Cervical spondylosis is a syndrome of a series of clinical symptoms caused by degenerative degeneration of the cervical discs and osteophytes of the cervical spine, such as numbness and pain in the neck, shoulder and upper limbs, muscle atrophy, and even tetraplegia. Some people may show dizziness, sudden collapse, etc. It is a disease that has gradually been fully recognized in the last 20 years. The onset of the disease is usually over 40 years old, but it is rare in younger age groups. The disease starts slowly and is not noticed at the beginning, only the neck discomfort, some manifest as frequent “pillow”, after a period of time, gradually showing the gradual emergence of upper limb radiating pain. Cervical spondylosis can produce pain in the posterior neck, upper back, scapular region and anterior thoracic region, as well as nerve root pain in the cervical 5 to thoracic region. Lesions in the middle and lower cervical spine may compress the spinal cord and produce paralysis.
Typology and clinical manifestations
For the sake of description, cervical spondylosis is divided into neurogenic, spinal cord, vertebral artery and sympathetic types. However, in clinical practice, a mixture of symptoms and signs of each type can often be seen.
1.Nerve root type
This is caused by the irritation or compression of the cervical spinal nerve roots by the protrusions occurring at the posterior and lateral sides of the cervical spine, and has the highest incidence, accounting for about 60% of cervical spondylosis.
There is paroxysmal or persistent vague or severe pain in the cervical occipital region and neck and shoulder. There is burning or cutting-like pain along the direction of travel of the affected cervical spinal nerve, or electroshock-like or pins-and-needles numbness, and the symptoms are aggravated when the neck activity or abdominal pressure increases. At the same time, the upper limbs feel sunken and weak. The neck has varying degrees of stiffness or painful oblique neck deformity, muscle tension, and restricted movement. The affected cervical spinal nerve has pressure pain at its exit below the corresponding transverse process and next to the spinous process. The brachial plexus nerve pull test is positive and the intervertebral foraminal squeeze test (also known as posterior cervical test) is positive. In addition, there is sensory disturbance in the skin of the affected innervation area, muscle atrophy and altered tendon reflexes.
Clinical examination: (1) brachial plexus nerve pull test; (2) posterior cervical extension compression test; (3) deviated head compression test
2.Spinal cord type
This is due to the compression of the spinal cord by the protruding object. The clinical manifestation is spinal cord compression with different degrees of tetraplegia, accounting for about 10-15%. The symptoms of this type are complicated, mainly numbness, soreness, burning sensation, stiffness and weakness of the limbs, which mostly occur in the lower limbs and then develop into the upper limbs; however, it also occurs in one upper or lower limb first. In addition, symptoms such as headache, dizziness or abnormal urination and defecation may also occur. (1) Unilateral compression of the spinal cord: the typical spinal cord hemisection syndrome (Brown-séquard Syndrme) may occur. (2) Bilateral compression of the spinal cord: In the early stage, the symptoms are mainly sensory impairment and motor impairment, with the latter being the most common. In the later stage, spastic paralysis with different degrees of upper motor neuron or nerve bundle damage, such as limb inflexibility, clumsy gait, unstable walking, even bedridden, and inability to urinate on their own. Physical examination may reveal increased muscle tone, decreased muscle strength, hyperactive tendon reflexes, loss of superficial reflexes, positive pathological reflexes such as Hoffmann and Babinski signs, positive ankle clonus and patellar clonus. The plane of sensory disturbance often does not correspond to the lesion segment and lacks regularity. In addition, thoracolumbar girdle sensation is also a frequent complaint.
Symptoms and signs of cervical nerve root compression in the corresponding segment
Nerve root, intervertebral disc, symptoms, muscle strength and reflex changes
Cervical 3 Cervical 2-3 Numbness of the skin on the back of the neck, pain in the auricle and mastoid process, and pressure on the greater occipital nerve cannot be detected clinically unless electromyography is performed
Cervical 4 Cervical 3-4 Numbness in the back of the neck, pain radiating along the scapular muscles, sometimes to the anterior chest No finding unless electromyography is performed
Cervical 5 Cervical 4-5 pain radiates to the shoulder along the lateral side of the neck, numbness in the upper deltoid muscle (axillary nerve distribution area), sometimes also in the lateral side of the upper arm and the radial side of the forearm, but no effect on the hand weakness in the upper limbs and shoulder extension, especially above 90°, atrophy of the deltoid muscle, no reflex changes
Neck 6 Neck 5-6 Pain radiates to the lateral aspect of the upper arm and forearm, often to the thumb and index finger. Numbness at the tip of the thumb or the first dorsal bony muscle on the back of the hand Biceps muscle weakness, reduced biceps reflexes
Cervical 7 Cervical 6-7 Pain radiates to the middle forearm and middle finger, but pain is often present in the index finger, and there is pressure pain in the inner border of the scapula and pectoralis major muscle Triceps weakness, decreased triceps reflex, and decreased wrist extension and finger extension.
