We have introduced a lot of new technologies and methods, but in terms of diagnosis, including the basic understanding of some common diseases instead we have a lot of deficiencies. So today in this section I will talk about our topic today: diagnosis of cervical degenerative disease in conjunction with the lecture by President Tian Wei of the Jishuitan Hospital on the most common, cervical degenerative degeneration of the Jishuitan diagnostic classification proposal. We all know that we often say cervical spondylosis cervical spondylosis, in fact, it is a very old generalized concept, generally speaking, it is accompanied by degenerative changes in the cervical spine, certainly not trauma nor congenital deformity, and then appear neurological aspects, such as the spinal cord and nerve roots are compressed and clinical symptoms of a class of diseases. There is a description of the concept in the textbook of surgery, but it is rather vague, meaning that it is a proliferative cervical spine disease, a degenerative change causing nerve compression. Many doctors are confused about the diagnosis of degenerative cervical spine disease, and I think there are two main reasons for this. One of them is unclear about the pattern and localization method of nerve compression stimulation. Many people talk about cervical spine disease cervical spondylosis, what is the relationship with the nerve? It has never been studied. Secondly, there is a lack of understanding of the substance and classification of the pathology of the disease. This phenomenon is more common, so it is naturally more confusing in the choice of treatment. There are many debates including how we go about choosing treatment. First of all, how to make a neurological diagnosis, we will first introduce the anatomical characteristics of the occurrence of neurological symptoms. The neurological symptoms that occur in cervical degeneration are still related to the diameter of the spinal canal. Then you say that the diameter is congenitally wide and narrow, which is indeed the case. But even for people who are developmentally narrower, he has certain limitations, and generally a diameter of less than 13 mm is in a more dangerous state. But in fact, it is often due to hyperplasia, or some other reasons that cause the local vertebral canal to become narrower, but of course there are anatomical and anthropological features, such as the spinal cord, although the size and thickness of each person is different, but it is still constant relative to the overall changes in the physique, that is, whether you are a Hercules or the recent hot show Star Diving Cube in Wang Li-kun The most important thing is that they are relatively similar in terms of nerves. However, there is a big difference in the size of the bones. The Japanese did a study on this at a very early stage, and he compared the anterior and posterior diameters of the bony cervical spine of Japanese and white people and found that they are very different. Especially for the part of the frequently moving, around the cervical 3 to cervical 7, Japanese people are obviously different from whites. That is, the spinal canal is narrower in Asians. Whites are relatively wider. The figure on the right shows the thickness of the spinal cord in whites and yellows through myelography, and we can see that the two are relatively similar in this respect. In other words, if the nerves are the same size, the smaller the bony spinal canal is, the more likely it is to have symptoms if something goes wrong. In addition, the same applies to the nerve root. Many doctors often take an oblique film and say, “Oh, you’ve got a long bony canal and the nerve is compressed. In fact, the width of the nerve root canal is still very high. This means that even if there is a certain amount of hyperplasia, it does not necessarily mean that there is nerve root compression. So we still have to conclude based on the clinical symptoms, and we cannot simply rely on taking a picture to explain the problem. Another anatomical feature worth considering is the ligamentum flavum. The ligamentum flavum expands into the spinal canal with age, and these two pictures show two people who are older, and we can see that their ligamentum flavum is clearly expanding into the spinal canal. This is especially true when you’re extending posteriorly. These are all anatomical factors that we have to be aware of when we are diagnosing a patient. Also we have to know that the medullary segments are obliquely distributed. We say that cervical 3 and 4 correspond to the medullary ganglion of 5, and cervical 4 and 5 correspond to the medullary ganglion of 6. 5 and 6 correspond to the medullary ganglion of 7. This regularity helps us to make a diagnosis in the clinic. But you must know the concept of medullary ganglion. It refers to the part of the gray matter of the spinal cord. The compression of nerves in degenerative cervical spine diseases is generally divided into spinal cord compression and nerve root compression. The gray matter of the spinal cord is mainly the cellular cytosolic portion, so this is more susceptible to compression, while the periphery is the striated white matter, which is the axon of neurons and is relatively more able to withstand compression. But even if the spinal cord is compressed, there is actually only one place where the compression and his clinical presentation are related. It is not right to look at the film and say, “Hey, many places are compressed and there are problems. This has been studied more clearly in the previous spinal cord electrophysiology experiments. There is a characteristic of spinal cord compression. It usually starts in the center, and not as soon as it is compressed, the whole body is compressed, so often the inner medullary segment is compressed first and the symptoms appear, then the lateral white matter appears, and finally the whole lateral cord. This is his characteristic, so the clinical manifestation is