or turned. When the neck needs to be turned, the trunk must be turned at the same time, and symptoms of dizziness may also appear. 2.
2. A few patients may have reflex shoulder, arm and hand pain, swelling and numbness, and the symptoms do not worsen when coughing or sneezing.
3. Clinical examination: In the acute stage, the movement of the cervical spine is absolutely limited, and the range of movement of the cervical spine in all directions is close to zero. There is pressure pain in the cervical paravertebral muscles, thoracic 1 to thoracic 7 paravertebral or rhomboid muscles and sternocleidomastoid muscles, and there may be pressure pain in the supraspinatus and infraspinatus muscles. If there is secondary anterior oblique muscle spasm, the spastic muscle can be felt at the medial side of the sternocleidomastoid muscle, which corresponds to the level of the transverse process of cervical 3 to cervical 6, and with slight pressure, radiating pain in the shoulder, arm and hand can occur.
II. Nerve root type cervical spondylosis
1. Neck pain and stiffness of the neck are often the earliest symptoms. Some patients also have pain in the shoulder and the medial edge of the scapula.
2. Radiating pain or numbness in the upper extremities. This pain and numbness radiates along the course and innervation area of the affected nerve root and is characteristic, hence the name root-type pain. The pain or numbness can be episodic or persistent. Sometimes there is a clear relationship between the appearance and relief of symptoms and the position and posture of the patient’s neck. Neck movement, coughing, sneezing, exertion and deep breathing can cause an increase in symptoms.
3. The affected upper extremity feels heavy, has reduced grip strength, and sometimes appears to fall from holding objects. There may be vasomotor nerve symptoms, such as swelling of the hand. Muscle atrophy may appear in the late stage.
4. Clinical examination: neck stiffness and restricted movement. Tension in the affected neck muscles, pressure pain in the spinous process, paraspinal process, medial border of the scapula and muscles innervated by the affected nerve roots. The presence of pressure pain in the intervertebral foramina with radiating pain or numbness in the upper extremities, or aggravation of existing symptoms, has localizing significance. A positive intervertebral foramen crush test and a positive brachial plexus nerve pull test are indicated. Careful and thorough neurological examination helps to localize the diagnosis.
III. Spinal cord type cervical spondylosis
1. Most patients first experience numbness and heaviness in one or both lower extremities, followed by gradual difficulty in walking, tightness of various groups of muscles in the lower extremities, slow lifting and inability to walk fast. Then, when going up and down the stairs, it is necessary to hold the handrail with the upper limb in order to ascend the steps. In severe cases, the gait is unstable and walking is difficult. Patients have the feeling of stepping on cotton in both feet. In some patients, the onset of the disease is insidious, often trying to catch a bus that is about to leave, but suddenly found that the legs can not walk fast.
2. Numbness and pain in one or both upper limbs, weakness and inflexibility in both hands, difficulty in completing fine movements such as writing, fastening, holding chopsticks, etc., and the tendency to drop objects. In severe cases, the patient cannot even eat by himself.
Patients often feel a belt-like binding sensation in the chest, abdomen, or both lower limbs, called “belt sensation”. At the same time, there may be a burning sensation and cold sensation in the lower extremities.
4. Some patients have bladder and rectal dysfunction. Such as weak urination, frequent urination, urgent urination, incomplete urination, urinary incontinence or urinary retention and other urinary disorders, constipation. Sexual function is reduced. If the disease develops further, the patient can only walk with crutches or with the help of others, until there is spastic paralysis of both lower limbs, bedridden and unable to take care of themselves.
5. Clinical examination: There are no signs in the neck. The upper extremities or trunk show segmental distribution of superficial sensory disorders, while deep sensation is mostly normal, muscle strength decreases, and grip strength of both hands decreases. Tendon reflexes are active or hyperactive, including biceps, triceps, radialis, knee tendon and Achilles tendon reflexes; patellar clonus and ankle clonus are positive. Positive pathological reflexes: such as Hoffmann’s sign, Rossolimo’s sign, Barbinski’s sign and Chacdack’s sign in the upper limbs. Superficial reflexes such as abdominal wall reflex and testicular reflex are weak or absent. If the tendon reflexes of the upper extremity are weak or absent, the lesion is at the level of that nerve segment.
