Anatomical illustration of cervical spine
Cervical spondylosis is a clinical syndrome caused by degenerative degeneration of cervical discs, hypertrophy and hyperplasia of cervical vertebrae, as well as cervical injury, resulting in osteophytes of cervical vertebrae, or prolapsed discs and thickened ligaments, which stimulate or compress the cervical spinal cord, cervical nerves and blood vessels and produce a series of symptoms. The main manifestations are neck and shoulder pain, dizziness and headache, numbness of upper limbs, muscle atrophy, spasm of both lower limbs in severe cases, difficulty in walking, and even paralysis of all four limbs, urinary and fecal disorders, and paralysis. It mostly occurs in middle-aged and elderly people, with a higher incidence in men than in women. At present, due to the existence of the trend of cervical spondylosis younger, especially the population of ambulatory work, and even appear in secondary school students. Zhang Jianqiao, Department of Orthopedics, Zhejiang Armed Police General Hospital
Classification of cervical spondylosis
(1) Nerve root type: The stimulation of degenerative changes of cervical intervertebral disc or osteophytes compresses the spinal nerve roots, causing sensory and motor dysfunction of the upper limbs, often manifesting as motor impairment or sensory numbness of one upper limb segment.
(2) Spinal cord type: cervical disc herniation, ligamentous hypertrophy and ossification or other causes of cervical spinal stenosis
Example of cervical disc herniation
The spinal cord is compressed and ischemic, causing spinal cord conduction dysfunction. In some cases, the disease starts in the upper limbs and progresses to the lower limbs; in some cases, the disease starts in the lower limbs and progresses to the upper limbs. The main manifestations are unstable walking, numbness of the limbs, and difficulty in urination and defecation.
(3) Vertebral artery type: Due to the stimulation of degenerative changes of the hook vertebral joint, compression of the vertebral artery, resulting in inadequate blood supply to the vertebral basilar artery, often accompanied by dizziness, black haze and other symptoms, related to the rotation of the neck.
(4) Sympathetic nerve type: stimulation of degenerative changes of the cervical disc, compression of sympathetic nerve fibers in the neck, causing a series of reflex symptoms, is clinically rare, and is often mixed with cardiovascular disease and endocrine disease, making it difficult to distinguish.
(5) Other types: refers to the esophageal compression type with foreign body sensation in swallowing, which is very rare clinically. [2-3]
Causes of morbidity
Cervical spondylosis is one of the common and prevalent diseases in middle-aged and elderly people. According to statistics, its incidence increases with age. Chronic strain is the primary culprit in the development of cervical spondylosis. Long-term injury to local muscles, ligaments, and joint capsule can cause local hemorrhagic edema, inflammatory changes, gradual inflammatory mechanization at the site of the lesion, and the formation of osteophytes, which affect local nerves and blood vessels. Trauma is a direct factor in the occurrence of cervical spondylosis. Often, people already have varying degrees of pathology prior to trauma, putting the cervical spine at high risk, and trauma directly induces the onset of symptoms. Poor posture is another major cause of cervical spine injury. Long hours of low work, lying in bed watching TV, reading books, like high pillows, long hours of computer operation, violent rotation of the neck or head, sleeping in a moving car, all these bad posture will make the neck muscles in a long-term fatigue state, prone to injury. Cervical dysplasia or defects are also one of the causes of cervical spondylosis that cannot be ignored. Asian races have a smaller spinal canal volume compared to Europeans and Americans, which makes them more prone to spinal cord compression and symptoms. In patients with unilateral vertebral artery agenesis, the incidence of vertebral artery type cervical spondylosis is almost 100%, and the difference is only a matter of time. In addition, cranial base depression, congenital fused spine, root canal stenosis, and small spinal canal, among others, are all congenital developmental abnormalities that are also important causes of this disease. [1]
Pathophysiology
One of the basic pathological changes in cervical spondylosis is degenerative degeneration of the intervertebral discs. The cervical disc has a large range of motion and is susceptible to excessive subtle trauma and strain. The main pathological changes are: early dehydration of the cervical intervertebral disc, reduction of the water content of the nucleus pulposus and fibrous swelling of the annulus fibrosus, followed by degeneration and even rupture. After the degeneration of the cervical disc, the resistance to compression and tension is reduced. Restricted or extensive bulging may occur, resulting in narrowing of the intervertebral disc space, overlapping and misalignment of the articular processes, and reduction of the longitudinal diameter of the intervertebral foramen.
