Cervical spondylosis

Pathology

The term spondylosis encompasses several degenerative pathological processes affecting the vertebral column and intervertebral discs which conspire to produce neurological deficits due to compression of the spinal cord and spinal roots.

Pathological features include:

  • Osteophyte formation leading to narrowing of the neural foramina
  • Thickening of the posterior longitudinal ligament
  • Degenerative disc disease

These factors lead to narrowing of the spinal canal and compression of spinal nerve roots, producing a combination of:

  • Myelopathy: long-tract signs from cord compression
  • Radiculopathy: dermatomal and myotomal signs from nerve root compression

Clinical features

In general cervical spondylosis presents with gradually worsening neck pain associated with a combination of radicular symptoms in the upper limbs and long-tract signs. The level/s and severity of the spondylosis determines the location and severity of symptoms and signs.

  • Radiculopathy:

    • Pain
      • Sharp, stabbing pain, worse on straining
    • Sensory disturbance
      • Dermatomal numbness/paraesthesiae
    • Motor change
      • LMN weakness
      • Areflexia
    • Wasting
  • Myelopathy
    • Motor
      • UMN weakness below the level
    • Sensory
      • Long tract signs, possibly a level

Features of specific radiculopathies are detailed below:

Root Sensory loss Movements Reflex
C5 Upper outer arm Shoulder abduction

Elbow flexion

Biceps
C6 Outer forearm

Palmar surface of thumb and index finger

Elbow flexion when semi-pronated Supinator (brachioradialis)
C7 Palmar surface of middle finger Elbow extension

Finger extension

Triceps
C8 4th and 5th digit

Medial forearm

Finger flexion Finger jerk
T1 Medial arm Small muscles of the hand

Investigation

Further investigation is required if there is a hard neurological deficit, if there is suspicion of another cause for the clinical findings (i.e compression by a mass lesion), or if surgery is being considered.

  • MRI is the gold standard for evaluating the extent of cord and root compression
  • EMG and Nerve Conduction Studies help to confirm the diagnosis of radiculopathy

Management

  • Conservative measures should be tried first in most patients:
    • Analgesia
    • Immobilisation with a collar
    • Physio
  • Epidural steroid injections
    • Can be tried in people with severe symptoms or those unfit for surgery
  • Surgery
    • Indications
      • Progressive neurological deficit
      • Intractable pain
      • Failure of conservative management
    • Options
      • Anterior decompression + fusion
        • Best for anterior cord compression, especially if more than one vertebra is involved
      • Posterior approach: laminectomy or foraminotomy
        • Laminectomy involves decompression at several levels and so is best for multilevel compression, esp. if pre-existing congenital stenosis
    • Prognosis: surgery reduces progression, it does not reverse deficit.