IV. Sympathetic cervical spondylosis
1. Head symptoms: such as dizziness or vertigo, headache or migraine, head sinking, occipital pain, poor sleep, memory loss, difficulty in concentration, etc. Occasionally, people may fall down due to dizziness.
2. Eye, ear, nose and throat symptoms: eye swelling, dryness or teariness, change in vision, blurred vision, fog in front of the eyes, etc.; tinnitus, ear blockage, hearing loss; nasal congestion, “allergic rhinitis”, foreign body sensation in the throat, dry mouth, vocal cord fatigue, etc.; taste changes, etc.
3. Gastrointestinal symptoms: nausea and even vomiting, bloating, diarrhea, indigestion, belching, and foreign body sensation in the throat, etc.
4. Cardiovascular symptoms: palpitations, chest tightness, changes in heart rate, arrhythmia, changes in blood pressure, etc.
5. Excessive sweating, no sweating, chills or fever on the face or a certain limb, sometimes pain, numbness but not according to the distribution of nerve segments or travels. The above symptoms are often clearly related to the neck activity, aggravated when sitting or standing, and reduced or disappeared when lying down. It is obvious when there is a lot of neck activity, prolonged head bowing, long working hours in front of the computer or exertion, and improves after rest.
6. Clinical examination: The movement of the neck is mostly normal, and the soft tissue around the interspinous process of the cervical spine or the small joints of the paravertebral spine is painful. Sometimes there may also be changes in heart rate, heart rhythm, blood pressure, etc.
V. Vertebral artery type cervical spondylosis
1. Episodic vertigo, diplopia with nystagmus. Sometimes accompanied by nausea, vomiting, tinnitus or hearing loss. These symptoms are related to the change of neck position.
2. Sudden weakness of lower limbs with sudden collapse but consciousness, mostly when the head and neck are in a certain position.
3. Occasionally, there is numbness and abnormal sensation in the limbs. Transient paralysis and episodic coma may occur.
Part IV Diagnostic criteria of cervical spondylosis
I. Clinical diagnostic criteria
1. Cervical type: with a typical history of fallen pillow and the above-mentioned cervical symptoms and signs; imaging examination may be normal or only have physiological curvature changes or mild spinal space narrowing, with little bone formation.
2. Nerve root type: symptoms (numbness, pain) and signs of radicular distribution; positive intervertebral foramen squeeze test or/and brachial plexus pull test; imaging findings are basically consistent with clinical manifestations; pain due to extra-cervical pathology (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, biceps longus tendinitis, etc.) is excluded.
3. Spinal cord type: clinical manifestations of cervical spinal cord damage; imaging shows degenerative changes in the cervical spine, cervical spinal stenosis, and confirms the presence of cervical spinal cord compression consistent with clinical manifestations; except for progressive amyotrophic lateral sclerosis, spinal cord tumor, spinal cord injury, secondary adhesive arachnoiditis, multiple peripheral neuritis, etc.
4. Sympathetic type: diagnosis is difficult, and there is a lack of objective diagnostic indicators. Clinical manifestations of sympathetic nerve dysfunction and imaging show segmental instability of the cervical spine. In some patients with atypical symptoms, if the symptoms are reduced after planetary ganglion closure or high cervical epidural closure, it will help the diagnosis. Vertigo due to other causes : (1)
(1) Otogenic vertigo : Vertigo is caused by vestibular dysfunction in the inner ear. For example, Meniere’s syndrome and embolism of the auditory artery in the ear.
(2) Ophthalmogenic vertigo: refractive error, glaucoma and other ophthalmic disorders.
(3) Cerebral vertigo: Inadequate blood supply to vertebrobasilar artery due to atherosclerosis, lacunar cerebral infarction; brain tumor; sequelae of traumatic brain injury, etc.
(4) Vertigo of vascular origin: Vertebrobasilar insufficiency due to stenosis of V1 and V3 segments of vertebral artery; hypertension, coronary artery disease, pheochromocytoma, etc.
(5) Other causes: diabetes mellitus, neurosis, overexertion, long-term sleep deprivation, etc.