Disc degeneration often causes secondary intervertebral instability, increased intervertebral mobility and mild slippage of the vertebral body, followed by osteophytes of the posterior tuberosity, hook joint and lamina, degeneration of the ligamentum flavum and collateral ligament, chondrogenesis and ossification. The gap formed between the vertebral body and the protruding disc and ligamentous tissue, due to the accumulation of tissue fluid, together with the bleeding shaped by microscopic injury, causes this bloody fluid to mechanize and then calcify and ossify, and thus forms a bony flab.
The laxity of the anterior and posterior ligaments of the vertebral body makes the cervical vertebrae unstable and increases the chance of trauma, so that the bone superfluous gradually increases. Together with the bulging fibrous ring, the posterior longitudinal ligament and the edema or fibrous scar tissue caused by the traumatic reaction, the bone superfluous forms a mixture of protrusion into the spinal canal at the equivalent of the intervertebral disc, which has a compressive effect on the cervical nerve or spinal cord. The osteophytes of the hook vertebral joint may protrude from anterior to posterior into the intervertebral foramen to compress the nerve roots and vertebral artery.
Osteochondritis at the anterior border of the vertebral body does not usually cause symptoms, but there are reports in the literature of such anterior osteochondritis affecting swallowing or causing hoarseness. Compression of the spinal cord and nerve roots starts with functional changes only and gradually produces irreversible changes if the pressure is not relieved in time. Therefore, if non-surgical treatment is ineffective, prompt surgical treatment should be performed. [1][3]
Clinical presentation
Prevalent groups
1. People who read books and sit in offices for a long time: keeping the head and neck in a single position for a long time, leading to
Cervical spondylosis is common among people who read books and sit in offices for a long time
To local over-activity, injury to local intervertebral discs, ligaments, etc., prone to cervical spondylosis.
Head and neck trauma: head and neck trauma does not directly cause cervical spondylosis, but is often an aggravating factor for cervical spondylosis symptoms, some patients are in a narrow critical state due to cervical spine osteophytes, cervical disc bulge, soft tissue lesions in the spinal canal, plus neck trauma often induces symptoms, and even paralysis occurs. Inadequate neck massage is also often reported in the occurrence of paralysis.
3. Bad posture: such as lying in bed watching TV, reading books, high pillows, sleeping in a sitting position, etc.; sleeping in a recumbent car, poor muscle protection when sleeping, easy to have neck injury when braking.
4. cervical spine structure dysplasia: congenital small spinal canal is also the basis for the development. The incidence of cervical spondylosis is one times higher than normal in people with narrow central cervical spinal canal and nerve root canal.
Disease symptoms
The symptoms of cervical spondylosis are very rich, diverse and complex. Most patients start with mild symptoms and gradually worsen them later, while some have more severe symptoms. One type is often combined with several other types, which is called mixed cervical spondylosis.
The main symptoms are:
1. neck and shoulder pain that can radiate to the head and occipital region and upper limbs.
2.Heavy feeling in the back of one shoulder, weakness in the upper limbs, numbness of the fingers, loss of sensation in the skin of the limbs, weakness in holding things in the hands, and sometimes unconscious gripping of things on the ground.
3, its serious typical performance is: lower limb weakness, unstable walking, two feet numbness, walking like stepping on cotton feeling.
4. In the most serious cases, there is even loss of control of bowel movements and urination, sexual dysfunction, and even tetraplegia.
5, often accompanied by head, neck, shoulder, back and arm pain, neck and neck stiffness, limited movement.
6.Some of them are accompanied by dizziness, house rotation, heavy cases are accompanied by nausea and vomiting, bedridden, a few may have vertigo and sudden collapse.
7.When cervical spondylosis involves sympathetic nerve, dizziness, headache, blurred vision, swelling of the second eye, dryness, inability to open the second eye, tinnitus, ear blockage, loss of balance, tachycardia, panic, tight c feeling in the chest, and some even have symptoms such as gastrointestinal distension. There are also symptoms such as dysphagia and dysphonia.
Most of the symptoms are mild at the onset and are not taken seriously, most of them can recover on their own, sometimes light and sometimes heavy, and only when the symptoms continue to worsen and cannot be reversed and affect work and life do they get attention. If the disease remains untreated for a long time, it can cause psychological damage and produce symptoms such as insomnia, irritability, anger, anxiety, and depression. [1]
Diagnosis and Differentiation
Auxiliary examination
Cervical spine MRI
1, cervical spine X-ray: cervical spine disease X-ray often shows the loss of the normal physiological curvature of the cervical spine or reversion, narrowing of the intervertebral space, narrowing of the spinal canal, formation of bone redundancy at the posterior edge of the vertebral body, and segmental instability of the cervical spine can also be observed in the hyperextension and hyperflexion of the cervical spine.
