Cervical spondylosis

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Cervical spondylosis

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Cervical spondylosis is a disorder in which there is abnormal wear on the

cartilage and bones of the neck (cervical vertebrae).

See also:

• Neck pain
• Herniated disk
• Spinal stenosis

Causes

Cervical spondylosis is caused by chronic wearing away (degeneration) of the

cervical spine, including the cushions between the neck vertebrae (cervical disks)
and the joints between the bones of the cervical spine. There may be abnormal
growths or "spurs" on the bones of the spine (vertebrae).

These changes can, over time, press down on (compress) one or more of the
nerve roots. In advanced cases, the spinal cord becomes involved. This can
affect not just the arms, but the legs as well.

The major risk factor is aging. By age 60, most women and men show signs of
cervical spondylosis on x-ray. Other factors that can make a person more likely
to develop spondylosis are:

• Past neck injury (often several years before)

• Severe arthritis
• Past spine surgery
Symptoms

Symptoms often develop slowly over time, but may start suddenly.

More common symptoms are:

• Neck pain (may radiate to the arms or shoulder)

• Neck stiffness that gets worse over time
• Loss of sensation or abnormal sensations in the shoulders, arms, or
(rarely) legs
• Weakness of the arms or (rarely) legs
• Headaches, particularly in the back of the head

Less common symptoms are:

• Loss of balance
• Loss of control over the bladder or bowels (if spinal cord is compressed)

Exams and Tests

Examination often shows limited ability to bend the head toward the shoulder and
rotate the head.

Weakness or loss of sensation can be signs of damage to specific nerve roots or

to the spinal cord. Reflexes are often reduced.

The following tests may be done:

• CT scan or spine MRI

• Spine or neck x-ray
• EMG
• X-ray or CT scan after dye is injected into the spinal column (myelogram)

Treatment

Even if your neck pain does not go away completely, or it gets more painful at
times, learning to take care of your back at home and prevent repeat episodes of
your back pain can help you avoid surgery.

Symptoms from cervical spondylosis usually stabilize or get better with simple,
conservative therapy, including:

• Nonsteroidal anti-inflammatory medications (NSAIDs)

• Narcotic medicine or muscle relaxants
• Physical therapy to learn exercises to do at home
• Cortisone injections to specific areas of the spine
 • Various other medications to help with chronic pain, including phenytoin,
carbamazepine, or tricyclic antidepressants such as amitriptyline

If the pain does not respond to these measures, or there is a loss of movement
or feeling, surgery is considered. Surgery is done to relieve the pressure on the
nerves or the spinal cord.

CERVICAL SPONDYLITIS

Do's
§ Do regular exercise to maintain neck strength, flexibility and range of
motion.
§ Use firm mattress, thin pillow.
§ Do turn to one side while getting up from lying down position.
§ Wear a cervical collar during the day.
§ Regularly walk or engage in low-impact aerobic activity.
§ In order to avoid holding the head in the same position for long periods,
take break while driving, watching TV or working on a computer.
§ Use a seat belt when in a car and use firm collar while traveling.
§ When in acute pain take rest, immobilize the neck, and take medications
as directed.

Don'ts
§ Avoid sitting for prolonged period of time in stressful postures.
§ Avoid running and high-impact aerobics, if you have any neck pain.
§ Do not lift heavy weights on head or back.
§ Avoid bad roads, if traveling by two or four wheelers.
§ Do not drive for long hours; take breaks.
§ Avoid habit of holding the telephone on one shoulder and leaning at it for
long time.
§ Do not take many pillows below the neck and shoulder while sleeping.
§ Do not lie flat on your stomach.
§ In order to turn around, do not twist your neck or the body; instead turn
around by moving your feet first.
§ Do not undergo spinal manipulations if you are experiencing acute pain.
What are the bad postures that can worsen cervical spondylitis?

1. The head held forward from normal position

2. The shoulders held up and forward
3. The chest bent and rounded
4. The pelvic area tilted backwards
5. The hips, knees and ankles bent
 Neck pain is one of the most common problems that one encounters in day to day life. It is
probably as common as common cold. Cervical spondylosis may be caused by one or more of
several complaints. A very common mistake is to perceive the cause of illness as a singular
factor.Treating the patient for a single factor like a spur seen on X-ray or a slipped disc in the
neck seen on a myelogram or CT scan need not always completely alleviate the patient's
suffering. Many a time reference to a specialist also may not prove fruitful. Cervical Spondylosis
is more frequently seen in women than men.

