1.Cervical cervical spondylosis
Mostly seen in young adults, but also individually seen in middle-aged and old people. The neck is sore, swollen, painful and uncomfortable, and the head feels like it does not know what position to put. The neck movement is limited or forced into a position, and the back of the shoulder is stiff. Some patients may reflexively have transient upper limb sensory abnormalities, coughing, sneezing when the pain is aggravated, numbness is not aggravated.
Neck stiffness, the patient’s neck is mostly in a “military upright” position, cervical movement is limited, there is significant pressure pain in the paravertebral muscles, trapezius muscle and sternocleidomastoid muscle, and there is also significant pressure pain between the spinous processes of the affected vertebrae. The intervertebral foramen squeeze test and brachial plexus nerve pull test were negative.
X-ray examination: the physiological curvature of the cervical spine is straightened, the intervertebral joints are destabilized, and signs such as “bilateral” and “double protrusion” appear.
2.Nerve root type cervical spondylosis
It has a slow onset and long course over 30 years old, and can be triggered acutely by strain and injury. It is mostly seen in C5/6 and C6/7 intervertebral spaces. The pain in the neck, shoulder and arm can be persistent vague or sore, or paroxysmal sharp pain, or pins and needles-like or burning pain. The pain may be aggravated by coughing, sneezing, and other movements that increase abdominal pressure. Lesions in the lower cervical segment may present with pain and numbness in the shoulder arm hand along the nerve root distribution area, and the pain is mostly radiating. Sensory disturbances, accompanied by radicular pain, are more common, such as numbness like a spacer, sensory hypersensitivity, or diminished sensation. It is consistent with the extent of the affected nerve root innervation area. Longer duration of the disease may be associated with loss of muscle strength in the affected limb and unstable grip. If sympathetic nerve damage is also present, swelling of the affected finger, headache, eye pain, sweating, etc. may occur.
The cervical muscles are tense, the neck is straightened, often in a protected position, passive and active activities are restricted, and pain is easily induced when the neck is extended. The cervical spinous process and the paraspinal process of the lesioned segment have obvious pressure pain, and even radiating pain may appear. Pressure points can be found in the trapezius, supraspinatus, infraspinatus and rhomboid muscles. In severe cases, the affected limb has hypotonia, decreased muscle tone, biceps and triceps tendon reflexes, and diminished radial reflexes. Intervertebral foramen squeeze test: the presence of neck pain and radiating pain in the shoulder and arm is considered positive. Brachial plexus nerve pull test: positive if nerve root pain and radiating pain are present.
Positive head compression test: If the patient sits upright with the head tilted back and to the affected side, and the operator places the palms of both hands on the top of the head and applies pressure in the longitudinal direction, a positive result is seen if the neck radiates to the affected limb.
X-ray examination: orthopantomogram can be seen as hyperplasia of the hook vertebral joint. Lateral radiographs show straightening of the cervical curvature, or antalgia, or vertebral joint instability, with bilateral or double protrusion. Calcification of the collateral ligament and narrowing of the vertebral space. Osteomalacia at the posterior edge of the vertebral body. Oblique radiographs show hyperplasia of the hook vertebral joint, narrowing of the intervertebral foramen, deformation, and hyperplasia of the synovial joint.
CT examination: CT examination can clearly show narrowing of the cervical spinal canal and nerve root canal, disc herniation and spinal nerve compression.
MRI examination: MRI can observe structural changes in the spinal canal from the sagittal, cross-sectional and coronal planes of the cervical spine, showing the spinal cord and intervertebral disc tissues clearly, but the protrusions compressing the nerve roots are small and sometimes not as clear as CT.
Neuromyography: The involved nerve root innervated muscle segments may show low voltage and multi-phase motor potentials. The conduction velocity of the median ulnar nerve may be reduced to varying degrees. The nerve roots involved are different for different segments of cervical degeneration and hyperplasia, the most common ones are cervical 56 and cervical 67.
3.Vertebral artery type cervical spondylosis
Headache and dizziness can often be aggravated by sudden rotation of the neck. The headache is mostly on one side and has a defined meaning, with temporal region being more common. The pain is mostly throbbing and swelling. Dizziness is more common and may be accompanied by tinnitus, deafness and other vagal symptoms. Sudden collapse: sudden onset, when turning the neck in a certain position, the muscle tone suddenly disappears and falls to the ground. Subsequently awake, can immediately stand up, conscious. Phytodystrophy symptoms: nausea, vomiting, excessive or no sweating, salivation, bradycardia or tachycardia, chest tightness, chest pain, or positive Horner’s sign. Diminished vision, blurred vision, or blindness. Slurred pronunciation, swallowing disorder, choking on drinking water, hoarseness. Neurological weakness, memory loss. In severe cases, symptoms of vertebral tract involvement and ataxia may be present.
