Cervical spondylosis is a common clinical condition, which is traditionally divided into three specialist stages (types): cervical discogenic cervical spondylosis stage, osteogenic cervical spondylosis stage, and spinal degenerative cervical spondylosis stage [1]. Since Xuan Lao founded the theory of soft tissue surgery [2], it has been found that the muscular system has an increasingly important role in the pathogenesis of cervical spondylosis as research progresses [3 ,4 ]. Based on the above three types of typology, the authors proposed the “myogenic cervical spondylosis stage” [5-7], which was published in the Chinese Journal of Orthopedics and Traumatology in May 2008 [8]. Now, we would like to discuss “myogenic cervical spondylosis stage” again in the light of the study of Xuan Zhe Ren’s Soft Tissue Surgery in recent years.
Introduction of the name of cervical spondylosis
In 1928, Stookey reported seven cases of “cervical chondrosarcoma”, and in 1931, Esberg concluded that In 1937, Stookey restated that the so-called chondromas were actually herniated intervertebral discs. In 1948, Brain combined the symptoms of cervical spine osteophytes and degenerative changes of the cervical discs and called it cervical spondylosis. In 1989, Lestini and Wiesel explained cervical spondylosis as “a general disorder affecting all segments of the cervical spine that involves degeneration of the intervertebral discs, vertebral bulges, small joint and laminar hyperplasia, ligamentous hypertrophy, and intersegmental instability as a result of age-related changes.” In this way cervical spondylosis again encompasses the process of degenerative changes in the cervical spine. In the English-Chinese dictionary translated by Wang Xiancai et al, “Cervical Spondylosis” refers to cervical spine joint stiffness, degenerative arthropathy of the cervical spine, ligaments and connective tissue around the intervertebral disc, and sometimes abnormal sensation radiating to the arm due to compression of the spinal nerve.” It limits cervical spondylosis to cervical spine degeneration and partial nerve root irritation producing symptoms. The Practical Orthopedics considers cervical spondylosis to be a variety of symptoms caused by degenerative degeneration of the cervical intervertebral discs, instability between the vertebral bodies, the production of bony redundancy at the edges of the vertebral bodies or rupture of the intervertebral discs, and prolapse of the nucleus pulposus that compresses the nerve roots, spinal cord, or vertebral artery [9 ]. Modern Orthopedics considers cervical spondylosis as a syndrome of a series of clinical symptoms and signs caused by degenerative changes in the intervertebral discs, vertebral bodies, small joints and related ligaments in the neck or by strain, exposure to wind, cold and dampness, etc., resulting in irritation or damage to muscles, ligaments, nerves, spinal cord and blood vessels [10].
From the above review, it can be seen that the determination of the name of cervical spondylosis has undergone a process from osteoarthritis to disc degeneration, and then to disc, vertebral body, small joints and ligament degeneration leading to a series of syndromes caused by irritation and damage to muscles, ligaments, nerves, spinal cord, blood vessels, etc.
Features that a reasonable cervical spondylosis staging should have
Since the understanding of cervical spondylosis is a continuous process of deepening. Therefore, any kind of staging or typing has its own criteria of the times. Because the pathological anatomy and pathophysiology of cervical spondylosis are quite complex, and the lesions are extensive and vary greatly among individuals. Therefore, it is currently difficult to encompass all phenomena with a particular staging and typing, but an ideal staging and typing should have the following characteristics [1].
Clarification of the pathological anatomy and pathophysiological substance of the lesion This is the most important point for any kind of disease, and only if the substance of the disease is more correctly reflected, can we have an overall understanding and evaluation of its whole picture. Therefore, the pathologic anatomy and pathophysiological features are the basis for classification and typing.
Clarify the characteristics of the lesion Cervical spondylosis is a long-lasting and developing disease, and a proper staging and typing should reflect the characteristics of this lesion, so that it has diagnostic significance and is different from other diseases or different periods of the same disease.
Based on this staging and staging, the clinician can know at a glance the stage of the patient’s pathology and decide what treatment is most appropriate, including the choice of non-surgical treatment, the type of surgical treatment, the route of operation and the procedure.
The prognosis of each group of cases should be accurately reflected by their diagnostic stages and staging. The prognosis of the disease must also be obvious based on the classification based on the pathological anatomy and pathophysiological characteristics of the disease.