Most people will experience neck pain at some point in their life. It is very important to attempt to
ascertain the facts that can cause it. A thorough knowledge of the structure and functioning
of the neck has become essential to understand and hence successfully treat cervical
spondylosis. There are several theories about why many people suffer neck pain. For most
people, no specific reason for cervical spondylosis can be found. Cervical Spondylosis can
come from a number of disorders and diseases of any structures in neck. Neck pain can be
caused by an injury, muscular problem or by trapped nerve between vertebrae.
Inappropriate working or sleeping posture can also be the cause. Biochemical engineering
has helped us to understand the dynamics of the functioning of the various joints of the
cervical spine and thus their role in production of the pain. Mobility of the spine is
dependent on several small joints, the derangement of the functioning of one of which, can
cause neck pain and reduced movements. It has also been possible to study the effects on
the spine of external influences like concussion, hypertension, hyper flexion, etc. Routine
activity like traveling, household work, office jobs though in themselves quite innocuous are
potential harbingers of serious damage to the neck which results in prolonged cervical
spondylosis. This will be explained later along with measures to avoid their deleterious
effects.
A knowledge
of such
aggravating
factors would
prove
beneficial and
ensure a
successful
therapy. and
thus helps
fighting this,
though
general
measures
should always
be taken to
avoid it.

With the
 L in k B a r 0

STRUCTURE AND FUNCTION OF CERVICAL SPINE

natomy

an cervical spine is an excellent example of engineering and

manship. its mechanism of functionaing is complex and boimechanics of
ovements are very gentle and graceful. The cervical spine is made up
ven seperate bones called vertebrae and the functioning of the spine
-operative effort of the vertebrae, In addittion, each vertebra has
wn functions to perform and hence the shape of each vertebra varies.

xample, the skull has to rotate to look at the back. To provide this
y movement; the joint between the skull and the top of the spine is
pivot joint. Similarly the spinous process of last cervical vertebra is
ongest and strongest because it has to anchor muscles and the ligaments
g from the head.

nterior strong and solid portion of each vertebra is known as its

Behind this the bone tends to be thinner and more delicate. It forms
rms on either side, embracing the spinal cord by forming a circle,
are known as laminae. A hard knob is formed at the meeting of two
ae behind known as the spinous process. This knob can be felt under
kin

oints

vertebra has at its back four joints, two on either side of the
ne, one above and one below. They are known as intervertebral joints.
e front, a disc of soft elastic but strong tissue of about 8mm
ness is interposed between two vertebrae. It is known as
vertebral disc and is made up of elastic fibres and is compressible.
ession of several disc can produce a smooth curved in half or one
of a circle.

unction Of The Spine

e animals, human beings walk on two legs. The spine is called upon to
mit weight of the body to the ground. The bodies of the vertebrae do
unction of transmission of weight. It is the law of physics that if
eight is transmitted alona a straight line the stress is maximum.
our spine is provided with curves so that it can last. In the
cal spine the convexity is at the level of disc between fifth and
cervical vertebrae.

cervical spine has a constant number of vertebrae i.e. seven.

ome people have long necks and some have very short necks. This is a
l configuration of each human being. broad shoulders make the neck
broader and shorter.

s been mentioned earlier that laminae coming from each side of the
bra surround the spinal cord and meet at the back.

aminae of consecutive vertebrae from the spinal canal protects the

from external injurious forces. During various movements of the neck
pinal cord is well protected.

roots come out from the spinal cord at each lever of the vertebrae on
ither side. At their exit from the canal the nerve roots must not be
essed or pinched during normal movements of the neck.

What is treatment for Cervical Spondylosis?

1.Medical
2.Physiotherapy
3.Relaxation
4.Ergonomics
5.Do's and Dont's

Medical Treatment

Usually Analgesics and muscle relaxants are advised . In more severe cases the
orthopaedic doctor may suggest cortisone injections near the joints of the vertebral bodies
to ease the swelling of the nerves and relieve pain.

Surgical Treatment

If the medical treatment and

physiotherapy fails, and the condition is severe, where the nerves are affected, surgery
may be required.. Decompression of the nerve is done to relieve the nerve which is
compressed by the bones and the disc.