(5) Vertebral artery type: sudden collapse attack with cervical vertigo; positive neck rotation test; imaging shows segmental instability or hook joint hyperplasia; except for other causes of vertigo; positive neck motion test.
II. Imaging and other auxiliary examinations
X-ray is an important tool for the diagnosis of cervical spine injury and certain disorders, and is also the most basic and commonly used examination technique for the neck, and is an important examination method that cannot be ignored even under the highly developed conditions of imaging technology. X-ray plain films provide an imaging basis for determining the severity of the injury, treatment selection, and treatment evaluation. The whole cervical spine is often photographed in frontal and lateral views, cervical extension and flexion dynamic lateral views, oblique views, and cervical 1 to 2 open views and tomographic views when necessary. Sometimes a high-density shadow of the posterior longitudinal ligament (Ossification of posterior longitudinalligament (OPLL)) can be seen at the posterior edge of the vertebral body.
Cervical spinal canal measurement: Developmental cervical spinal stenosis is diagnosed if the ratio of the midsagittal diameter of the spinal canal to the midsagittal diameter of the vertebral body is less than or equal to 0.75 on lateral cervical radiographs of any of the vertebrae C3 through C6. Segmental instability is important in the diagnosis of sympathetic cervical spondylosis and is measured as the sum of the distance between the extension of the posterior border of the vertebral body and the lower border of the slipped vertebral body to the posterior border of the same vertebral body ≥ 2 mm on a lateral cervical hyperflexion/extension radiograph; intervertebral body angles >11°u12290XCT can show the shape of the spinal canal and the extent of OPLL and encroachment on the spinal canal; myelography with CT can show compression of the dural sac, spinal cord, and nerve roots. Myelography with CT can show the compression of the dural sac, spinal cord and nerve roots.
MRI of the neck can clearly show changes in the spinal canal and spinal cord, as well as changes in the site and morphology of spinal cord compression, and is of great value in the diagnosis of cervical spine injury, cervical spondylosis and tumors. When the cervical disc degenerates, its signal intensity also decreases, and the diagnosis of disc herniation can be accurately made in both the sagittal and cross-sectional planes. In the diagnosis of cervical spine diseases, magnetic resonance imaging can not only show the extent and degree of backward compression of the dural sac by cervical spine fractures and disc herniation, but also reflect the pathological changes after spinal cord injury. Intraspinal hemorrhage or substantial damage generally appears as a dull and gray image on T2-weighted images. In contrast, spinal cord edema often appears as a uniformly dense striated or pyknotic signal.
Transcranial color Doppler (TCD), DSA, and MRA can probe basilar artery blood flow and intracranial blood flow in the vertebral artery, and presume vertebral artery ischemia, which is an effective means of examining inadequate blood supply to the vertebral artery and is also a common test for clinical diagnosis of cervical spondylosis, especially vertebral artery cervical spondylosis. Vertebral artery angiography and vertebral artery “ultrasound” can be helpful in diagnosis.
Part V. Treatment of cervical spondylosis
The treatment of cervical spondylosis is divided into surgical and non-surgical. Most patients with cervical spondylosis have excellent results with non-surgical treatment, and only a small percentage of patients require surgery because non-surgical treatment is ineffective or serious.
I. Non-surgical treatment Non-surgical treatment
At present, it is reported that 90% to 95% of patients with cervical spondylosis are cured or relieved by non-surgical treatment. Non-surgical treatment is currently mainly a combination of Chinese medicine, Western medicine, Chinese and Western medicine, and rehabilitation therapy, etc. Chinese medicine treatment means combined with Western medicine anti-inflammatory and analgesic, vasodilator, diuretic and dehydrating, nerve nutrition and other types of drugs.