Limitations of the current understanding of cervical spondylosis
Based on the above characteristics of reasonable cervical spondylosis staging, the following limitations in the current understanding of cervical spondylosis can be seen.
Limitations in the current understanding of the etiology and pathology of cervical spondylosis In the pathogenesis of cervical spondylosis, “dynamic imbalance is the first and static imbalance is the main”. The cervical muscles are the dynamic balance system of the cervical spine, and the bones, ligaments and intervertebral discs are the static balance system of the cervical spine. Therefore, in the pathogenesis of cervical spondylosis, there are degeneration of intervertebral disc, ligament and vertebral body as well as strain injury of muscle. The three stages of “cervical discogenic cervical spondylosis”, “osteogenic cervical spondylosis” and “spinal degenerative cervical spondylosis” do not include muscle lesions.
The current understanding of cervical spondylosis does not explain all types of cervical spondylosis. Cervical spondylosis is divided into cervical, radicular, spinal, vertebral artery, sympathetic and other types. The “cervical discogenic cervical spondylosis phase”, “osteogenic cervical spondylosis phase” and “spinal cord degenerative cervical spondylosis phase” can be used to explain the latter five types of cervical spondylosis, but cannot explain cervical cervical spondylosis. Cervical cervical spondylosis is characterized by neck discomfort, pain and swelling, and imaging changes are rarely found in the intervertebral discs, vertebrae and spinal cord, except for changes in cervical curvature. In contrast, cervical spine curvature changes are the manifestation of cervical muscle injury in the early stages of cervical spondylosis[11] . The most common soft tissue injury lesion in the neck is the drop pillow, which can develop into cervical cervical spondylosis with repeated episodes or become a precursor to other types of cervical spondylosis[12] . However, there is no “myogenic cervical spondylosis stage” in the existing staging.
According to the current understanding of cervical spondylosis, the occurrence of cervical spondylosis is first and foremost attributed to disc degeneration. The so-called “degeneration” refers to the morphological and functional degeneration that occurs after the peak of physiological changes, along with the increase in age. In recent years, the incidence of cervical spondylosis has been increasing and is becoming younger due to the long-term addiction to computer games among primary and secondary school students, long-term desk work among wage earners, prolonged mahjong playing among middle-aged people, and prolonged television viewing with poor posture [13]. A clinical epidemiological survey found that
The total prevalence of cervical spondylosis was 64.52% in the age group of 21 to 83 years old, including 36.61% in the age group of 21 to 30 years old [14]. neck pain, cervical stiffness, tinnitus and dizziness, hearing impairment, eye pain, and other symptoms are often seen in patients under 30 years old, even in elementary school students. X-rays, CT and MRI in these patients do not indicate cervical disc degeneration and cervical spine osteophytes. However, Doppler examination suggested that the vertebral artery supply was inadequate, and X-ray showed deviation of the cervical spinous process and change of cervical curvature, which the authors considered to be a manifestation of “myogenic cervical spondylosis”.
The inconsistency between imaging and clinical symptoms There are patients with cervical disc herniation on X-ray or MRI, but no clinical symptoms; there are patients with no cervical disc herniation on X-ray or MRI, but clinical symptoms are severe [2]. This suggests that there may be factors other than disc degeneration and cervical osteophytes that contribute to the development of cervical spondylosis, and the authors concluded that the role of the neck muscles should be taken into account.
Self-relievability of symptoms in patients with cervical spondylosis There are patients in the clinic whose symptoms can be reduced or even disappear over a period of time without any medical treatment, just rest, or appropriate activities to reduce the strain on the neck muscles. In the case of cervical disc degeneration and cervical osteophytes, which are pathological changes leading to cervical spondylosis, it is impossible for the clinical symptoms to be relieved by themselves.
The effectiveness of therapeutic measures targeting the neck muscles The common external treatments for cervical spondylosis have certain efficacy, but none of the main mechanisms are effective against cervical disc degeneration and cervical osteophyte lesions. Clinical treatment of cervical spondylosis commonly used injection method, soft tissue pressure point massage, small needle knife therapy, physiotherapy, Chinese medicine external application and soft tissue release, which mainly target the muscles of the neck rather than the cervical intervertebral discs and cervical osteophytes, have all achieved certain efficacy, which indicates that this part of cervical spondylosis is caused by the factors of the muscles of the neck.