Physiotherapy

The goal of physiotherapy treatment is to relieve pain, and enhance movements of the
neck.

Shortwave Diathermy - A disc or heating pad is placed over the back of the neck. The
warmth obtained from the shortwave diathermy current relaxes the muscle and the pain is
relieved.

Cervical Traction - Traction is a mechanical device, which supports the head and chin. It
is used to relieve the nerve compression by a bone.

Posture correction - Simple postural exercises can be taught to correct the faulty
position of the neck.

Motivation is given to maintain the erect posture:

Collars - Two types of collars can be prescribed:

Soft Collar - Soft collar is used during night times to prevent awkward position of the neck
during sleep.

Firm Collar - Firm collar steadies the neck and relieve pain, especially during traveling or
work. It is removed when the pain subsides.

Relaxation

Relaxation is essential part of treatment. Tension in neck and shoulder muscle, pain,
anxiety are all relieved by relaxation.

Relaxation can be done in two ways:

Physical Relaxation.

Mental Relaxation.

Physical Relaxation:

The whole body is relaxed by free suitable and comfortable positions, so that the muscles
are freed from tension and the pain is relieved. For eg., position of relaxation - when you
are lying flat on your back.
One pillow under the head

One cushion for the shoulder and

One under knees.

The pillow should be firm and thin

This position will allow relaxation for your body while lying down.

Relaxation while sitting.

The head, neck and shoulder are supported by high backed chair, with a small pillow at
lower back.

Feet supported on stool or low bench

Arm, resting on arm of chair or pillow

Ergonomics

Ergonomics concentrates on the architectural design of furnitures like desk, chairs, tables
etc. The design of the furniture should be such that it should support the body structure
without causing any undue strain to the muscles of the back and neck .

Do's and Dont's

If you are prone to cervical spondylosis, Avoid bad roads, if travelling by two or four
wheelers

Do not sit for prolonged period of time in stressful postures

Do use firm collars while traveling

Do not lift heavy weights on head or back

Do not turn from your body but turn your body moving your feet first

Do turn to one side while getting up from lying down

Do the exercises prescribed regularly

Do use firm mattress, thin pillow or butterfly shaped pillow

Do not lie flat on your stomach.

How is Cervical Spondylosis diagnosed?
What are the symptoms of Cervical Spondylosis?

Pain

Neck pain
Shoulder pain
Headache

Muscle tightness

The muscles covering the regions like back of neck shoulder , side of neck will be
stiff and painful.

Referred pain

There may be no pain felt over the neck but referred pain maybe present in arm,
elbow, thumb and fingers.

Limitation of movement

The neck movements are limited. Extending the neck up is difficult and restricted
due to pain and stiffness, but flexing the neck down is possible.

Loss of bladder and bowel control

In extremely severe cases, if the spinal cord is affected, there will be loss of
balance and also loss of bladder and bowel control.

Muscle weakness

The muscles responsible for maintaining the neck in erect position can become
weak.

Sensory loss

The bones of the neck applies pressure over the nerves passing through them and
can causes loss of sensation in the arm or fingers.

What are the causes of Cervical Spondylosis?

1.Injury
2.Bad posture
3.Occupational strain
4.Body type
5.Life style

Injury

cervical spondylosis can be caused by previous injury, repeated fractures or dislocations

of the joints of neck. These cause abnormal tear of joints, ligaments and the structures
surrounding the joints.

Bad posture

Incorrect posture adapted by habit or due to poor skeletal set up in the neck predisposes
abnormal tear of the neck joints.

What is bad posture that can cause cervical spondylosis ?

The head is held forwards from normal position.

The shoulders are held up and forward.

The chest is bent and rounded.

The pelvic area is tilted backwards.

The hips, knees and ankles are bent.

Occupational strain

The physical discomfort, which arises through an occupation is occupational stress. The
physical strain, intensity of work and duration of working hours all constitutes the
occupational strain.

Life style

The various styles of activity adapted in daily life can cause strain or tear of the structures
of the neck and lead to cervical spondylosis. An example is awkward positions adapted
while sleeping.

Body type

Body type also predisposes cervical spondylosis

- Thick necks with hump at the back

 - Long backs

These body types are more prone to cause strain or tear of the neck tisues.

