Cervical spondylosis is a syndrome with complex symptoms due to changes in the physiological curvature of the cervical spine and degenerative changes in the intervertebral discs, joints and other tissues that stimulate or compress the cervical nerve roots, spinal cord, vertebral artery and sympathetic nerves in the neck. The lesions mainly involve the cervical spine, intervertebral discs, surrounding ligaments and fibrous structures. The main clinical manifestations of the patient are pain in the head, neck, arm, hand and anterior chest, and progressive limb sensory and motor dysfunction, which may lead to tetraplegia in severe cases. He Yongjin, Department of Pain, Tianjin First Central Hospital
Causal factors of cervical spondylosis
Gender There is no obvious correlation between gender and the occurrence of cervical spondylosis, but it may have some significance when considered together with occupation and labor intensity.
2. Age Cervical spondylosis is a common and frequent disease among middle-aged and elderly people, and the peak of the disease is between the ages of 40 and 60. In recent years, with the widespread use of computers, television and automobiles, there is a trend of younger age of onset.
3. Occupation Cervical spondylosis occurs in people who work with their heads down, such as accountants, drivers, typists, embroidery workers, etc.
4. Trauma Among patients with cervical spondylosis, the cause of the disease varies from 10.3% to 32.6% due to trauma. It has been reported that about 70% of patients with sympathetic cervical spondylosis have a history of trauma.
5. Lifestyle habits ① Sleeping with a high pillow. ②Heavy head: The prevalence of cervical spondylosis in Korean women is four times higher than that in Han Chinese women. ③Drinkers are more likely to suffer from cervical spondylosis.
Anatomical variations such as fusion of the 2nd to 3rd cervical vertebrae, cervical ribs, hypertrophy of the transverse process of the 7th cervical vertebrae, cervical spine occlusion, low cranial depression, etc.
7. Climate High altitude, thin air, low atmospheric pressure, low oxygen partial pressure, cold, large temperature difference between day and night, strong ultraviolet light and other factors can change the geographical distribution of cervical spondylosis.
8. Genetic factors Some scholars believe that the occurrence of cervical spondylosis may be related to heredity.
Classification of cervical spondylosis
1. Cervical cervical spondylosis is one of the more common types of cervical spondylosis. The clinical characteristics of patients include stiffness and discomfort in the neck, pain in the back of the neck, upper shoulder, scapula, medial edge of the scapula, shoulder, upper arm, forearm and hand, and anterior thoracic region, mostly persistent soreness or vague pain, which may be aggravated by paroxysms.
2. Neurogenic cervical spondylosis The main clinical characteristics are as follows: ①Most of them develop over 40 years old, with slow onset and long course. ②The main symptoms are pain and numbness in the neck, shoulder, arm and hand. The pain and numbness are distributed according to nerve roots and have localization value. The symptoms can be unilateral or bilateral. ③The affected limbs may show muscle weakness, muscle atrophy, grip strength loss, and may have fallen objects held. ④Some patients have neck stiffness and restricted movement, and significant pressure pain may appear in the spinous process, paraspinatus, supraspinatus and infraspinatus muscles, and scapular spine margin. The biceps and triceps tendons and radial periosteal reflexes of the affected limbs may be active in the acute stage. The reflexes are weakened in those with long duration of disease.
3. Vertebral artery cervical spondylosis is most often seen in patients over 40 years of age and is often combined with other types of cervical spondylosis. Patients have signs and symptoms of insufficient blood supply to the vertebral basilar artery, manifesting as one-sided migraine, dizziness, chest tightness and chest pain, and the onset of the disease is related to cervical rotation. ②Limb weakness type. ③Consciousness disorder type or syncope type. ④Sudden collapse type. (5) Headache type. (6) Blurred vision type.
4. Spinal cord type cervical spondylosis This type of cervical spondylosis is mainly caused by compression of the cervical spinal cord or impaired blood circulation. The main symptoms of patients include: progressive weakness of both lower or upper extremities, stumbling, easy to fall, and may be accompanied by ascending numbness and abnormal sensation. This type of patient is not easily detected in the early stage.
5. Sympathetic cervical spondylosis is caused by sympathetic nerve compression or stimulation and has complex clinical manifestations.
6. Esophageal cervical spondylosis is caused by excessive osteophytes on the anterior edge of the cervical vertebrae, which compress the esophagus or cause esophagitis, or stimulate the esophageal nerve and cause esophageal spasm. It is manifested as a strange sensation or tingling in the pharynx and behind the sternum, and the symptoms are obvious when the head is tilted back.