Tension and spasm of the cervical muscles. There may be pressure pain next to the spine at the lesioned vertebral segment. The neck is afraid to move, otherwise it will make dizziness and headache significantly worse. If the lesion involves the spinal cord or nerve roots, the corresponding signs will appear. The trapezius and sternocleidomastoid muscles are spastic and stiff. Rotation test may aggravate the patient’s dizziness and headache symptoms.
X-ray examination: lateral films are more important and show intervertebral joint hyperplasia, narrowing of the intervertebral space, straightening or reversion of the cervical curve, and instability of the intervertebral segments. The orthopantomogram shows that the spinous process of the vertebral body is skewed to one side, and the oblique film shows that the hook vertebral joint is hyperplastic and the intervertebral foramen is narrowed and deformed. Note the need to routinely take open-mouth films to observe whether there is displacement of the atlantoaxial spine.
Transcranial Doppler examination: it can be seen as a manifestation of incomplete or impaired blood supply to the vertebrobasilar artery, which is of great significance in the diagnosis of this type of cervical spondylosis.
Vertebral artery angiography: A tube can be inserted from the brachial or femoral artery to the vertebral artery to inject contrast. If twisting and narrowing of the vertebral artery is seen (compression by bone), manipulation may be considered. Vertebral artery angiography is mostly used for preoperative localization.
Cerebral hemogram: It has a reference value for the diagnosis of vertebral artery type cervical spondylosis. If there is rounding of the peak angle of the main wave, low or absent peak of the repetition wave, prolonged rise time of the main wave and reduced wave amplitude, it can indicate ischemic changes in the vertebral basilar artery.
Electroencephalography: The diagnostic significance of electroencephalography for vertebral artery cervical spondylosis is still at the stage of exploration and research. It has been reported that 80% of this disease has low voltage activity and metastatic slow waves and small sharp waves can be seen in the temporal region.
4. Sympathetic cervical spondylosis
There are no sympathetic nerve cells in the cervical spinal cord, and all sympathetic fibers ascend from the chest. The cervical spinal nerve has no white communicating branch, but only the gray communicating branch is connected to the sympathetic ganglion. The pathogenesis of this type is not well understood, and it is generally believed that stimulation of various structural cervical spine lesions can produce a series of sympathetic symptoms through spinal reflexes or brain and spinal reflexes.
Sympathetic cervical spondylosis is dominated by symptoms of sympathetic excitation, such as headache or migraine, sometimes accompanied by nausea and vomiting. Neck disorders are painful, and patients often complain of a feeling that their neck cannot support the weight of their head. Symptoms in the eyes include blurred vision, decreased visual acuity, swelling and pain in the eye sockets, tearing, weakness of the eyelids, and dilated or narrowed pupils. There is often tinnitus and hearing loss or loss. Cardiovascular symptoms such as precordial pain, arrhythmia, tachycardia and elevated blood pressure may also be present. In case of sympathetic depression symptoms, the main manifestations are dizziness, blurred eyes, lacrimation, nasal congestion, bradycardia, decreased blood pressure and gastrointestinal distention.
Symptoms of discomfort and pain in the neck and occipital area can be significantly increased when the head and neck are turned. Compression of the spinous processes of the patient’s unstable vertebral segments may induce or aggravate sympathetic symptoms.
X-ray examination: In addition to the common degenerative changes of the cervical spine, X-ray examination can confirm the presence of cervical segmental instability in flexion and extension, with cervical 3/4 intervertebral instability being the most common.
CT, MRI and other examination results are similar to those of neurogenic cervical spondylosis.
5.Spinal cord type cervical spondylosis
It is mostly seen in patients above middle age with a history of chronic strain injury of the neck, or a history of falling pillow, or a history of trauma to the neck. There are few neck symptoms or only slight neck discomfort. Most of them show numbness and weakness of one or both lower limbs, heavy and tight legs, unstable and awkward gait, and a feeling of stepping on cotton when walking. Then, the numbness, pain and weakness of the upper limbs on one or both sides, reduced grip strength, easy to fall, and inability to complete fine movements, such as buttoning and peanut clutching. The neck is stiff, and the upper limbs or extremities are tingling when the neck is extended. There is a feeling of banding in the chest, abdomen or pelvic area. In severe cases, there is difficulty walking, incontinence or urinary retention, or even tetraplegia and bedridden. Some patients may exhibit sympathetic symptoms such as dizziness, headache, and hemiplegic sweating.