Cervical Spondylosis
Post your experience
See others (298 there)
Cervical spondylosis is a 'wear and tear' of the vertebrae and discs in the
neck. It is a common cause of neck pain in older people. Symptoms tend
to wax and wane. Treatments include neck exercises and painkillers. In
severe cases, surgery may be an option.

What is the cervical spine?

The spine is made up of many bones called vertebrae. These are roughly circular
and between each vertebra is a 'disc'. The discs are made of strong 'rubber-like'
tissue which allows the spine to be fairly flexible. The cervical (neck) spine is the
upper part of the spine.

The spinal cord, which contains the nerves that come from the brain, is protected
by the spine. Nerves from the spinal cord come out from between the vertebrae
to take and receive messages to various parts of the body. The nerves coming
from the spinal cord in the cervical region go to the shoulder, neck, arm, and
upper chest.

Strong ligaments attach to the vertebrae. These give extra support and strength
to the spine. Various muscles also surround, and are attached to, various parts of
the spine. (The muscles and most ligaments are not shown in the diagram for
clarity.)
What is cervical spondylosis?

Cervical spondylosis is a cause of neck pain. It tends to develop after the age of
30, and becomes more common with increasing age. The underlying cause is the
age-related degeneration ('wear & tear') of the vertebrae and discs in the neck
region.

To an extent, we all develop a degree of degeneration in the vertebrae and discs

as we become older. However, cervical spondylosis is a term used if the degree
of degeneration is more severe, and causes more symptoms, than is expected
for a given age.

As the 'discs' degenerate, over many years they become thinner. Sometimes the
vertebrae develop small, rough areas of bone on their edges. The nearby
muscles, ligaments, and nerves may become irritated by these degenerative
changes which can cause troublesome symptoms.

What are the symptoms of cervical spondylosis

Symptoms can vary from mild to severe. You may have a flare up of symptoms if
you over-use your neck, or if you sprain a neck muscle or ligament. Symptoms
include:

• Pain in the neck. This may spread to the base of the skull and shoulders.
Movement of the neck may make the pain worse. The pain sometimes spreads
down an arm to a hand or fingers. This is caused by irritation of a nerve which
goes to the arm from the spinal cord in the neck. The pain tends to wax and wane
with flare-ups from time to time. However, some people develop chronic
(persistent) pain.
• Some neck stiffness, particularly after a night's rest.
• Headaches from time to time. The headaches often start at the back of the head
just above the neck and travel over the top to the forehead.
• Numbness, pins and needles or weakness may occur in part of the arm or hand.
Tell a doctor if these symptoms occur as they may indicate a problem with a
'trapped nerve'.

What are the treatments for cervical spondylosis?

Exercise your neck and keep active

Aim to keep your neck moving as normally as possible. As far as possible,
continue with normal activities. In the past, some people have worn a neck collar
for long periods when a flare-up of neck pain developed. It is now known that if
you wear a collar for long periods it may cause the neck to 'stiffen up'. Therefore,
try to keep your neck as active as possible.

Medicines
Painkillers are often helpful. You need only take them when symptoms flare-up.

• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg
tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than
paracetamol. They include ibuprofen which you can buy at pharmacies or get on
prescription. Other types such as diclofenac, naproxen, or tolfenamic need a
prescription. Some people with asthma, high blood pressure, kidney failure, or
heart failure may not be able to take anti-inflammatory painkillers.
 • A stronger painkiller such as codeine is an option if anti-inflammatories do not
suit or do not work well. Codeine is often taken in addition to paracetamol.
Constipation is a common side-effect from codeine. To prevent constipation, have
lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is sometimes prescribed for a few days
during a flare-up of pain if your neck muscles become tense and make the pain
worse.

Other advice

• A good posture may help. Brace your shoulders slightly backwards, and walk
'like a model'. Try not to stoop when you sit at a desk. Sit upright.
• A firm supporting pillow seems to help some people when sleeping.
• Physiotherapy. Therapies such as traction, heat, cold, manipulation, etc, may be
tried when you have a flare-up of pain. However, the evidence that these help is
not strong. What may be most helpful is the advice a physiotherapist can give on
neck exercises to do at home.

Treatment may vary and you should go back to see a doctor if:

• the pain becomes worse.

• numbness, weakness, or pins and needles develop in an arm or hand.