7. Mixed type cervical spondylosis has two or more manifestations of the above types.
Prevention of cervical spondylosis
Prevention of cervical spondylosis is better than treatment, and careful prevention in daily life can help reduce the occurrence of cervical spondylosis: ① Do not take the prone position when sleeping, and the pillow should not be too high, too hard or too flat. ② Avoid and reduce acute injuries, such as avoiding lifting heavy objects, not tightening the emergency brake, etc. ③Prevent wind and cold, humidity, avoid taking a bath or being blown by wind and cold at midnight or early morning. Wind chill causes local vasoconstriction and reduced blood flow, which hinders the metabolism of tissues and waste removal, and humidity hinders skin evaporation. ④ Actively treat local infections and other diseases. ⑤ Correct poor posture and reduce strain. Every 1~2h of head lowering or head tilting, appropriate neck activities should be performed to reduce muscle tension.
Clinical manifestations of neurogenic cervical spondylosis
1. Symptoms Pain and sensory abnormalities in patients with neurogenic cervical spondylosis are mainly manifested in the neck, shoulder, arm and finger range. Because the lower cervical vertebrae are relatively fixed and have a large weight-bearing capacity, the lower cervical vertebrae are more likely to be involved, and the cervical vertebrae at the C5-6 and C6-7 levels are the most common in clinical practice.
Neurogenic cervical spondylosis has a slow onset and occasionally starts acutely due to trauma. In the early stage, it is mostly discomfort, soreness and dull pain in the arm and shoulder after waking up, which can be aggravated by changing the position of the head and neck or exerting force, and sometimes there can be severe nerve root pain or numbness, which is manifested as knife-like or pinprick-like radiating pain, often aggravated by increased abdominal pressure such as coughing, sneezing, breath-holding and exertion, and can be accompanied by sensory allergy, which can improve after rest. Patients with long duration of disease often have abnormal sensation, and the nature of pain is mainly dull pain.
2. Physical signs Restricted neck movement, stiffness of cervical muscles, pressure pain in the oblique, supraspinatus, infraspinatus, rhomboid, pectoralis major, and cervical nerve root outlet. Weak tendon reflexes, muscle weakness and muscle atrophy of the affected spinal nerve innervated muscles.
3. Localization examination of nerve root lesions When the cervical nerve roots are compressed or have lesions, patients often present with pain and numbness in the cervical shoulder, scapula, scapulae, upper arm to the hand, and it is consistent with abnormal sensation and temperature perception in the innervated area of this nerve as well as diminished tendon reflexes. ① intervertebral space lesions of the 4th to 5th cervical spine: for C5 spinal nerve root involvement, which can cause pain and numbness and hyperalgesia in the neck, shoulder, scapula, deltoid and lateral upper arm; and diminished biceps and brachioradialis reflexes. (ii) Intervertebral space lesion of the 5th to 6th cervical vertebrae: for C6 spinal nerve root involvement, which may cause pain and numbness and hypesthesia in the neck, shoulder, lateral upper arm, radial side, thumb and index finger; weakened or absent muscle strength and tendon reflexes of the biceps and thoracic major muscles. (3) Intervertebral space lesions of the 6th to 7th cervical vertebrae: involvement of the C7 spinal nerve root may cause pain, numbness, and hypesthesia in the neck, shoulder, scapula, lateral thoracic wall, radial side of the upper arm, and middle finger (sometimes index finger); muscle strength of the triceps and posterior rotator muscles are weakened, and tendon reflexes are weakened or absent. ④7th cervical to 1st thoracic intervertebral space lesion: for C8 spinal nerve root involvement, which can lead to pain and numbness and hypesthesia in the neck, shoulder, chest wall, upper arm, ulnar side of forearm, little finger, ring finger; weakened or absent ulnar membrane reflex; sometimes Horner’s sign can appear.
Treatment of neurogenic cervical spondylosis
1. General treatment ①Change the poor working and living posture: choose a moderate size health pillow, not a large pillow, a hard pillow, a flat pillow, and not to take a prone position when sleeping; pay attention to keeping the neck warm in the cold season; carry out multi-directional exercises for the neck in between work and study. ②Add the neck circumference: the neck circumference can restrict the head and neck activities and can achieve pain relief for patients with acute attacks of neurogenic cervical spondylosis. (③) Head traction: often use 4-6 kg weights for head traction, which can relax the neck muscles, widen the vertebral space and open the intervertebral foramen, which is conducive to the return of early bulging discs. ④ Physical exercise of the head and neck: it helps to relax the neck muscles, promote the blood circulation of the neck, and enhance the muscle strength of the neck muscles and the stability of the head and neck.
2. Drug therapy ①Neurotrophic drugs: commonly used drugs include B vitamins, adenosine coenzyme B12, neurotoxicity and so on. ②Analgesic drugs: including non-steroidal anti-inflammatory analgesics, central analgesics tramadol, etc. ③Vasodilator and blood-activating drugs: through promoting systemic blood circulation to achieve nutrition and repair of nerves, reduce or eliminate edema of spinal nerve roots.
