Classification of cervical spondylosis
Depending on the tissue and structure involved, cervical spondylosis is divided into: cervical (also known as soft tissue), radicular, spinal, sympathetic, vertebral artery, and other types (currently mainly referring to the 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 neck muscles, ligaments and joint capsule, 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 sleeping 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.
Nerve root type 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. It is mostly unilateral and single-root onset, but there are also bilateral and multi-root onset cases. It is usually seen in people aged 30-50 years and usually has a slow onset, but there are also cases with acute onset. There are more men than women.
C. Spinal cord type 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 aged 40-60. 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
Due to factors such as disc degeneration and segmental instability, which cause stimulation of sympathetic nerve endings around the cervical spine, sympathetic nerve dysfunction is produced. 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 accompanied by inadequate blood supply to the vertebrobasilar artery system in addition to the symptoms of several systems in the body.
V. Vertebral artery type cervical spondylosis
In normal people, when the head is tilted or twisted to one side, the vertebral artery on the same side is squeezed and the blood flow of the vertebral artery is reduced, but the vertebral artery on the opposite side can compensate, thus ensuring that the blood flow of 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 bony bulge at the vertebral body edge and the hook vertebral joint can directly compress the vertebral artery or stimulate the sympathetic nerve fibers around the vertebral artery, causing spasm of the vertebral artery and instantaneous changes in vertebral artery blood flow, resulting in inadequate blood supply to the vertebrobasilar system and symptoms, and therefore not accompanied by symptoms outside the vertebral artery system.
Clinical manifestations of cervical spondylosis
I. Cervical cervical spondylosis
1, cervical straightness and pain, there may be pain and stiffness in the whole shoulder and back, unable to nod, tilt the head, and turn the head, in a sloping neck position. When the neck needs to be turned, the trunk must be turned at the same time, and the symptoms of dizziness may also appear.
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 cervical spine activity is absolutely limited, and the range of motion of the cervical spine in all directions is nearly zero. There is pressure pain in the cervical paraspinal muscles, thoracic 1 to thoracic 7 paraspinal or rhomboid muscles, sternocleidomastoid muscles, and there may also be pressure pain in the supraspinatus and infraspinatus muscles. If there is secondary spasm of the anterior oblique muscle, the spastic muscle can be found on 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 can appear in the shoulder, arm and hand.
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.Radiation 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 term 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 aggravation of symptoms.
3. The affected upper extremity feels heavy, has reduced grip strength, and sometimes appears to hold objects falling down. There may be vasomotor nerve symptoms, such as swelling of the hand. Muscle atrophy can occur 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 edge 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 comprehensive neurological examination can help localize the diagnosis.
C. Spinal cord type cervical spondylosis
1. Most patients first experience numbness and heaviness in one or both lower limbs, followed by gradual difficulty in walking, tightness of various groups of muscles in the lower limbs, slow lifting and inability to walk fast. Then, when going up and down the stairs, it is necessary to hold the puller with the upper limb 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. Some patients start insidiously, often trying to catch a bus that is about to leave, but suddenly find that both legs cannot 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 easy falling of 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 burning 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.
Further development of the disease, the patient must be crutches or with the help of others to walk, until the emergence of spastic paralysis of both lower limbs, bedridden, unable to take care of themselves.
5. Clinical examination: There are no signs in the neck. The upper extremities or trunk have segmental distribution of superficial sensory disorders, deep sensation is normal, muscle strength is reduced, and grip strength of both hands is reduced. Tendon reflexes are active or hyperactive: including biceps, triceps, radial membrane, knee tendon and Achilles reflex; patellar clonus and ankle clonus are positive. Positive pathological reflexes: such as Hoffmann’s sign, Rossolimo’s sign in the upper extremity, Barbinski’s sign and Chacdack’s sign in the lower extremity. Superficial reflexes such as abdominal wall reflex and tic reflex are diminished or absent. If the tendon reflexes of the upper extremity are diminished or absent, it suggests that 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 tearfulness, vision changes, 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 or even vomiting, bloating, diarrhea, indigestion, belching, and foreign body sensation in the throat, etc.
4, cardiovascular symptoms: palpitations, chest tightness, heart rate changes, arrhythmia, blood pressure changes, etc.
5. Excessive sweating, no sweating, chills or fever on the face or a certain limb, sometimes pain and numbness but not according to the distribution of nerve segments or travels.
The above symptoms are often clearly related to neck activities, aggravated when sitting or standing, and alleviated or disappeared when lying down. It is obvious when there are many neck activities, prolonged head bowing, long working hours in front of computer or exertion, and improves after rest.
