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Updated: Jun 23 2021

Cervical Spondylosis

  • summary
    • Cervical Spondylosis represents the natural degenerative process of the cervical motion segment which can lead to cervical radiculopathy, cervical myelopathy, or axial neck pain. 
    • Diagnosis can be made with plain radiographs of the cervical spine.
    • Treatment can be observation, medical management, or surgical management depending on the severity and chronicity of pain, presence of instability or, presence of neurological deficits. 
  • Epidemiology
    • Incidence
      • typically begins at age 40-50
        • 85% of patients >65 years of age demonstrate spondylotic changes regardless of symptomatology
    • Demographics
      • more common in men than women
    • Anatomic location
      • most common levels are C5-6 > C6-7 because they are associated with the most flexion and extension in the subaxial spine
    • Risk factors
      • excessive driving
      • smoking
      • lifting
      • professional athletes
  • Pathophysiology
    • Pathoanatomy
      • Spondylosis is a natural aging process of the spine
        • characterized by degeneration of the disc and the four joints of the cervical motion segment which include
          • two facet joints
          • two uncovertebral joints of Luschka)
      • Degenerative cycle includes
        • disc degeneration
          • disc desiccation, loss of disc height, disc bulging, and possible disc herniation
        • joint degeneration
          • uncinate spurring and facet arthrosis
        • ligamentous changes
          • ligamentum flavum thickening and infolding secondary to loss of disc height
        • deformity
          • kyphosis secondary to loss of disc height with resulting transfer of load to the facet and uncovertebral joints, leading to further uncinate spurring and facet arthrosis
      • Associated conditions
        • often leads to the clinical conditions of
          • cervical radiculopathy
          • cervical myelopathy
          • discogenic neck pain
  • Mechanism of Neurologic Compression
    • Nerve root compression
      • leads to the clinical condition of radiculopathy
      • foraminal spondylotic changes
        • secondary to chondrosseous spurs of facet and uncovertebral joints
      • posterolateral disc herniation or disc-osteophyte complex
        • between posterior edge of uncinate and lateral edge of posterior longitudinal ligament (PLL)
        • affects the exiting nerve root (C6/7 disease will affect the C7 nerve root)
      • foraminal soft disc herniation
        • affects the exiting nerve root (C6/7 disease will affect the C7 nerve root)s
    • Central cord compression (central stenosis)
      • leads to the clinical condition of myelopathy
      • occurs with canal diameter is < 13mm (normal is 17mm)
      • worse during neck extension where the central cord is pinched between
        • degenerative disc (anterior)
        • hypertrophic facets and infolded ligamentum (posterior)
  • Imaging
    • Radiographs
      • common radiographic findings include
        • degenerative changes of uncovertebral and facet joints
        • osteophyte formation
        • disc space narrowing
        • endplate sclerosis
        • decreased sagittal diameter (cord compression occurs with canal diameter is < 13mm)
      • incidence
        • radiographic findings often do not correlate with symptoms
      • lateral
        • important to look for sagittal alignment and size of spinal canal
      • oblique
        • important to look for foraminal stenosis which often caused by uncovertebral joint arthrosis
      • flexion and extension views
        • important to look for angular or translational instability
        • look for compensatory subluxation above or below the spondylotic/stiff segment
    • MRI
      • axial imaging is the modality of choice and gives needed information on the status of the soft tissues. It may show
        • disc degeneration
        • spinal cord changes (myelomalacia)
        • preoperative planning
      • has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis)
    • CT myelography
      • can give useful information on bony anatomy
      • most useful when combined with intrathecal injection of contrast (myelography) to see status of neural elements
      • contrast is given via C1-C2 puncture and allowed to diffuse caudally or given via a lumbar puncture and allowed to diffuse proximally by putting the patient in Trendelenburg position.
      • particularly useful in patients that can not have an MRI (pacemaker) or has artifact from hardware
    • Discography
      • controversial and rarely indicated in cervical spondylosis
      • approach is similar to that used with ACDF
      • risks include esophageal puncture and disc infection
  • Clinical Presentation
    • Axial neck pain
    • Cervical Radiculopathy
    • Cervical Myelopathy
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