also very complicated, but as long as you catch some characteristics, it is actually not difficult. It is not only the Japanese cone type, like the European and American, but also the very old crandall, which divides him into central cord syndrome. the meaning is the same, that is, the central spinal cord is compressed, but such a compression because it comes from the gray matter, the anterior and posterior horn cells of the spinal cord are damaged, there is numbness and weakness of the upper limbs, and the fingers cannot extend and flex freely. In some patients, the interosseous and interphalangeal muscles of the hand are atrophied, and the muscle tone and tendon reflexes of the affected muscles may be diminished or absent. In terms of finger sensation, generally 3~4 have any compression, it will appear in the medullary segment of 5 that place of compression symptoms, generally appear 1~5 finger numbness, 4~5 is 1~3 finger numbness, 5~6 is 3~5 finger numbness, many people radial three fingers are numb, see if 4~5 that place of the problem. 6, 7 and neck 7 chest 1 rarely appear finger sensation regular distribution characteristics, may appear upper limb dexterity. There may be difficulties with upper limb dexterity. Further compression of the posterior part of the lateral cords will result in disorders of the white matter of the motor system and a spastic gait, mainly due to compression of the vertebral body bundle, which is characterized by progressive numbness, pain and weakness of both lower extremities, and a feeling of stepping on cotton when walking. In more severe cases, due to damage to the thalamic tract of the spinal cord, numbness of the trunk and lower extremities, and even urinary and fecal dysfunction may occur. However, there are some special types, such as Brown-sequard syndrome, where the spinal cord is pressed in half, and mixed spinal cord syndrome, where only the motor system is pressed. There are also special types, such as cervical spinal cord compression, which can present as paraplegia? There are some specific compressions that can also manifest paraplegia. Many people look for the thoracic spine when the upper extremity is fine and the lower extremity is not, which is correct. This is a relatively uncommon type. There is another type of hemiplegia, which can be easily confused with brain nerve problems. So don’t forget that this can also be caused by a specific compression. Spinal cord compression has a pattern of clinical manifestations, with upper extremities showing upper motor neuron damage and lower motor neuron damage. For example, 3 and 4 are the medullary ganglia that turn 5, and 6 is below it, so it will show hyperreflexia of the biceps tendon. At 4 and 5, it will drop, like 5 and 6 it will also show a drop. In 3 and 4, there will be hypotonia of the deltoid muscle, and in 4 and 5, the medullary ganglion of 6 will show a decrease in biceps (C6 innervation) muscle strength, and in 5 and 6, that is, 7, the medullary ganglion will show a decrease in triceps (C7 innervation) muscle strength. When judging this kind of nerve compression, we have several characteristics, one is sensory impairment, we generally take the lighter side as the indicator. If both sides are numb, you will not be able to see clearly if you look at the heavy side. The place where the numbness first appears is very important. Including numbness ah, pain ah, this is the most credible. But tendon reflexes are instead dominated by the heavier side. Hypotonia appears relatively late, but it is an indicator of higher diagnostic value. The nerve root compression, it will be different, it is from the spinal cord to the root of the place, rarely all at once both sides of the root compression, or a string of several roots are compressed, so the general performance is a certain nerve root. Of course the most common, statistically still 6 and 7 are more frequent. And 5 and 6 are relatively less. Other places will be even less. It presents in the acute phase as a kind of pain, like in the neck, in the shoulder, in the scapular area. And some people will present with pain in the anterior chest area, sometimes mistaken for angina. Sometimes it is quite difficult to distinguish it from internal diseases. A detailed diagnosis is needed, although angina pectoris in internal medicine is related to exercise, but the symptoms of nerve root are sometimes easier to show in quiet time, but sometimes the opposite is also true, and this really cannot be generalized. So we have to do some tests. Because the real angina may also occur in quiet time, but usually there is unilateral upper limb radiating pain. In the chronic phase it turns into a heaviness, numbness and pain in the hands, and sometimes sudden muscle paralysis. The distribution of nerve roots is different from the medullary segment of the spinal cord, for example, in the example given here, cervical 5/6, if it is a medullary segment, it is the medullary segment of 7, while the nerve root comes out at the tip of the cervical 6 vertebrae. So when there is a problem with cervical 5/6, it is mainly the cervical 6 nerve root that is being compressed, and these are the things we need to remember in the clinic. What we see clinically is that whichever root is compressed is the problem. If the anterior root is predominantly compressed, the muscle strength changes are more obvious (including reduced muscle tone and muscle atrophy, etc.), and if the posterior root is predominantly compressed, the symptoms of sensory impairment are more severe. However, in clinical practice the two mostly coexist, mainly because in the narrow root canal, multiple tissues are densely packed together, and it is difficult for everyone to have room to retreat. As a result, sensory and motor dysfunction are predominantly both present at the same time. However, the sensory nerve fibers are more sensitive and thus the symptoms of sensory abnormalities will manifest earlier. The symptoms are more pronounced