6.Clinical examination: the neck activity is normal, and the soft tissue around the interspinous process of the cervical spine or the paravertebral small joints is painful. Sometimes it may also be accompanied by changes in heart rate, heart rhythm, blood pressure, etc.
V. Vertebral artery type cervical spondylosis
1. Episodic vertigo with diplopia accompanied by nystagmus. Sometimes accompanied by nausea, vomiting, tinnitus or hearing loss. These symptoms are related to the change in the position of the neck.
2.Sudden weakness of lower limbs and sudden collapse, but consciousness, mostly occurs 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.
Diagnostic criteria of cervical spondylosis
I. Clinical diagnostic criteria
1.Cervical type: with typical history of falling pillow and the above-mentioned cervical symptoms and signs; imaging examination may be normal or only have physiological curvature change or mild spinal space narrowing, with little bone formation.
2.Neurogenic 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 caused by extra-cervical pathologies (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, elbow tunnel syndrome, frozen shoulder, biceps long head tenosynovitis, etc.) is excluded.
3, spinal cord type: clinical manifestations of cervical spinal cord damage; imaging shows cervical degenerative changes, 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 more 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 are present. 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 besides.
(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) Vertigo of cerebral origin: Inadequate blood supply of vertebrobasilar artery and lacunar cerebral infarction caused by atherosclerosis; brain tumor; sequelae of traumatic brain injury, etc.
(4) Vertigo of vascular origin: vertebrobasilar artery supply insufficiency due to V1 and V3 segment stenosis of vertebral artery; hypertension, coronary heart disease, pheochromocytoma, etc.
(5) Other causes: diabetes, neurosis, overexertion, long-term sleep deprivation, etc.
(5) Vertebral artery type: previous episodes of sudden collapse with cervical vertigo; positive rotational neck test; imaging shows segmental instability or hook joint hyperplasia; except for other causes of vertigo; positive cervical motion test.
II. Imaging and other auxiliary examinations
X-ray examination 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-rays provide an imaging basis for determining the severity of 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 1-2 open views and tomograms when necessary. Sometimes a high-density striated shadow at the posterior edge of the vertebral body – ossification of the posterior longitudinal ligament of the cervical spine – can also be seen.
Cervical spinal canal measurement: on lateral cervical radiographs, the ratio of the midsagittal diameter of the spinal canal to the midsagittal diameter of the vertebral body is diagnosed as developmental cervical spinal stenosis if the ratio is less than or equal to 0,75 on any of the vertebral segments from C3 to C6. Segmental instability is important in the diagnosis of sympathetic cervical spondylosis and is measured: i.e., on a lateral cervical hyperflexion-hyperextension film, the sum of the distances from the point where the extension line of the posterior border of the vertebral body and the inferior border of the slipped vertebral body intersect to the posterior border of the same vertebral body ≥ 2 mm; the angle between the vertebral bodies is > 11°. CT can show the shape of the spinal canal and the extent of OPLL and the degree of encroachment on the spinal canal; myelography with CT examination can CT can show the shape of the spinal canal and the extent of OPLL and its encroachment on the spinal canal; myelography with CT can show compression of the dural sac, spinal cord and nerve roots.
MRI of the neck, on the other hand, can clearly show changes within the spinal canal and the spinal cord, as well as changes in the site and morphology of spinal cord compression, which is of great value for the diagnosis of cervical spine injury, cervical spondylosis and tumors. When the cervical intervertebral 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 dark and gray images 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 a common test for clinical diagnosis of cervical spondylosis, especially vertebral artery-type cervical spondylosis. Vertebral arteriogram and vertebral artery “ultrasound” can be helpful in diagnosis.
Treatment of cervical spondylosis
The treatment of cervical spondylosis is divided into surgical and non-surgical. Most patients with cervical spondylosis have excellent results through non-surgical treatment, and only a small percentage of patients need surgery because non-surgical treatment is ineffective or the condition is serious.
I. Non-surgical treatment
At present, it is reported that 90-95% of patients with cervical spondylosis are cured or in remission after 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.
(A) Traditional Chinese medicine treatment
1, Chinese medicine evidence-based treatment: the basic method should be to differentiate the type of evidence-based medicine.
(1) Cervical cervical spondylosis: it is appropriate to dredge the wind and relieve the surface, disperse the cold and open the ligaments, commonly used Gui Zhi plus Ge Gen Tang (Gui Zhi, Paeonia, Licorice, Ginger, Jujube, Ge Gen) or Ge Gen Tang (Ge Gen, Ephedra, Gui Zhi, Paeonia, Ginger, Jujube, Licorice), accompanied by throat inflammation, plus Yuan Shen, Ban Lan Gen, Jin Yin Hua, etc.