Nerve block therapy Nerve block therapy is currently the most effective method in the conservative treatment of neurogenic cervical spondylosis. Nerve block can eliminate the inflammation and edema of nerve or local pain points, release muscle spasm, block the pain malignant circulation mechanism, increase local blood circulation, and achieve the purpose of analgesia. The commonly used nerve block methods are.
(1) cervical epidural gap block: ① posterior approach epidural gap block, applicable to various types of cervical spondylosis, cervicogenic headache, shoulder and arm pain, vertigo, cervical scapular pain, upper limb pain, etc. C6 to 7 or C7 to T1 intervertebral space puncture is generally chosen. ② High cervical epidural space block: Applicable to patients with high cervical spondylosis, vertebral artery spasm, vertebrobasilar artery insufficiency, suboccipital pain, cervicogenic headache, etc. It is advisable to perform under X-ray guidance, and the vertebral space from C1 to C6 can be selected according to the type of cervical spondylosis.
Precautions for cervical epidural space block operation: ①Because the cervical spinal cord exists with cervical expansion and the spinal canal is relatively narrow, therefore, caution and care should be exercised during the operation, proceed slowly, and experience the area reached by the puncture layer by layer to prevent injury to the spinal cord. ②Prepare monitoring instruments such as ECG and blood pressure and resuscitation drugs. The injection of the drug solution should be slow, while closely observing the changes in the patient’s vital signs. In case of special circumstances, the injection should be stopped immediately and handled promptly according to the situation. ③ If there is a possibility of puncture failure or anesthesia accident, the patient and family should be informed in advance and cooperation should be obtained. ④The operation is contraindicated for patients who are uncooperative, have coagulation dysfunction, low blood volume, serious systemic infection or infection at the puncture site.
(2) Cervical nerve root block: cervical nerve root block is feasible from cervical 2 to cervical 5. It is suitable for various types of cervical spondylosis, cervicogenic headache, lateral shoulder and arm pain, vertigo, neck and shoulder pain, scapular pain, shoulder and arm pain, thumb pain and numbness, etc. Positioning method: the bony prominence that can be pressed 1.5~50px5 from the mastoid process is the 2nd cervical transverse process, the bony prominence at the midpoint of the posterior edge of the sternocleidomastoid muscle is the 4th cervical transverse process, and the bony prominence that can be felt every approximately 1~37.5px is the corresponding cervical transverse process, and the corresponding transverse process injection site is selected according to the pain site and the corresponding distribution of the cervical spinal nerve. The needle tip is stopped when it reaches the transverse process, and 3-5 ml of anti-inflammatory and analgesic drugs are slowly injected after the return of blood and cerebrospinal fluid.(3) Oblique angle muscle and intermuscular sulcus block: Applicable to cervical spondylosis, neck and shoulder syndrome, thoracic outlet syndrome, phrenic neuralgia, etc. The patient is placed in a supine position with the head slightly turned to the healthy side. A small muscle, the anterior oblique muscle, can be palpated at the posterior edge of the clavicular head of the sternocleidomastoid muscle; the outer edge of the anterior oblique muscle is the middle oblique muscle; the depression between the anterior and middle oblique muscles is the intermuscular groove. The intersection of a horizontal line at the level of the cricoid cartilage and the intermuscular sulcus is the puncture point. A No. 5 needle is chosen for puncture, and the needle is advanced vertically and then slightly caudally until there is a sensation or the transverse process (6th cervical transverse process) is pierced. The muscle belly can also be punctured directly to a depth of no more than 25 px. Anti-inflammatory and analgesic drugs can be injected if there is no abnormality in the retraction.
(4) Hook vertebral joint block: It is suitable for patients with cervical spondylosis, cervical radiculitis, hook vertebral arthritis, neck and shoulder pain and neck and shoulder syndrome who have long cervical vertebrae and thin body size. Because the soft tissue above the level of C4 is thicker and not easy to touch, and C7 is close to the tip of the lung, so the method is more commonly used for the hook vertebral joint of C4 to 6. At the level of the cricoid cartilage, the common carotid artery and internal jugular vein are pushed laterally at the anterior border of the sternocleidomastoid muscle with the index and middle fingers of the left hand, and the tracheoesophagus is pushed medially, and the anterolateral border of the 5th to 6th cervical vertebrae can be touched by downward pressure, and the needle is inserted vertically, and 4 to 5 ml of anti-inflammatory and analgesic drugs can be injected slowly after the tip of the needle touches the vertebral body and aspirates no blood or cerebrospinal fluid.
(5) Stellate ganglion block: It is suitable for patients with various types of cervical spondylosis, cervicogenic headache, cervical radiculitis, hook spine arthritis, neck and shoulder pain, neck and shoulder syndrome, thoracic outlet syndrome, anterior oblique angle muscle syndrome, phrenic neuralgia, etc.