(ii). Rehabilitation treatment
1. Physiotherapy
The main function of physical factor therapy is to dilate blood vessels, improve local blood circulation, release the spasm of muscles and blood vessels, eliminate inflammation and edema of nerve roots, spinal cord and surrounding soft tissues, reduce adhesions, regulate the function of plant nerves, and promote the recovery of nerve and muscle functions. Commonly used treatment methods
(1) Direct current ion introduction therapy
Commonly, various western medicines (glacial acetic acid, VitB1, VitB12, potassium iodide, nufacaine, etc.) or Chinese medicines (Wu Tou, Wei Ling Xian, Safflower, etc.) are placed on the back of the neck, and the anode or cathode is connected according to the performance of the medicine, and the other electrode is placed opposite or diagonally opposite, and each time the electricity is applied for 20 minutes, which is suitable for all types of cervical spondylosis.
(2) Low-frequency modulated medium-frequency electrotherapy
Generally, 2000Hz-8000Hz medium frequency electricity is used as the carrier frequency, and low frequency electricity of different waveforms (square wave, sine wave, triangle wave, etc.) from 1 to 500Hz is used as the modulating waveform, which is modulated in different ways and compiled into different prescriptions. The prescription is chosen according to different conditions, and the electrode placement method is the same as that of direct current, and each treatment generally lasts 20~30 minutes.
(3) Ultrashort wave therapy
The treatment is carried out with ultrashort wave of wavelength about 7m. Generally, two medium-sized electrode plates are placed behind the neck and the extensor side of the forearm of the affected limb, or a single pole is placed behind the neck. In the acute stage, no heat is applied once a day for 12 to 15 minutes, and in the chronic stage, micro heat is applied for 15 to 20 minutes each time. 10 to 15 times is a course of treatment. It is suitable for nerve root type (acute phase) and spinal cord type (spinal edema phase).
(4) Ultrasonic therapy
Frequency 800kHz or 1000kHz ultrasonic therapy machine, sound head and neck skin close contact, along the vertebral space and paravertebral movement, intensity with 0.8 ~ 1 W/cm2, hydrocortisone cream can be used as a contact agent, once a day, each time 8 min, 15 ~ 20 times a course of treatment. For the treatment of spinal cord type cervical spondylosis. The ultrasonic frequency is the same as above, the acoustic head moves along both sides of the neck and the two supraganglial fossa, the intensity is 0.8 ~ 1.5 W/cm2, 8 ~ 12 min each time, the rest is the same as above, used for the treatment of cervical spondylosis of nerve root type.
(5) Ultrasonic conductivity targeted transdermal drug delivery treatment
Ultrasonic conductivity instrument and ultrasonic conductivity gel patch are used, and 2% lidocaine injection is selected as the transdermal drug. The patch was first fixed in the treatment transmitter head of the instrument, and 1 ml of prepared lidocaine injection was added to the two coupling gel patches separately, and then the patch was fixed to the front of the patient’s neck together with the treatment transmitter head. The treatment parameters were selected as conductivity 6, ultrasound intensity 4, frequency 3, treatment time 30 minutes, once a day, 10 days as a course of treatment. It is used for the treatment of vertebral artery and sympathetic cervical spondylosis.
(6) High potential therapy
Using a high-potential therapy instrument, the patient sits on a plate electrode or a treatment chair with the foot on an insulated pad for 30 to 50 minutes per treatment. At the same time, rolling electrodes can be used to roll in the posterior neck collar area or the affected area for 5 to 8 minutes once a day, and every 12 to 15 days is a course of treatment, which can be used for all types of cervical spondylosis, among which sympathetic cervical spondylosis has the best effect.
(7) Light therapy
Ultraviolet ray therapy: the back of the neck on the flat hairline down to the second thoracic vertebra, the amount of erythema (3 ~ 4 biomass), once every other day, 3 times a course of treatment, with ultra-short wave treatment nerve root type acute stage. Infrared therapy: various infrared instruments are available, irradiation behind the neck. 20 ~ 30 min/ time. It is used for soft tissue cervical spondylosis, or with cervical traction therapy (infrared therapy before cervical traction).
(8) Other therapies
Such as magnetic therapy, electrical excitation therapy, audio electrotherapy, interference electrotherapy, wax therapy, laser irradiation and other treatments are also cervical
(8) Other therapies such as magnetic therapy, electrical excitation therapy, audio electrotherapy, interference electrotherapy, wax therapy, laser irradiation and other therapies are also frequently used in the physical treatment of cervical spondylosis.