(2) Nerve root type cervical spondylosis: divided into.
If pain is the main cause, it is advisable to remove blood stasis and clear the ligaments, and it is often used in body pain and stasis removal soup (Angelica sinensis, Chuanxiong, Myrrh, Tao Ren, Qiang Wu, Hong Hua, Wu Ling Li, Gentiana macrophylla, Xiang Shen, Niu Knee, Di Long, Roasted grass); if it is damp-heat, it is advisable to clear heat and dampness, and it is used in Angelica sinensis and pain soup (Angelica sinensis, Dang Shen, Bitter ginseng, Cang X, Bai X, Sheng Ma, Fang Ji, Qiang Wu, Ge Ge Ge, Zhi Mu, Pig’s ling, Yin Chen, Scutellaria, Ze Diarrhea, Licorice, Dazao). If accompanied by numbness, add antispasmodic powder (centipede and whole scorpion) to the above formula.
If numbness is predominant, accompanied by muscle atrophy, take the method of benefiting qi, resolving stasis and opening up the ligaments, and commonly use the method of tonifying yang and returning to the fifth soup (astragalus, angelica, Chuanxiong, peony, peach kernel, safflower, dilong) plus centipede, whole scorpion, etc.
(3) Vertebral artery type cervical spondylosis, divided into.
For dizziness with headache, in favor of blood stasis, it is advisable to remove blood stasis and open the ligaments, to resolve dampness and pacify the liver, commonly used in Blood Mansions and Eliminating Blood Stasis Soup (Radix Angelicae Sinensis, Chuanxiong, Radix Paeoniae, Radix et Rhizoma, Rhizoma Peach, Safflower, Niubizi, Chai Hu, Citrus Aurantium, Radix Platycodon, Glycyrrhiza); in favor of phlegm and dampness, it is advisable to use Han Xia Bai Zhu Tian Ma Tang (Han Xia, Bai Zhu, Tian Ma, Fu Ling, Chen Pi, Glycyrrhiza, Dazao), etc.
Dizziness and head distension like wrapping, drowsiness, mouth pain, insomnia, is due to disharmony of the gall bladder and stomach, internal disturbance of phlegm and heat, it is advisable to regulate qi and resolve phlegm, clear the gall bladder and stomach, commonly used to warm the gall bladder soup (Hexia, Fu Ling, Chen Pi, Zhu Ru, Citrus aurantium, Glycyrrhiza glabra).
For dizziness, fatigue and weakness, with a less florid face, it is advisable to benefit qi and ying to resolve dampness, commonly used to benefit qi and smart soup (Astragalus, Radix Codonopsis, Radix Paeoniae Alba, Phellodendron, Radix et Rhizoma, Radix et Rhizoma Glycyrrhizae).
(4) Spinal cord type cervical spondylosis: those with increased muscle tone and a feeling of binding in the chest and abdomen take the method of dispelling blood stasis and opening up the internal organs, and use Fu Yuan and Invigorating Blood Soup (Da Huang, Chai Hu, Hong Hua, Tao Ren, Angelica sinensis, Smallpox powder, Andrographis paniculata, roasted licorice). If the lower limbs are weak and the muscles are atrophied, take the method of tonifying the middle and benefiting the qi and nourishing the spleen and kidneys, and use the method of Dihuang Drink (Radix et Rhizoma Polygonati, Gui Zhi, Cistanches, Cornu Cervi Pantotrichum, Radix Rehmanniae, Bacopa Monnieri, Acorus Calamus, Yuan Zhi, Dendrobium, Poria, Mai Dong, Wu Wei Zi) together with Sheng He Tang (Astragalus, Radix Codonopsis, Radix Angelicae Sinensis, Radix Paeoniae Alba, Rhizoma Chuanxiong, Radix Rehmanniae, Chai Hu).
Sympathetic cervical spondylosis has more symptoms, so it is appropriate to treat according to the condition.
2.Therapeutic method of Chinese herbal medicine: Chinese herbal medicines with different effects such as promoting qi and dispersing blood stasis, warming the meridians and dispersing cold, relaxing tendons and activating collaterals or clearing heat and detoxifying toxins are made into different dosage forms and applied to the relevant parts of patients with cervical spondylosis. The common treatment methods of external treatment of cervical spondylosis Chinese medicine include teng medicine, compress medicine, spray medicine, etc.
