Cervical Spondylosis

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Topic updated on 04/10/14 10:49pm
Introduction
  • Cervical spondylosis is defined as chronic disc degeneration and associated facet arthropathy that can lead to the following clinical conditions
    • cervical radiculopathy 
    • cervical myelopathy 
    • discogenic neck pain
  • Epidemiology
    • cervical spondylosis typically begins at age 40-50
    • most common levels are C5-6 > C6-7 because they are associated with the most flexion and extension in the subaxial spine
    • more common in men than women
  • Risk factors include
    • excessive driving
    • smoking
    • lifting
    • professional athletes  
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 dessication, loss of disc height, disc bulging, and possible disc hernaition
    • joint degeneration
      • uncinate spurring and facet arthrosis
    • ligamentous changes
      • ligamentum flavum thickening and infolding secodary 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
Mechanism of Neurologic Compression
  • Nerve root compression (radiculopathy) caused by
    • foraminal spondylotic changes
      • secondary to chondrosseous spurs of facet and uncovertebral joints
    • posterolateral disc herniation
      • between posterior edge of uncinate and lateral edge of PL
    • usually affects the nerve root below (C6/7 disease will affect the C7 nerve root)
  • Central cord compression (myelopathy)
    • occurs with canal diameter is < 13mm (normal is 17mm)
    • worse during neck extension whe central cord is pinched between
      • degenerative disc (anterior)
      • hypertrophic facets and infolded ligamentum (posterior)
    • in asians can be caused by ossification of the posterior longitudinal ligament
Evaluation
  • Radiographs
    • common radiographic findings include
      • degenerative changes of uncovertebral and facet joints
      • osteophyte formation
      • disc space narrowing
      • endplate sclerosis
      • decreased sagital diameter (cord compression occurs with canal diameter is < 13mm)
      • changes often do not correlate with symptoms
        • 70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays
    • lateral
      • important to look for sagital 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 given via C1-C2 puncture and allowed to diffuse caudally or given via a lumbar puncture and allowed to diffuse proximally by putting patient in trendelenburg position.
    • paricularly useful in patients that can not have an MRI (pacemaker) or has artifact (local hardware)
  • Discography
    • controversial and rarely indicated in cervical spondylosis
    • approach is similar to that used with ACDF
    • risks include esophageal puncture and disc infection
  • Nerve conduction studies
    • high false negative rate
    • may be useful to distinguish peripheral from central process (ALS)
Presentation and Treatment
  • Cervical radiculopathy 
  • Cervical myelopathy 

 

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