2. Traction therapy
Cervical spine traction is a common and effective method for treating cervical spondylosis. Cervical traction helps to release muscle spasm in the neck, relax the muscles and relieve pain; release soft tissue adhesions and stretch contracted joint capsules and ligaments; improve or restore the normal physiological curvature of the cervical spine; enlarge the intervertebral foramen and relieve the stimulation and compression of nerve roots; enlarge the vertebral space and reduce the pressure in the intervertebral disc. Adjust the microscopic abnormal changes of the small joints, so that the synovial membrane of the joint embedment or the misalignment of the synovial joint can be reset; the three major elements of the direction (angle) of traction force, weight and traction time must be mastered when cervical spine traction treatment, in order to obtain the best therapeutic effect of traction.
(1) traction mode: commonly used occipito-mandibular band traction method, usually using sitting traction, but the condition is heavy or can not sit traction horizontal traction. Continuous traction, intermittent traction or a combination of both can be used.
(2) Traction angle: generally according to the lesion site, such as lesions mainly in the upper cervical segment, traction angle should be 0-10 °, such as lesions mainly in the lower cervical segment (neck 5 ~ 7), traction angle should be slightly forward, can be between 15 ° -30 °, while paying attention to the patient’s comfort to adjust the angle.
(3) Traction weight: the weight of intermittent traction can be determined by 10%-20% of its own body weight, while continuous traction should be reduced appropriately. Generally, the initial weight is light, such as 6 kg, and then gradually increase.
(4) Traction time: Traction time should be 20 minutes for continuous traction and 20 to 30 minutes for intermittent traction, once a day, 10 to 15 days as a course of treatment.
(5) precautions: individual differences should be fully considered, the elderly and frail people should be traction weight lighter, traction time is shorter, young and strong can hold heavier and longer; traction process should pay attention to observe and ask the patient’s reaction, if there is discomfort or symptom aggravation should immediately stop traction, find the cause and adjust and change the treatment plan.
(6) Contraindications to traction: obvious discomfort or aggravation of symptoms after traction, no improvement after adjustment of traction parameters; obvious spinal cord compression and serious segmental instability; serious degenerative degeneration of aged vertebrae and joints, obvious narrowing of the spinal canal, serious calcification and ossification of ligaments and joint capsule.
3.Manipulation treatment
It is based on the anatomical and biomechanical principles of cervical vertebrae and joints, and is a passive activity treatment of pushing, pulling and rotating the spine and small joints of the spine to adjust the anatomical and biomechanical relationship of the spine, and at the same time to loosen and rationalize the muscles and soft tissues related to the spine, so as to improve the function of the joints, relieve spasm and reduce pain. The purpose is to improve joint function, relieve spasm and reduce pain.
Commonly used methods are Chinese and Western techniques. Chinese techniques refer to the traditional Chinese massage and tui-na techniques, which generally include bone and joint repositioning techniques and soft tissue massage techniques. Western-style techniques commonly used in China include McKenzie (Mckenzie) method, joint release (Maitland technique), chiropractic (chiropractic) and so on.
It should be particularly emphasized that manipulative treatment of cervical spondylosis must be performed by trained medical professionals. It is advisable to control the strength of the manipulation according to the individual situation and to be as gentle as possible, avoiding violence. If it is difficult to exclude lesions such as tumors in the spinal canal, developmental stenosis of the spinal canal, spinal cord compression, bony destruction of the vertebral body and accessories, ossification of the posterior longitudinal ligament or cervical deformity, acute inflammation of the pharynx, larynx, neck and occiput, obvious neurosis, or if the diagnosis is unknown, the use of any massage and orthopedic manipulation is cautiously used or prohibited.
4. Exercise therapy
Exercise therapy for cervical spine refers to the exercise of the neck and other related parts as well as the whole body by using appropriate exercise methods. Exercise therapy can enhance the muscle strength of the neck, shoulder and back muscles, stabilize the cervical spine, improve the function of the joints between the vertebrae, increase the range of motion of the cervical spine, reduce nerve stimulation, reduce muscle spasm, eliminate pain and other discomfort, correct abnormalities or deformities in the alignment of the cervical spine, and correct poor posture. Long-term adherence to exercise therapy can promote the body’s adaptation to the compensatory process, thereby achieving the purpose of consolidating the therapeutic effect and reducing recurrence.