3.Tui na and orthopedic manipulation: it has the function of adjusting the internal organs, balancing yin and yang, promoting the generation of qi and blood, activating blood circulation and eliminating blood stasis, promoting tissue metabolism, releasing muscle tension, and managing tendon reset. The basic techniques include massage, kneading, pointing, pressing and wrenching.
Special emphasis is placed on the fact that massage must be carried out by a medical professional. Cervical spondylosis manipulation should be gentle and not violent. The vertebral artery type and spinal cord type patients should not apply posterior joint manipulation. It is difficult to exclude lesions such as tumors in the spinal canal, developmental stenosis of the spinal canal, spinal cord compression symptoms, 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, as well as the diagnosis is unknown, the use of any massage and orthopedic manipulation is prohibited.
4, acupuncture therapy: including acupuncture and moxibustion method. Acupuncture is the use of refined metal needles into certain parts of the body, with appropriate techniques to stimulate, while moxibustion is the use of moxa or moxa cones ignited and smoked acupuncture points for stimulation, through stimulation to achieve the adjustment of the human meridian organs qi and blood function, prevention and treatment of disease.
(B) Rehabilitation treatment
1.Physical factor therapy
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 vegetative nerves, and promote the recovery of nerve and muscle functions. Commonly used treatment methods.
(1) Direct current ion introduction therapy
Commonly used with a variety of Western medicine (glacial acetic acid, VitB1, VitB12, potassium iodide, nufocaine, etc.) or Chinese medicine (Wu Tou, Wei Ling Xian, safflower, etc.) placed on the back of the neck, according to the performance of drugs connected to the anode or cathode, with another electrode opposed or oblique opposed, each time the electricity for 20 minutes, applicable to all types of cervical spondylosis.
(2) Low-frequency modulated medium-frequency electrotherapy
Generally, 2000Hz-8000Hz IF electricity is used as the carrier frequency, and low- frequency electricity of different waveforms (square wave, sine wave, triangle wave, etc.) from 1-500Hz is used as the modulating waveform, which is modulated in different ways and compiled into different prescriptions. The prescriptions are selected according to different conditions, and the electrode placement method is the same as that of DC. Each treatment generally lasts 20-30 minutes and is suitable for all types of cervical spondylosis.
(3) Ultrashort wave therapy
The treatment is carried out with ultra-short wave of wavelength about 7m. Generally, two medium-sized electrode plates are used, which are placed behind the neck and the extensor side of the forearm of the affected limb, or monopolar 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 15-20 minutes each time. 10-15 times is a course of treatment. Applicable to 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 the skin of the neck in close contact, along the vertebral space and paravertebral movement, intensity with 08 ~ 1W/cm2, hydrocortisone cream can be used as a contact agent, once a day, each time 8min, 15-20 times a course of treatment. For the treatment of spinal cord type cervical spondylosis.
Ultrasound frequency as above, sound head moving along both sides of the neck with two supraganglial fossa, intensity 08～1,5W/cm2, 8-12min each time, the rest as above, used for the treatment of nerve root type cervical spondylosis.
(5) Ultrasonic conductivity targeted transdermal drug delivery treatment
Ultrasonic conductivity instrument and ultrasonic conductivity gel patch were used, and 2% lidocaine injection was selected as the transdermal drug. The patch was first fixed in the treatment transmitter head of the instrument, and 1ml of prepared lidocaine injection was added to the two coupling gel patches respectively, 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 to treat vertebral artery type and sympathetic nerve type cervical spondylosis.
(6) High potential therapy
Using the high-potential therapy instrument, the patient sits on the plate electrode or treatment seat with the foot on the insulating pad, and each treatment lasts 30-50 minutes. At the same time, rolling electrodes can be used for 5-8 minutes in the posterior neck collar area or the affected area once a day for 12-15 days, which can be used for all types of cervical spondylosis, among which sympathetic cervical spondylosis has the best effect.
(7) Light therapy
Ultraviolet therapy: the back of the neck on the flat hairline down to the second thoracic vertebra, the amount of erythema (3 to 4 biological amount), once every other day, 3 times a course of treatment, with ultra-short wave treatment of nerve root type acute stage.
Infrared therapy: various infrared instruments are available, behind the neck irradiation, 20 ~ 30min / time. Used for soft tissue type cervical spondylosis, or with cervical traction treatment (infrared therapy before cervical traction).
(8) Other therapies
Such as magnetic therapy, electric excitation therapy, audio electrotherapy, interference electrotherapy, wax therapy, laser irradiation and other treatments are also frequently used in the physical therapy of cervical spondylosis, and the proper choice can achieve certain results.