in those with anterior root compression, with an early increase in muscle tone, but soon weakening and myasthenia. The involvement is limited to the muscle group innervated by the spinal nerve root. In the hand, the greater and lesser interosseous muscles and the interosseous muscles are the most obvious. The tendon reflexes are altered, i.e., the reflex arcs involved in the affected spinal nerve roots are abnormal. It appears active in the early stages and decreases or disappears in the middle and late stages and should be compared with the contralateral side during examination. Root involvement alone should not have pathological reflexes, but if it is accompanied by pathological reflexes, it indicates simultaneous involvement of the spinal cord. In cases of posterior root compression, sensory disturbances in the distribution area of the nerve root are seen, with numbness in the fingers, sensory hypersensitivity in the fingertips, and decreased skin sensation being the most common. In the case of C5/6, the 6th cervical spinal nerve root involvement, numbness is often seen in the radial forearm and thumb; in the case of C6/7, the 7th cervical spinal nerve root involvement, numbness is seen in the index finger and middle finger; in the case of C7 cervical/T1, the 8th cervical spinal nerve root involvement, numbness is seen in the little finger and ring finger. So these are the things that we have to distinguish clinically. But what would you say is the difference between these two types of problems? In terms of conscious symptoms, spinal cord compression is usually more numbness, while the nerve roots are painful. The spurling test is a kind of pulling test that we often do to increase the tension of spinal nerve roots. He is based on the nerve root must be very sensitive state, his threshold is very low, so when you do this action, a stimulus he will appear crosstalk, that is certainly a nerve root type of problem will appear. The cervical compression test (Quecken queckenstedt lumbar puncture with compression of the jugular vein to observe changes in cerebrospinal fluid pressure) often shows severe obstruction of the spinal canal, so it is still a spinal cord type. The spinal cord type has a poor prognosis and usually requires surgical treatment. Many people forget that the spinal cord type includes two parts: gray matter disorder and white matter disorder, and look at the lower extremity symptoms first. This is a huge mistake. Gray matter compression also appears in the upper extremity symptoms, which is the spinal cord type of symptoms. Then the second part is how we classify. In the past, many names were used, such as pain, spinal cord type, nerve root type, mixed type, esophageal type, KEEGAN type, and of course, some people used disc herniation, spinal stenosis, posterior longitudinal ligament calcification, etc. So what is the problem with them. One is the crossover of names, the crossover of cervical spondylosis and subtypes of cervical spondylosis, and the lack of understanding in the past, so there is confusion about these perceptions, and sometimes it is a problem of the doctor’s own level. Another is that we often have a mix of the terms cervical disc herniation and cervical spondylosis. This can easily cause confusion in classification. In the past, we did not know about cervical disc herniation, but only about cervical spondylosis. Professor Tian mentioned that when he came back from Japan in the early 1990s to follow the professor’s ward, he mentioned that this patient was a cervical disc herniation, which he learned abroad at that time. However, domestic professors say that there is no herniated disc in the cervical spine, but only cervical spondylosis in the cervical spine. Now there are still many doctors who are not clear about this. For most of our doctors should still be able to distinguish. Also OPLL and this hyperplasia some people can not distinguish. And often use some wrong words, such as calcification, calcification and ossification are two completely different concepts, and this is also a problem we often have. Another one is that there is no diagnostic name, for example, he is pain, how do you diagnose. The customary usage is also problematic. What exactly do you mean by this disease? I think the source should be the Japanese kanji back in the day, they called it cervical spondylosis. This was also translated from the West. Many Japanese translations came to us, and the Chinese accepted it selectively. There is also what we used to call non-skeletal cervical spinal cord injury, which we still use a lot. In fact, it was used when we did not know it. With the availability of MRI and CT, we found that OPLL, cervical disc herniation, spinal stenosis, as long as there are these problems, after a small injury, he may have symptoms. But we don’t have a good classification on ICD-10, you can see he only has two, one is spondylosis, and the other is cervical disc disorders, and these are not a very detailed classification. Therefore, according to the actual situation, in 2009, Jishuitan Hospital tried to carry out a classification, hoping to help reach a common understanding, in fact, is to divide him into several diseases clearly, one is cervical disc herniation, it is the compression caused by the rupture of the intervertebral disc, he has the spinal cord and also the nerve roots. The other is ligamentous ossification, which is a hereditary disease, and it is important to recognize that it has ossification of the anterior and posterior longitudinal ligaments, and also ossification of the ligamentum flavum, of course, in the cervical spine, we should pay special attention to ossification of the ligamentum flavum, which is present, but rare. The rest we think is degenerative cervical spinal stenosis. This is actually a kind of hyperplasia. Therefore, I think it is very useful for our clinical treatment to make a clear distinction between these several, and to make a diagnosis.