Rational basis for the existence of myogenic cervical spondylosis period
Clinical confirmation
From February 1985 to March 1986, 76 cases with typical clinical manifestations of cervical spondylosis combined with abnormal cerebral hemogram changes were studied by Xuan Lao in the electrophysiology department of Shanghai Jing’an District Central Hospital. x-ray films indicated that all cases had changes in cervical spinal curvature and 41 cases had degenerative manifestations such as small intervertebral foramina, intravertebral foramina, narrowing of intervertebral gaps and mild slipped vertebrae. The group was diagnosed as “vertebral artery cervical spondylosis” in 34 cases and “vertebral artery-nerve root type” cervical spondylosis (mixed type) in 42 cases according to the traditional criteria. After Xuan Lao performed a one-time strong stimulation massage on the head, neck, back and shoulder soft tissue damage highly sensitive pressure points in all patients, the signs disappeared completely or nearly disappeared in 75 cases (96.8%), and only one case (1.32%) was invalid, indicating that all signs of the disease could be eliminated by treating only the aseptic inflammatory soft tissue outside the spinal canal without dealing with cervical spinal disc degeneration and bony degeneration. x-ray review The improvement in spinal curvature after treatment was seen in 45 cases (59.21%), indicating that the change in curvature was mostly related to muscular factors. The results of cerebral hemogram review treatment and the X-ray manifestations of cervical spinal bony degeneration were analyzed. In the 75 cases with significant effects, massage normalized the abnormal cerebral hemogram in more than 2/3 of the cases; in less than 1/3 of the cases, there was no improvement or only partial improvement. The cerebral hemogram was restored in only 40% of the cases, and in 60% of the cases, the cerebral hemogram was still disturbed as before, indicating that there was no inevitable causal relationship between the elimination of cranial signs and the restoration of normal cerebral hemogram. The results of this clinical study by Xuan Lao fully confirmed the existence of myogenic cervical spine stage. And the aseptic inflammation of muscles in the myogenic cervical phase was confirmed pathologically [15].
Confirmation of animal experiments The authors successfully created an animal model of cervical spondylosis in rabbits after 3 months by keeping them in a squatting and low head position with a special brace. The model rabbits showed muscle atrophy and degeneration with muscle fiber rupture and cellular inflammatory infiltration, indicating that chronic muscle damage caused cervical spondylosis [16,17 ]. The authors’ PhD supervisor, Professor Qi Shi, led the researchers to cause a cervical paralysis model by stimulating the neck of rabbits in the low head position with wind-cold-dampness. The results showed that wind-cold-damp invasion of the neck could cause soft tissue edema, inflammatory cell infiltration, muscle tissue degeneration, swelling and other manifestations of aseptic inflammation, and successfully created a model of myogenic cervical spondylosis. Then, the instructor observed the intervertebral discs of the rabbits in the model and found that wind, cold and dampness could cause disc degeneration after prolonged stimulation, thus proving the transmission from the “myogenic cervical spine stage” to the “discogenic cervical spondylosis stage”. In order to further prove the role of cervical muscle lesions in the development of cervical spondylosis, the supervisor carried out an animal model of cervical muscle and ligament severance causing dynamic and static force imbalance in rats, and successfully induced disc degeneration, and finally proposed a new pathogenesis of cervical spondylosis in which “dynamic imbalance is the first and static force imbalance is the main”. The stage of myogenic cervical spondylosis is the “power imbalance stage” of cervical spondylosis.
With the above clinical and animal experimental results, the authors believe that further understanding of the “myogenic cervical spondylosis phase” is needed.
Definition and clinical characteristics of myogenic cervical spondylosis
Definition of myogenic cervical spondylosis
Long-term poor posture of the head and neck, as well as the invasion of external evil, can easily cause lesions in the neck muscles, leading to aseptic inflammation of the muscles. Inflammation stimulates pain receptors to produce pain, and pain can induce muscle spasm, which in turn can aggravate aseptic inflammation, thus forming a vicious circle. The lesioned muscles stimulate the vascular nerves (including vegetative nerves) that travel through them and cause the various symptoms of cervical spondylosis. As a result of muscle lesions, muscle tension or relaxation causes imbalance in neck dynamics, which can cause displacement of the cervical vertebrae, stimulating blood vessels and nerves and causing symptoms. Therefore, the authors define “myogenic cervical spondylosis” as: “myogenic cervical spondylosis” refers to various causes of cervical muscle lesions, local inflammatory factors, or muscle tension or relaxation, which straighten the physiological curvature of cervical vertebrae, reverse arch, vertebral body rotation, and stimulate The syndrome occurs when the blood vessels and nerves of the neck are stimulated.