Cervical spine exercise therapy is commonly used in the form of freehand exercises, stick exercises, dumbbell exercises, etc. Mechanical training cervical flexibility exercises, cervical muscle strength training, cervical spine correction training, etc. can also be used when available. In addition, there are whole-body sports such as running, swimming, ball games, etc. are also common therapeutic sports for cervical spine disorders. Patients with cervical spondylosis can be instructed to adopt the “Neck and shoulder disease exercise prescription”. Exercise therapy is applicable to patients with all types of cervical spondylosis in remission and post-operative recovery. The specific methods and approaches vary according to different types of cervical spondylosis and different individual physiques, and should be carried out under the guidance of a specialist. 5. Application of orthopedic braces
Orthopedic braces for cervical spine are mainly used to fix and protect the cervical spine, correct the abnormal mechanical relationship of the cervical spine, reduce neck pain, prevent over-extension, over-flexion and over-rotation of the cervical spine, avoid further damage to the spinal cord and nerves, reduce spinal edema, reduce the traumatic reaction of the intervertebral joints, help repair the tissues and relieve the symptoms, and cooperate with other treatment methods at the same time to consolidate the therapeutic effect and prevent recurrence.
The most commonly used ones are neck circumference and neck brace, which can be applied to patients in the acute stage of all types of cervical spondylosis or those with severe symptoms. Cervical brace is also mostly used for patients with cervical fracture or dislocation and intervertebral instability or subluxation even after early treatment. Wearing a neck brace for protection is necessary when riding in high-speed cars and other means of transportation, whether with or without cervical spondylosis. However, unreasonable long-term use should be avoided as it may lead to cervical muscle weakness and poor cervical mobility.
Regardless of that type of cervical spondylosis, the basic principle of its treatment is to follow the basic principle of non-surgical treatment first and then surgery after it is ineffective. This is not only because of the pain and injury and complications associated with surgery itself, but more importantly because the vast majority of cervical spondylosis itself can be stopped, improved or even cured through non-surgical treatment. Unless there are a few cases with clear indications for surgery, regular non-surgical treatment should be started and continued for 3 to 4 weeks, which is generally effective. For those with progressive development (mostly spinal cervical spondylosis), early surgery is required.
(B) Surgery
The main purpose of surgical treatment is to relieve the severe compression on the spinal cord or blood vessels due to disc herniation, bone formation or ligament calcification, and to rebuild the stability of the cervical spine. Once the diagnosis of spinal cord cervical spondylosis is confirmed, those whose condition has been aggravated by non-surgical treatment should be actively treated surgically; those whose symptoms of neurogenic cervical spondylosis are heavy and affect the patient’s life and work, or those who have muscle movement disorders; and other types of cervical spondylosis whose conservative treatment is ineffective or whose efficacy is not consolidated and has recurrent attacks should be considered for surgical treatment.
The indications for minimally invasive treatment (myelolysis, percutaneous aspiration, PLDD, radiofrequency ablation, etc.) must be strictly mastered.
The surgical procedures are divided into anterior and posterior cervical approaches.
1.Anterior cervical surgery
The anterior cervical approach involves removal of the diseased disc and posterior spur and intervertebral bone grafting. The advantage is that the spinal cord is directly decompressed and the cervical spine is permanently stabilized after fusion of the bone graft. The use of titanium plates for internal fixation at the same time as the bone graft can improve the fusion rate of the bone graft and maintain the physiological curvature of the cervical spine. Indications for anterior discectomy interbody bone graft fusion surgery: nerve root or spinal cord ventral compression due to disc herniation or bone bulge in 1-2 segments; segmental instability. Bone grafting materials can be autologous iliac bone, allogeneic bone, artificial bone such as hydroxyapatite, calcium phosphate, calcium sulfate, coral ceramic, etc. The intervertebral fusion device (Cage) has the function of maintaining the intervertebral height, enhancing local stability and improving the fusion rate, and at the same time, due to its advantages of low incision, it can significantly reduce the postoperative foreign body sensation in the pharynx and swallowing difficulties, and the special iliac bone extraction device can achieve minimally invasive bone extraction. For isolated OPLL; limited spinal stenosis etc., subtotal laminectomy, intervertebral bulk bone graft and titanium plate internal fixation can be used. If the titanium cage is filled with autologous bone (resected vertebral body) and fixed with a titanium plate, bone retrieval can be avoided. For patients with mild intervertebral joint degeneration and no significant narrowing of the intervertebral space, artificial disc replacement can be performed after removal of the diseased disc.