2.CT of cervical spine: the hyperplastic calcification of cervical spine can be observed more clearly, and it has a clear diagnostic value for spinal stenosis and vertebral body posterior edge bone superfluous formation.
3, cervical MRI: can clearly observe the herniated disc compressing the spinal cord, and is routinely used as evidence of preoperative imaging to clarify the segment and resection range of surgery.
4.Vertebrobasilar artery Doppler: It is used to detect the blood flow of vertebral artery and can also observe the travel of vertebral artery, and it has a high value for the identification of patients with vertigo as the main symptom.
5.Electromyography: It is suitable for patients with muscle weakness as the main manifestation. The main purpose is to clarify the localization of the diseased nerve and to differentiate it from neurological diseases such as lateral sclerosis and neurodegeneration, but it requires more demanding conditions for examination and often has false positive results.
Differential diagnosis
Clinical symptoms of cervical spondylosis are present, but they should also be differentiated from symptoms not caused by cervical spondylosis. If vertigo symptoms are also present, otogenic vertigo, vestibular dysfunction, auditory neuroma, etc. should be excluded first. There are also vertigo of cerebral origin and vertigo of ocular origin. In addition, the same neck and shoulder upper extremity pain should also be differentiated from such as drop pillow, frozen shoulder, thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome. Rheumatic muscle and arthritis, spondylitis tumor, etc. should be distinguished.
However, in clinical practice, it is often difficult to distinguish vertebral artery cervical spondylosis from sympathetic cervical spondylosis, and this diagnosis should be made with caution to avoid misdiagnosis and delay in the treatment of other diseases. [1]
Disease treatment
Conservative treatment
1, oral drug therapy: mainly used for pain relief, local anti-inflammatory, relaxation muscle treatment, for cervical instability and other secondary local soft tissue strain and other efficacy is clear, but can not treat cervical spondylosis at the root. For patients with weakness or numbness of the limbs, neurotrophic drugs can also be used to assist rehabilitation and promote recovery of the compressed nerves.
2.Traction method: Through the mutual balance between traction force and anti-traction force, the head and neck are relatively fixed in the physiological curve state, so that the cervical spine curve is gradually changed, but its efficacy is limited and only suitable for patients with mild neurogenic cervical spondylosis; and traction is prohibited in the acute period to prevent local inflammation and edema from aggravating.
3, physiotherapy: physiotherapy is the abbreviation of physical therapy. It is the application of natural and artificial physical factors, such as sound, light, electricity, heat, magnetism and other effects on the human body, in order to achieve the purpose of treatment and prevention of disease. However, its effect is also weak and cannot be treated at the root. And often physical therapy is easy to produce burns on the skin.
4, Chinese medicine is profound, the efficacy but with the doctor’s personal experience has a lot to do with, need to be carefully selected.
Surgical treatment
For patients with cervical spondylosis with clear diagnosis, serious symptoms of nerve root compression and no significant improvement of symptoms after conservative treatment, surgery should be adopted, while for patients with spinal cord type cervical spondylosis, i.e. patients who mainly show symptoms such as walking weakness and unstable walking of both lower limbs, surgery should be implemented as early as possible to obtain good recovery effect, because the treatment effect of such patients is closely related to the length of nerve compression. For patients with vertebral artery and sympathetic nerve excitation, the surgical effect is relatively less definite.
The main surgical methods are as follows.
1, anterior cervical surgery: as the name implies, that is, surgery in front of the neck. At present, most anterior cervical surgery is a minimally invasive technique, with small surgical incisions and fast postoperative recovery. The surgery mainly removes the protruding and deformed intervertebral discs, and for those with osteophytes, also removes the osteophytes and the hook vertebral joints on both sides to avoid residual possible pressure-causing materials. Reconstruction after removal of normal structures is varied, mostly using plates and fusion devices to reconstruct the height and stability of the cervical spine. Regardless of the type of endograft, the primary role is to restore the normal curvature of the cervical spine and to grow several cervical vertebrae together for surgical manipulation. In recent years, artificial disc replacement has also emerged, which can preserve the motion function between cervical segments and has good clinical efficacy for suitable patients.
