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Introduction
  • Cervical spondylosis represents the natural degenerative process of the cervical motion segement (intervertebral disc and facets)
    • often leads to the clinical conditions of
      • cervical radiculopathy 
      • cervical myelopathy 
      • discogenic neck pain
  • Epidemiology
    • 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
  • Pathophysiology
    • pathoanatomy
      • see below
    • 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
    • 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 whe 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 sagital diameter (cord compression occurs with canal diameter is < 13mm)
    • incidence
      • radiographic findings often do not correlate with symptoms
        • 85% of patients >65 years of age demonstrate spondylotic changes regardless of symptomatology 
    • 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
Clinical Presentation
  • Axial neck pain
  • Cervical radiculopathy 
  • Cervical myelopathy 
 

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Questions (1)

(SBQ07.30) Prospective studies have shown professional athletes in which of the following sports have the highest incidence of degenerative changes in the cervical and lumbar spine? Review Topic

QID:1415
1

Horse racers (Jockeys)

65%

(1805/2794)

2

Badminton players

0%

(12/2794)

3

Hockey players

22%

(603/2794)

4

Volleyball players

3%

(92/2794)

5

Golfers

10%

(267/2794)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Professional horse racers (Jockeys) have the highest incidence of degenerative changes of both the cervical and lumbar spine when compared to age-matched, non-athletes.

There is significant risk of injury when working with horses. The most common acute injuries are extremity fractures from falls off of the horse. Chronic injuries are also well known with a high incidence of degenerative changes of the spine, most commonly in the cervical and lumbar spine.

Tsirikos et al. performed a prospective study analyzing the long-term effects of horse riding on the cervical and lumbar spine in jockeys. A 13-year clinical follow-up of the 32 jockeys revealed the following: 15 (47%) jockeys reported mild to severe limitations of physical activities as a consequence of progressive degenerative changes of the spine. Twenty-four (75%) jockeys had degenerative lesions on the cervical and/or lumbar spine radiographs compared to 6 (18%) in the control group.

Cowley et al. reviewed the workers compensation claims for injuries sustained by horse racing professionals. Of the 358 horse-related injuries sustained by jockeys, 270 (75%) were associated with falls from a horse. They showed that fractures were the most common injury, with the leg and shoulder being the most common sites. There was no comment about long-term chronic injuries.

Illustration A shows a schematic representation of the spinal degenerative process. From left to right there is progressive loss of disc height and osteophyte formation.

Incorrect Answers:
Answers 2,3,4,5: None of the sports listed have been shown to have higher rates of degenerative spine problems than jockeys. The sports most commonly cited as having the greatest strain on the spine include: horse-racing, wrestling, rugby, ski-jumping, and gymnastics.

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