Clinical characteristics of myogenic cervical spondylosis
Myogenic cervical spondylosis mostly occurs in young people under 30 years of age with a history of trauma or strain (including a history of long-term poor neck posture) and symptoms related to cervical spondylosis in the head, neck, chest, back and upper extremities. Physical examination: lateral displacement of the spinous processes of the cervical spine; abnormal sensation in the corresponding locations of the cervical muscles and the presence of pressure points in the back of the neck and shoulders, and X-ray films showing changes in the physiological curvature of the cervical spine and rotation of the vertebrae.
Establish the clinical significance of myogenic cervical spondylosis
Comprehensive understanding of cervical spondylosis
The traditional view is that cervical spondylosis arises from cervical disc degeneration, which is an age-related aging process. Each disc in every individual undergoes a similar process of change during its growth. It varies from person to person in terms of early and late, degree and process. With this understanding, everyone goes through a “cervical discogenic phase” in their lifetime, but not everyone has symptoms of cervical spondylosis.
Chinese medicine considers the human body as an organic whole and divides it into five closely related tissues: skin, flesh, tendons, bones and veins. The onset of cervical spondylosis is due to degenerative changes in the neck muscles, intervertebral discs, bones, joints and ligaments, or due to strain, wind, cold and dampness (including throat infections), etc. The affected tissues include muscles, ligaments, nerves and blood vessels. The symptoms can appear in the neck, upper extremities, lower extremities, and also in the chest, forming symptoms of thoracic paralysis, such as the “cervical heart syndrome” of sympathetic cervical spondylosis. The disease involves the five systems of skin, flesh, tendons, veins and bones. Therefore, only when “myogenic cervical spondylosis” is established can we have a comprehensive understanding of cervical spondylosis.
Recently, some scholars have suggested that “bone misalignment” and “tendon out of groove” may be the key pathological mechanism for the occurrence of cervical spondylosis [18]. According to the authors, “tendon out of groove” and “bone misalignment” in the neck are the result of the dysfunction of the neck dynamics, and “tendon out of groove” can be the spasm and relaxation of the neck muscles, while “bone misalignment” is the result of the dysfunction of the neck dynamics. The “bone misalignment” is cervical instability and small joint locking, which are essentially the signs of myogenic cervical spondylosis, so this method can explain myogenic cervical spondylosis.
Early diagnosis of cervical spondylosis
Myogenic cervical spondylosis can be diagnosed in symptomatic patients, especially in younger patients, when X-rays show changes in cervical curvature or spinous rotation and pressure points in the back of the neck and shoulder. If the diagnosis is not clear according to the current understanding, treatment is not possible, and many patients are misdiagnosed with other diseases such as cardiovascular diseases. If the pathogenesis of myogenic cervical spondylosis is mastered, early diagnosis of cervical spondylosis can be made, making early treatment possible and preventing its development to the stage of cervical spondylosis such as discogenic and osteopathic.
Early prevention and treatment of cervical spondylosis
Myogenic cervical spondylosis is the early stage of cervical spondylosis. Through functional exercise of the neck, massage of the pressure points of the soft tissues of the neck, shoulder and back, exercise of the neck muscles, physiotherapy, acupuncture and external application of Chinese and Western medicines, the microcirculatory state of the soft tissues around the neck can be improved, nutrient metabolism promoted and muscle strength improved, thus restoring or enhancing the dynamic balance of the neck and interrupting the development of cervical spondylosis, thus playing an early prevention and treatment role for cervical spondylosis. Thus, it can play a role in the early prevention and treatment of cervical spondylosis.
Conclusion
Cervical spondylosis is a complex disease, and the understanding of cervical spondylosis has not been uniform until now, but the more consistent understanding is that cervical spondylosis is divided into “discogenic cervical spondylosis”, “osteogenic cervical spondylosis” and “spinal cord degenerative cervical spondylosis”. Cervical spondylosis” are three specialized subtypes. However, this typology is inadequate and cannot fully guide the clinical practice of cervical spondylosis. The introduction of “myogenic cervical spondylosis” has led to a more comprehensive understanding of cervical spondylosis, which is conducive to the prevention, treatment and rehabilitation of cervical spondylosis.