The cervical spinous process becomes paraspinal pressure pain, and posterior neck extension, lateral and bending are limited. The lower limbs have increased muscle tone and decreased muscle strength. There is sensory disturbance in the trunk, but it is irregular and the lesion segments cannot be clinically localized according to the level of sensory disturbance. The lower extremities are mostly sensory impaired. Physiological reflexes are hyperactive: biceps and triceps tendon reflexes, radial reflexes, Achilles and knee tendon reflexes are hyperactive. Positive pathological reflexes: positive Hoffman’s sign, ankle clonus, patellar clonus, and Babinski’s sign. Superficial reflexes such as abdominal wall reflex and testicular reflex are often decreased or absent, while anal reflex is often present. Some patients may have sensory dissociation, i.e., ipsilateral tactile sensation, deep sensory deficit, contralateral pain and temperature loss but normal tactile sensation. This is mostly seen in Brown-Sequard syndrome caused by hemi-lateral compression of the spinal cord.
X-ray examination: cervical curvature is straightened or angled backward in frontal and double oblique views of the cervical spine, narrowing of the intervertebral space, osteophytes at the posterior edge of the spine, narrowing of the intervertebral foramen due to hyperplasia of the hook vertebral joint, and calcification of the collateral ligament. The ratio of the sagittal diameter of the spinal canal to the sagittal diameter of the vertebral body on lateral radiographs is less than 0.75, which can be considered as spinal stenosis. The value of the median sagittal diameter of the spinal canal is mostly below 13.0 mm.
CT examination: the posterior edge of the vertebral body is seen to be bony, or the posterior longitudinal ligament is ossified, the yellow ligament is hypertrophied or calcified, and the cervical intervertebral disc is herniated. Measurement of the median sagittal meridian of the spinal canal and a value of less than 10.0 mm suggest absolute stenosis of the spinal canal and compression of the spinal cord.
MRI examination: MRI can show the degenerative changes of cervical disc and the degree of spinal cord compression more clearly.The T2-weighted image shows reduced signal of the nucleus pulposus of the intervertebral disc, protrusion into the spinal canal, compression of the dural sac, and indentation. In both the T1-weighted sagittal and axial planes, the degree of spinal cord compression, dural sac deformation and subarachnoid stenosis can be clearly demonstrated. Long-term spinal cord compression appears as low signal on T1-weighted images and as high signal or limited high signal foci on T2-weighted images. MRI can also show osteophytes and changes in the nerve roots and intervertebral foramina.
Myelography can be used to understand the location and nature of spinal cord compression.
A lumbar puncture usually shows complete or partial subarachnoid obstruction, suggesting spinal cord compression, but the site and cause of compression cannot be determined. Note that false-positive and false-negative results are excluded.
6.Mixed type cervical spondylosis
It is mostly seen in middle-aged and elderly people, and is more common in manual workers. It has the symptoms and signs of two types or two types of cervical spondylosis. （X-ray examination: extensive osteophytes, narrowing of the intervertebral space, hyperplasia of the hook vertebral joint, narrowing of the intervertebral foramen, or segmental instability of the vertebral body and calcification of the collateral ligament can be seen in the cervical spine.
If necessary, CT, MRI, vertebral arteriogram, transcranial Doppler and other auxiliary examinations are feasible.
7.Other types of cervical spondylosis
Difficulty in swallowing, mild: the difficulty in swallowing is obvious when the head is tilted up and reduced when the head is lowered. It is more difficult when swallowing hard food, and some of them may show a burning and tingling sensation behind the sternum after eating. Moderate: Cannot swallow hard food, can only swallow soft food, or liquid food, semi-liquid food. Severe: Only liquids such as milk, soy milk and water can be eaten. Soreness and tension in the neck muscles. Or with the manifestation of nerve root type, vertebral artery type, spinal cord type or sympathetic type cervical spondylosis, especially sympathetic nerve disorder symptoms are more common.
X-ray examination: lateral cervical spine film can be seen in the anterior edge of the cervical vertebral body with a typical beak-like bone superfluous, or connected to form a bone bridge. The prevalent site is mostly in the C5-6 interval. Barium fluoroscopy can clearly observe the degree of esophageal compression stenosis and the site of stenosis. The diagnosis is usually confirmed by X-ray without the need for CT or MRI.