2. Posterior approach surgery
The cervical spinal canal is enlarged through the posterior cervical approach so that the spinal cord can be decompressed. The commonly used procedures are single-opening and double-opening spinal canal enlargement. Indications for surgery: spinal cord cervical spondylosis with developmental or multisegmental degenerative spinal stenosis; multisegmental OPLL; cervical ligamentous hypertrophy or ossification resulting in ventral and dorsal compression of the spinal cord. In cases of segmental instability, lateral titanium plate screws or internal fixation via pedicle screws and bone graft fusion can be performed at the same time.
3. Rehabilitation treatment
Rehabilitation treatment in the “perioperative period” of cervical spondylosis is conducive to consolidating the efficacy of surgery, making up for the shortcomings of surgery, and relieving the local and systemic trauma caused by surgery, so as to achieve the purpose of restoring the physical and mental health of patients. The basic method of perioperative treatment cannot be separated from the rehabilitation medical treatment of cervical spondylosis (such as traditional Chinese medicine, physiotherapy, sports therapy, hyperbaric oxygen, etc.), and some new pathological factors, such as the mental burden of anxiety and panic brought to patients by surgery, and the trauma of surgery and postoperative weakness, cannot be ignored.
The “cervical spondylosis rehabilitation and health care gong” is used for the prevention and supplementary treatment of cervical spondylosis, and can be planned to be extended to the community, reflecting the academic idea of rehabilitation and prevention.
4. Evaluation of therapeutic effect
The Japanese Orthopaedic Society has developed a standard for assessing the spinal cord function of patients with cervical spinal cord disease (referred to as the 17-point scale) (Table 1), which has been accepted by international scholars. According to the national conditions of China, the corresponding standard (referred to as the 40-point method) has also been formulated (Table 2) and has been promoted and applied in China.
Part VI Prevention of cervical spondylosis
It is almost inevitable that degenerative changes occur in the intervertebral discs of the cervical spine as we grow older. However, if attention is paid to avoiding some factors that promote degenerative disc degeneration in life and work, it will help prevent the occurrence and development of cervical degenerative degeneration.
I. Correct understanding of cervical spondylosis, establish confidence to overcome the disease
The course of cervical spondylosis is relatively long, and the degeneration of the intervertebral disc, the growth of bone spurs, and the calcification of ligaments are related to ageing and aging of the body. The disease is often recurrent, and the symptoms may be heavy during the attack, affecting daily life and rest. Therefore, on the one hand, it is necessary to eliminate the fear of pessimism, and on the other hand, it is necessary to prevent the mentality of getting by and giving up active treatment.
II. About rest
Patients with acute attacks or first attacks of cervical spondylosis should pay proper attention to rest, and those with serious conditions should rest in bed for 2-3 weeks. From the perspective of prevention of cervical spondylosis, it is better to choose a bed that is conducive to the stability of the disease and to maintain the balance of the spine. The position, shape and material of the pillow should be selected, and a good sleeping position is also needed to maintain the physiological curvature of the entire spine and make the patient feel comfortable, so as to relax the muscles of the whole body and adjust the physiological state of the joints.
III. About health care
1. Exercise of medical sports and health care exercises
Those who do not have any symptoms of cervical spondylosis can perform slow flexion, extension, left and right lateral flexion and rotation of the neck several times a day in the morning and evening. Strengthen the isometric resistance contraction exercise of the neck and back muscles.
It is significant for cervical spine patients to quit smoking or reduce smoking to relieve their symptoms and recover gradually. Avoid overexertion that leads to recurrent inflammation of the throat, avoid excessive weight bearing and human vibration and thus reduce the impact on the intervertebral disc.