Other pain relieving techniques may be tried if the pain becomes chronic (persistent).
Chronic neck pain is also sometimes associated with anxiety and depression which may
also need to be treated.

In some cases, a nerve may become irritated, pressed on or 'trapped' which can
cause persistent severe pain or other symptoms in an arm such as muscle
weakness. In some cases special x-rays and scans may be advised to look for
the exact site of the problem. In some cases, surgery may be an option to relieve
the symptoms

Physiotherapy - Other Courses And Institutes

Physiotherapy means physiotherapeutic system of medicine which includes examination, treatment advice
and instructions to any person in connection with movement, dysfunction, bodily malfunction, physical
disorder, disability, healing and pain from trauma and disease.

The physiotherapists skill are required by the health care team in most disciplines of medicine including
surgery, neurology, orthopedics, gynecology, obstetrics, dermatology, ENT, cardiothoracic, vascular
surgery, pediatrics, rehabilitation and sports medicine, etc.

Purpose of physiotherapy :

The purpose of physiotherapy is to decrease body dysfunctions reduce pain caused either by trauma,
inflammation, degeneration, and surgery. The various conditions in which physiotherapy useful are as
 follows:

1) Management of a fracture and return to normal function is possible with simple methods of
physiotherapy. It allows for regain of full joint movements and muscles power after healing of a fracture.

2) In joints and soft tissue injury rapid repair of damaged tissue occurs with quick reduction of pain and
swelling.

3) Restoration of full joint movements with reduction of pain and deformity is possible various kinds of joint
diseases like osteoarthritis, rheumatoid, arthritis juvenile arthritis etc.

4) In degenerative disease of spine, physiotherapy arrests the progress of disease as in cervical

spondylosis. Suitable arthroses are also provided for giving support to spine. It also has a major role to play
congenital disease of spine like spina-bifida.

5) Chest physiotherapy has a vital role to play in medical and surgical conditions like bronchial asthma,
chronic obstructive lungs disease, pneumothorax but also surgical procedures involving spine, pelvis,
extremities and abdomen.

6) In hemiplegia or paraplegia physiotherapy greatly helps the patient to gradually increase his mobility.

7) In children physiotherapy is assuming real importance in children with cerebral palsy, spina-bifida,
clubfoot, muscular dystrophy etc.

8) It easies labour and return to normal after delivery. It is also useful in gynecological problems like
incontinence, prolepses of uterus, pelvis inflammatory disease.

9) Sort medicine- A physiotherapist is mandatory for any sport event. He maintains the fitness of sports
person and provide first aid in case of various sport injuries.

The aims of the physiotherapy education :

1. To produce the physiotherapists with basic knowledge and skill.

2. To enable them to recognize the disease, traumatic, physical and mental conditions affecting health.
3. Take steps to prevent such diseases.
4. To treat such diseases scientifically.
5. To be able to recognize and referred patients for the timely intervention of other healthcare professional
specialized in the area of investigation and skilled treatment.
6. Must be capable of under taking further study and advancing the knowledge and be able with further
training to undertake teaching, research and practice.

Scope of Physiotherapy :

Physical therapists practice in:

• Hospitals
• Nursing homes
• Residential homes/ Rehabilitation centers
• Private offices/Private practices/Private clinics
 • Out-patient clinics
• Community health care centers/ Primary health care centers
• Fitness centers/ Health clubs
• Occupational health centers
• Special schools
• Senior citizen centers
• Sports centers
• Teaching
• Foreign countries
• Companies
• N.G.O
• Public settings( e.g. shopping malls)

Courses : 1) Bachelor of physiotherapy/ B.Sc. (Hons.) physical therapy duration:- 4 and 1 /2 year
(including Internship) Eligibility for admission: - Inter Science with Biology with 50% marks.Process of
admission: Through entrance test. Entrance test will be held in April or May.Age: not less than 17 years.

2) Master in physiotherapy (M.P.T) Duration: 2 years , Eligibility: B.P.T. (4 and 1/2year) Speciality:
Neurology, Orthopedic/ Musculoskeletal, Sports, Cardiothroacic and Rehabilitation. Commencement of the
course: The course will commence from the 1st April, every year.