2.Traction therapy
Cervical spine traction is a common and effective method for treating cervical spondylosis. Cervical traction helps to release the muscle spasm of the neck, relax the muscle and relieve the pain; release the soft tissue adhesions, stretch the contracted joint capsule and ligaments; improve or restore the normal physiological curvature of the cervical spine; increase the intervertebral foramen, release the stimulation and compression of the nerve roots; enlarge the vertebral space and reduce the pressure in the intervertebral disc. Adjusting the microscopic abnormal changes of small joints, so that the synovial membrane of joint embedment or the misalignment of synovial joint can be reset.
Cervical spine traction treatment must master the three main elements of the direction of traction force (angle), weight and traction time 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 pay attention to the combination of patient 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 to start, and then gradually increase.
(4) traction time: traction time to continuous traction 20 minutes, intermittent traction is 20-30 minutes is appropriate, once a day, 10-15 days for a course of treatment.
(5) precautions: individual differences should be fully considered, the old and frail should be traction weight lighter, traction time shorter, young and strong can hold heavier and longer; traction process should pay attention to observe and ask the patient’s reaction, such as 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 for its pathological changes, passive activities such as pushing, pulling and rotating the spine and small joints of the spine are performed to adjust the anatomical and biomechanical relationship of the spine, and at the same time, the muscles and soft tissues related to the spine are loosened and straightened to improve joint function, 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. It is difficult to exclude lesions such as tumors in the spinal canal, developmental stenosis of the spinal canal, spinal cord compression symptoms, bony destruction of vertebrae and accessories, ossification of the posterior longitudinal ligament or cervical deformity, acute inflammation of the pharynx, larynx, neck and occipital area, obvious neurosis, and in cases where the diagnosis is unknown, the use of any massage and orthopedic manipulation is cautious or prohibited.
4.Exercise therapy
Exercise therapy for the cervical spine refers to the use of appropriate exercise methods to exercise the neck and other related parts as well as the whole body. 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 is also available when available. Types usually include cervical spine flexibility exercises, cervical muscle strength training, cervical spine correction training, etc. In addition, there are whole body exercises such as running, swimming, ball games, etc. are also common therapeutic exercises 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.Orthopedic support application
Orthopedic brace of cervical spine is mainly used for fixing and protecting cervical spine, correcting abnormal mechanical relationship of cervical spine, reducing neck pain, preventing over-extension, over-flexion and over-rotation of cervical spine, avoiding further damage to spinal cord and nerves, reducing spinal edema, reducing traumatic reaction of intervertebral joints, helping repair of tissues and relief of symptoms, and cooperating with other treatment methods at the same time can consolidate 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 individual cases with progressive development (mostly spinal cervical spondylosis), it is necessary to make an immediate decision and perform surgery as early as possible.
II. Surgical treatment
The main purpose of surgical treatment is to relieve the severe compression on the spinal cord or blood vessels caused by 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 with 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 procedure is divided into anterior cervical approach and posterior cervical approach.
1.Anterior cervical surgery: the anterior cervical approach is to remove the diseased disc and posterior spur and to insert bone between the vertebral bodies. 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 graft 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. 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, large intervertebral bone graft, and titanium plate internal fixation can be used. If the titanium cage is filled with autologous bone (resected vertebral body) and the titanium plate is internally fixed, bone retrieval can be avoided. For patients with mild degeneration of the intervertebral joint and no significant narrowing of the intervertebral space, artificial disc replacement can be performed after removal of the diseased disc.
2.Posterior surgery: The cervical spinal canal is enlarged through the posterior cervical approach so that the spinal cord can be decompressed. The commonly used surgical 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 yellow ligament hypertrophy or ossification resulting in ventral and dorsal compression of the spinal cord. For those with segmental instability, lateral block 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 patients’ physical and mental health.
The basic method of perioperative treatment cannot be separated from the rehabilitation medical treatment of cervical spondylosis, but some new pathological factors, such as the mental burden of anxiety and panic brought by surgery to patients, and the trauma of surgery and postoperative weakness, cannot be ignored.
The “cervical spine rehabilitation health care work” is used for the prevention and supplementary treatment of cervical spine disease, and can be planned to be extended to the community, reflecting the academic idea of rehabilitation and prevention.
4.Efficacy assessment
The Japanese Orthopaedic Society has established criteria for evaluating the spinal cord function of patients with cervical spinal cord disease, which has been accepted by international scholars. According to China’s national conditions, appropriate standards have also been developed and have been promoted and applied in China.