2. Avoid long-term low posture
To avoid prolonged head-down work, banking and accounting professionals, office desk work, computer operations and other personnel, this position makes the neck muscles, ligaments are strained for a long time and strain, prompting cervical disc degeneration. Change the position after about 1 hour of work. Change the bad work and life habits, such as lying in bed reading, watching TV, etc. 3.
3. Place the neck in a physiological state to rest
Generally, the adult neck padding is about 10 centimeters high, high pillow to make the neck in a flexed state, the result is the same as the low head posture. When lying on the side, the pillow should be raised to the height of the head does not appear lateral flexion.
4. Avoid neck trauma
Wear seat belts and avoid sleeping in the car to avoid injury to the cervical vertebrae due to relaxation of the neck muscles when braking sharply. When neck, shoulder and arm pain occurs, after a clear diagnosis and excluding cervical spinal stenosis, gentle massage is feasible, avoiding overly heavy rotation techniques to avoid damage to the intervertebral disc.
5. Avoid wind and cold, humidity
In summer, avoid fans and air conditioners blowing directly on the neck, and do not blow cold wind directly after sweating, or rinse the head and neck with cold water, or sleep on a cool pillow.
6. Pay attention to adolescent cervical spine health
With the intensification of the competitive pressure of adolescent schooling, the long hours of reading and studying have caused great harm to the cervical spine health of the majority of adolescents, resulting in the trend of cervical spondylosis at a younger age. It is recommended that health care knowledge about the cervical spine be vigorously promoted in primary and secondary schools and even universities to educate students to establish awareness of cervical spine health care, pay attention to cervical spine health, establish the concept of scientific learning and healthy learning, and intercept cervical spine disease at the source.
Table I Assessment of spinal cord functional status of patients with cervical spondylosis (17-point scale)
I. Upper limb motor function (4 points)
Unable to hold chopsticks or a spoon by themselves to eat (0 points)
Able to hold a spoon, but not chopsticks (1 point)
Able to hold chopsticks even though the hand is not flexible (2 points)
Can hold chopsticks and do general household chores, but has clumsy hands (3 points)
Normal (4 points)
II. Motor function of lower limbs (4 points)
Unable to walk (0 points)
Needs support even for walking on level ground (1 point)
Can walk on level ground without support, but needs to use when walking upstairs (2 points)
Walking on level ground or upstairs without support, but inflexible lower limbs (3 points)
Normal (4 points)
III. Sensory (6 points)
Obvious sensory impairment (0 points)
Mild sensory impairment (1 point)
Normal (2 points)
VI. Bladder function (3 points)
Urinary retention (0 points)
High degree of difficulty in urination, straining to urinate, incontinence or dribbling (1 point)
Mild dyspareunia, urinary frequency, urinary retention (2 points)
Normal (3 points)
Table 2 Assessment of spinal cord functional status in patients with cervical spondylosis (40-point scale)
I. Upper extremity function (left and right subcheck, total 16 points)
No use of function (0 points)
Barely holding food for meals, unable to fasten the buckle for writing (2 points)
Can hold a spoon to eat, can barely fasten the buckle and write with distortion (4 points)
Can hold chopsticks for meals, can fasten buckles, but inflexible (6 points)
Basically normal (8 points)
II. Lower extremity function (left and right are not distinguished, total 12 points)
Unable to sit and stand (0 points)
Can sit but cannot stand (2 points)
Able to stand but unable to walk (4 points)
Can walk with a double crutch or requires assistance (6 points)
Walking up and down stairs with a single crutch or escalator (8 points)
Able to walk independently, limping gait (10 points)
Basically normal (12 points)
III. Sphincter function (6 points in total)
Urinary retention, or urinary and fecal incontinence (0 points)
Difficulty in urination or defecation or other disorders (3 points)
Basically normal (6 points)
VI. sensation of the extremities (upper and lower extremities separately, 4 points in total)
Numbness, pain, tightness, dullness or hyperalgesia (0 points)
Basically normal (2 points)
V. Tethered sensation (trunk, 2 points)
Tight band sensation (0 points)
Basically normal (2 points)