Background
Cervical spondylosis is a common degenerative condition of the cervical spine. It is
most likely caused by age-related changes in the intervertebral disks. Clinically,
several syndromes, both overlapping and distinct, are seen. These include neck and
shoulder pain, suboccipital pain and headache, radicular symptoms, and cervical
spondylotic myelopathy (CSM). As disk degeneration occurs, mechanical stresses
result in osteophytic bars, which form along the ventral aspect of the spinal canal.
Frequently, associated degenerative changes in the facet joints, hypertrophy of the
ligamentum flavum, and ossification of the posterior longitudinal ligament occur. All
can contribute to impingement on pain-sensitive structures (eg, nerves, spinal cord),
thus creating various clinical syndromes. Spondylotic changes are often observed in
the aging population. However, only a small percentage of patients with radiographic
evidence of cervical spondylosis are symptomatic.

Treatment is usually conservative in nature; the most commonly used treatments are
nonsteroidal anti-inflammatory drugs (NSAIDs), physical modalities, and lifestyle
modifications. Surgery is occasionally performed. Many of the treatment modalities
for cervical spondylosis have not been subjected to rigorous, controlled trials.
Surgery is advocated for cervical radiculopathy in patients who have intractable pain,
progressive symptoms, or weakness that fails to improve with conservative therapy.
Surgical indications for cervical spondylotic myelopathy remain somewhat
controversial, but most clinicians recommend operative therapy over conservative
therapy for moderate-to-severe myelopathy.
A 48-year-old man presented with neck pain and predominantly left-sided radicular
symptoms in the arm. The patient's symptoms resolved with conservative therapy.
T2-weighted sagittal MRI shows ventral osteophytosis, most prominent between C4
and C7, with reduction of the ventral cerebrospinal fluid sleeve.

Pathophysiology
Cervical spondylosis is the result of disk degeneration. As disks age, they fragment,
lose water, and collapse. Initially, this starts in the nucleus pulposus. This results in
the central annular lamellae buckling inward while the external concentric bands of
the annulus fibrosis bulge outward. This causes increased mechanical stress at the
cartilaginous end plates at the vertebral body lip.

Subperiosteal bone formation occurs next, forming osteophytic bars that extend
along the ventral aspect of the spinal canal and, in some cases, encroach on
nervous tissue.1,2 These most likely stabilize adjacent vertebrae, which are
hypermobile as a result of the lost disk material.3,4 In addition, hypertrophy of the
uncinate process occurs, often encroaching on the ventrolateral portion of the
intervertebral foramina.1 Nerve root irritation also may occur as intervertebral discal
proteoglycans are degraded.5

Ossification of the posterior longitudinal ligament, a condition often seen in certain

Asian populations, can occur with cervical spondylosis. This condition can be an
additional contributing source of severe anterior cord compression.6

Cervical spondylotic myelopathy occurs as a result of several important

pathophysiological factors. These are static-mechanical, dynamic-mechanical, spinal
cord ischemia, and stretch-associated injury. As ventral osteophytes develop, the
cervical cord space becomes narrowed; thus, patients with congenitally narrowed
spinal canals (10-13 mm) are predisposed to developing cervical spondylotic
myelopathy.

Age-related hypertrophy of the ligamentum flavum and thickening of bone may result
in further narrowing of the cord space.2,7,8 Additionally, degenerative kyphosis and
subluxation are fairly common findings that may further contribute to cord
compression in patients with cervical spondylotic myelopathy.6,9 Dynamic factors
relate to the fact that normal flexion and extension of the cord may aggravate spinal
cord damage initiated by static compression of the cord. During flexion, the spinal
cord lengthens, resulting in it being stretched over ventral osteophytic bars. During
extension, the ligamentum flavum may buckle into the cord, pinching the cord
between the ligaments and the anterior osteophytes.7,10

Spinal cord ischemia also most likely plays a role in cervical spondylotic myelopathy.
Histopathologic changes seen in persons with cervical spondylotic myelopathy
frequently involve gray matter, with minimal white matter involvement—a pattern
consistent with ischemic insult. Ischemia most likely occurs at the level of impaired
microcirculation.11
Stretch-associated injury has recently been implicated as a pathophysiologic factor
in cervical spondylotic myelopathy.12 The narrowing of the spinal canal and abnormal
motion seen with cervical spondylotic myelopathy may result in increased strain and
shear forces, which can cause localized axonal injury to the cord.