Cervical 8 Cervical 7 Thoracic 1 Pain radiates to the medial forearm, the ring little finger and the middle ring finger with numbness, but rarely above the wrist joint Triceps and small hand muscles are weak, no reflex change
3.Vertebral artery type
This is due to the compression of the vertebral artery by a protrusion, which can be caused by (1) the lateral bone redundancy of the intervertebral disc; (2) the bone redundancy in front of the Zygapophyseal joint; (3) the unstable subluxation of the posterior joint, which can also be caused by the reflex arterial spasm due to the stimulation of the cervical sympathetic nerve. The diagnosis can be confirmed if the clinical manifestations are consistent with what is seen on imaging. For those with typical clinical manifestations of cervical spondylosis and normal imaging findings, attention should be paid to excluding other patients before diagnosing cervical spondylosis.
Treatment
1.Non-surgical treatment
For light cases, the symptoms can be reduced with proper rest and some anti-inflammatory and pain-relieving drugs such as anti-inflammatory pain and inflammatory pain Xikang, etc., supplemented by acupuncture and physiotherapy, etc. Good results can be obtained. In order to restrict the movement of the neck, a cervical collar can be worn. Generally, the symptoms can be relieved within 2 weeks to 1 month. If the symptoms are still obvious, then traction treatment should be performed. The purpose of traction is to open the cervical space and reduce the compression effect of the protrusion. However, the main function of traction is to rest the neck and release the spasm of the cervical muscles.
There are two types of traction: sitting traction and lying traction. In sitting traction, the patient sits on the orange, fixes the lower jaw and occiput with four head straps, and tracts vertically upward, using the weight as the counter traction force, the weight can be 10-20kg, 1~2 hours each time, 1~2 times a day, depending on the patient’s response, increase or decrease the traction time and weight, 1 month is a course of treatment. In bed traction, the patient lies supine on the bed, the head is elevated at the foot of the bed, and the four-headed belt is traction with the longitudinal axis of the body in the direction of 30° angle, the weight is 3kg, and the rest is 1 hour for every 2 hours of traction, and it can be done several times a day. 1 month is a course of treatment. Most patients with cervical spondylosis of the nerve root type can be cured by traction. At the end of the traction course, the symptoms are relieved or alleviated, and the cervical collar still needs to be fixed.
Cervical spondylosis should not be treated with traction and manipulation. If you need to push and hold, you should be gentle and avoid strong rotational techniques. Because the patient’s cervical spine is unstable, strong manipulation can cause cervical spine subluxation or dislocation or even cause tetraplegia.
2.Surgical treatment: If the diagnosis is clear, the person who is ineffective by non-surgical treatment or has spinal cord compression should undergo surgery. In the past, the posterior laminectomy decompression, but due to the small decompression effect is not effective, so some people from the posterior laminectomy after pulling the spinal cord to remove the protrusion, but pulling the spinal cord often aggravate the symptoms, and even cause irrecoverable paraplegia. 60s onwards, the anterior laminectomy and intervertebral body implant fusion, and achieved good results. Anterior surgery not only removes the herniation, but also reduces recurrence after fusion of the vertebral body, and the existing bone flab will be gradually absorbed. The operation is performed with the patient lying on his back, shoulder pillow, transverse incision on the left or right side of the neck between the medial carotid artery of the sternocleidomastoid muscle and the thyroid gland directly to the vertebral body, piercing the intervertebral disc that should be removed with a needle, and taking bedside film for positioning, removing the intervertebral disc and a part of the vertebral body above and below it with a bone knife, drill or circular saw, always seeing the posterior longitudinal ligament or dura, and then removing as much bone superfluous as possible from the posterior edge with a biting forceps or scraping spoon, and then taking the iliac bone for After surgery, the vertebral body is fixed with a cervical collar or cast, which usually takes 2 to 3 months, and the surgery can be performed under cervical plexus block or needle anesthesia, which is not likely to cause nerve root or spinal cord injury because the patient is awake.