2.Posterior cervical surgery: i.e. surgery from the back of the neck, applicable to multi-segmental cervical spondylosis with spinal stenosis or ossification of the posterior longitudinal ligament. Posterior surgery mainly achieves indirect decompression by removing all or part of the posterior vertebral plate, which is less risky than the anterior approach, simple to expose, and more effective for patients whose cervical spine itself has physiological curvature. Although the posterior approach has relatively little impact on the normal physiologic structure of the cervical spine, endografts are required to reestablish cervical stability. Procedures such as posterior single-opening vertebroplasty can preserve intercervical mobility with a low incidence of posterior convexity deformity and adjacent segmental degeneration.
Disease prevention
1. Establish a correct mentality, master the prevention and treatment of the disease by scientific means, cooperate with the doctor’s treatment and reduce recurrence.
2. Strengthen the exercise of neck and shoulder muscles, do forward flexion, backward extension and rotation of head and both upper limbs during free time at work, which can not only relieve fatigue, but also make the muscles developed and toughness enhanced, thus contributing to the stability of the spine of the neck segment and enhancing the ability of the neck and shoulder to conform to sudden changes in the neck.
3, correct bad posture and habits, avoid high pillow sleep, do not shrug your shoulders, talk, read a book to look at the front. Keep the spine straight.
4. Pay attention to keeping the neck and shoulder area warm, avoid carrying heavy objects on the head and neck, avoid overexertion, and do not doze off when riding in a car.
5. Early and thorough treatment of soft tissue strain in the neck, shoulder and back to prevent the development of cervical spondylosis.
6. Avoid contusions when working or walking, avoid head and neck injuries when braking sharply, and avoid falls.
Disease care
Post-operative care
1. return to the ward after surgery to maintain the horizontal position of the spine to move the patient, the neck brake both sides with sandbags fixed.
2. Patients may experience pharyngeal discomfort, dysphagia and dyspnea after surgery due to general anesthetic intubation and traction, and patients with mild symptoms can generally heal on their own. Routine nebulized inhalation is used to resolve sputum thickening and pharyngeal irritation.
3. observe the wound bleeding and respiratory frequency and rhythm in patients with anterior cervical approach, and notify them of any abnormalities.
4. Keep the drainage tube unobstructed without folding and pressure. Observe the color, nature and amount of drainage fluid.
5. Give the patient a change of position every two hours after surgery to prevent pressure sores.
6. Perform functional exercise as early as possible after surgery, sit up half a day after surgery and encourage coughing up sputum. One to two days after surgery, the patient can get out of bed and walk around. Perform small joint activities of the upper limbs, lower limbs and hands several times a day. Maintain good functional position of all joints. You can wear a neck brace when you get out of bed.
After discharge from the hospital, strengthen the functional exercises of the upper and lower extremities, and pay attention to the height of the pillow when sleeping, not too high.
Precautions
The precautions for cervical spondylosis at work are
1. Patients with cervical spondylosis need to change the head and neck position regularly, pay attention to rest and combine work and rest. Lift your head and gently move your neck in all directions, and do not keep your cervical spine in a bent position. The work should not last for a long time, more than 2 hours of continuous low work, it is difficult to make the high pressure in the cervical intervertebral space in a short period of time to get effective recovery relief, which will aggravate and accelerate the degeneration of the cervical spine.
2, patients who already have cervical spondylosis symptoms should reduce their workload and take appropriate rest. Those with heavy symptoms and frequent attacks should stop working and take absolute rest, and, preferably, be able to rest in bed. In this way, during the treatment of cervical spondylosis, it helps to improve the effect of treatment and promote the early relief of the disease and the early recovery of the body.
3, cervical spondylosis patients in the work should avoid prolonged blowing air conditioning, electric fans. As the onset of cervical spondylosis is the result of a combination of factors, cold and humidity tend to aggravate the symptoms of cervical spondylosis. You should try to reduce the amount of time you spend working with your head down for long periods of time in cold and humid conditions to prevent the appearance of cervical spondylosis symptoms or cervical spondylosis-induced neck and shoulder back pain.
4, cervical spondylosis patients should avoid participating in heavy physical labor, heavy lifting and so on, and should usually pay attention to the protection of the neck to prevent its injury. The upper limbs should avoid extracting heavy objects, when the upper limbs carry heavy objects, the force can be transferred to the cervical spine through the muscles of the suspended upper limbs, thus causing the cervical spine to be stretched and increasing the mutual pressure between the cervical spine. The symptoms of cervical spondylosis may be aggravated after the patient participates in heavy physical work.