Frequency
International

Cervical spondylotic myelopathy is the most common cause of nontraumatic spastic

paraparesis and quadriparesis. In one report, 23.6% of patients presenting with
nontraumatic myelopathic symptoms had cervical spondylotic myelopathy.13

Mortality/Morbidity
See Background, Pathophysiology, and History.

Race
Cervical spondylosis may affect males earlier than females, but this is not true in all
studied populations.

Sex
Irvine et al defined the prevalence of cervical spondylotic myelopathy using
radiographic evidence. In males, the prevalence was 13% in the third decade,
increasing to nearly 100% by age 70 years. In females, the prevalence ranged from
5% in the fourth decade to 96% in women older than 70 years. Another study
examined patients at autopsy. At age 60 years, half the men and one third of the
women had significant disease.14 A 1992 study noted that spondylotic changes are
most common in persons older than 40 years. Eventually, greater than 70% of men
and women are affected, but the radiographic changes are more severe in men than
in women.15

Age
See Sex.

Clinical

History
The various clinical syndromes seen with cervical spondylosis manifest quite
differently.

• Intermittent neck and shoulder pain, or cervicalgia, is the most common

syndrome seen in clinical practice.2 This can be a frustrating problem for
physicians and patients because often the patient has no associated
neurologic signs. When neurologic deficits are present, diagnostic imaging
can often help define the cause. When they are not present, however,
imaging findings are not usually helpful because the incidence of radiologic
 abnormalities is quite high in persons in this age group, even in asymptomatic
patients.
o A large part of the problem is that the source of pain in this situation is
poorly understood. This syndrome is possibly related to compression
of the sinovertebral nerves and the medial branches of the dorsal rami
in the cervical region.16
o The neck pain experienced with cervical spondylosis is often
accompanied by stiffness, with radiation into the shoulders or occiput,
that may be chronic or episodic with long periods of remission.2
o One third of patients with cervicalgia due to cervical spondylosis
present with headache, and greater than two thirds present with
unilateral or bilateral shoulder pain. A significant amount of these
patients also present with arm, forearm, and/or hand pain.16
• Another poorly understood clinical syndrome seen with cervical spondylosis is
chronic suboccipital headache. Although the C1 thru C3 dermatomes are
represented on the head and it would seem likely that occipitoatlantal and
atlantoaxial degeneration would cause pain in these areas, no contributions
to these joints occur from the dorsal rami of C1-C3. In addition, the greater
occipital nerve cannot usually be compressed by bony structures.
Regardless, headaches can be the dominant symptom in a patient with
degenerative cervical disease. The headaches are usually suboccipital and
may radiate to the base of the neck and the vertex of the skull.16
• Perhaps more thoroughly understood than the above-discussed syndromes is
radiculopathy associated with cervical spondylosis. The most commonly
involved nerve roots are the sixth and seventh nerve roots, which are caused
by C5-C6 or C6-C7 spondylosis, respectively. Patients usually present with
pain, paresthesias or weakness, or a combination of these symptoms. The
vast majority of these patients present without a history of trauma or other
recalled precipitated cause. The pain is usually in the cervical region, the
upper limb, shoulder, and/or interscapular region. At times, the pain may be
atypical and manifest as chest pain (pseudoangina) or breast pain. Usually,
the pain is more frequent in the upper limbs than in the neck, although it is
frequently present in both areas.17 Cervical radiculopathy is not usually
associated with myelopathy.2
• Cervical spondylotic myelopathy is the most common cause of nontraumatic
paraparesis and tetraparesis. The process usually develops insidiously.
o In the early stages, patients often present with neck stiffness. Patients
also may present with stabbing pain in the preaxial or postaxial border
of the arms.10 Patients with a high compressive myelopathy (C3-C5)
can present with a syndrome of "numb, clumsy hands," for which the
patient describes difficulty writing, a loss of manual dexterity,
nonspecific and diffuse weakness, and abnormal sensations.2 Those
patients with a lower myelopathy typically present with a syndrome of
weakness, stiffness, and proprioceptive loss in the legs. These
patients often exhibit signs of spasticity.
o Weakness or clumsiness of the hands may be seen in conjunction with
weakness in the legs. Motor loss in the hands with relative sparing of
 the legs, however, is a relatively rare syndrome. Symptoms are
commonly asymmetric in the legs.
o Loss of sphincter control and urinary incontinence are rare; some
patients, however, report urinary urgency, frequency, and/or
hesitancy.2,10
o Cervical spondylotic myelopathy significantly affects patients' quality of
life. A recent study reported that greater than one third of patients with
cervical spondylotic myelopathy have anxious or depressed moods
related to their decreased mobility.18
• Another syndrome that may be seen in relation to cervical spondylosis is
central cord syndrome. This syndrome typically occurs when an elderly
patient experiences an acute hyperextension injury with preexisting acquired
stenosis due to ventral osteophytes and infolding of redundant ligamentum
flavum, resulting in acute cord compression. Patients usually present with a
history of a blow to the forehead. The syndrome consists of greater upper
extremity weakness than lower extremity weakness, varying degrees of
sensory disturbances below the lesion, and myelopathic findings such as
spasticity and urinary retention.19
• Rarely, dysphagia or airway dysfunction has been reported secondary to
cervical spondylosis.20,21,22,23,24 Dysphagia may occur when large anterior
osteophytes cause mechanical compression of the esophagus or
periesophageal inflammation causes motion over the osteophytes.
Conservative therapy with anti-inflammatory medications and other modalities
has been advocated for mild-to-moderate cases of dysphagia, while surgery
has been reserved for more severe cases.22

Physical

• Examination findings include neck pain, radicular signs, and myelopathic

signs. Patients with neck pain from spondylosis often present with neck
stiffness. This is a nonspecific sign, and other causes of neck pain and
stiffness (eg, myofascial pain, intrinsic shoulder pathology) must be
considered and excluded.
• If the history is compatible with cervical radiculopathy, carefully search for
signs of muscle atrophy in the supraspinatus, infraspinatus, deltoid, triceps,
and first dorsal interosseus muscles.
• Winging of the scapula also may be present because it can occur with C6 or
C7 radiculopathy. Palpate all muscles because this may allow earlier
detection of wasting than visualization can provide. If weakness is detected in
either 1 myotomal distribution or 2-3 peripheral nerves, peripheral nerve injury
can likely be excluded as the cause. Muscle testing is important because
muscle findings have more specificity than sensory or reflex findings.
• Perform a detailed sensory and reflex examination in every patient who
presents with a history suggestive of cervical spondylosis. Note that radicular
findings often do not adhere strictly to textbook dermatomal charts. Patients
often experience more pain proximally in their limbs, while, distally,
paresthesias dominate.
• Look for physical evidence of other causes of radiculopathy-type symptoms
(eg, tenderness lateral to the neck in the supraclavicular fossa, Tinel sign).
• The neck compression test (Spurling test or sign), if positive, is useful when
assessing a patient for cervical radiculopathy.
o This test is best performed by having the patient actively extend his or
her neck, laterally flex, and rotate to the side of the pain while sitting.
Next, use careful compression by slight axial loading. This maneuver
works by narrowing the ipsilateral neural foramina during flexion and
rotation, while the initial extension causes posterior disk bulging.
o While this maneuver has a low sensitivity for cervical radiculopathy, it
has a specificity of nearly 100%. Other useful tests are the axial
manual traction test and the shoulder abduction test.
• In cervical spondylotic myelopathy, the most typical examination findings are
suggestive of upper motor dysfunction, including hyperactive deep tendon
reflexes, ankle and/or patellar clonus, spasticity (especially of the lower
extremities), the Babinski sign, and the Hoffman sign.
o The Hoffman sign is a reflex contraction of the thumb and index finger
after nipping the middle finger. Although this sign is usually present
with corticospinal tract dysfunction, unlike the Babinski sign, it can also
be present in generalized hyperreflexic states and in neurosis. It also
may be found (usually bilaterally and incomplete) in persons without
cervical spondylotic myelopathy.
o Thus, this sign is only valuable if it is associated with other upper
motor neuron–related findings. The Hoffman sign is best elicited by
positioning the patient's hand at rest and then stabilizing the proximal
phalanx between the examiner's index and middle finger; with the
examiner's thumb, the patient's distal middle finger is flicked
downward. The sensitivity of this examination maneuver may be
increased by examining the patient during multiple full flexions or
extensions of the neck (dynamic Hoffman sign).
• Another occasionally useful test is the pectoralis muscle reflex.
o This is elicited by tapping the pectoralis tendon in the deltopectoral
groove, which causes adduction and internal rotation of the shoulder if
hyperactivity is present. A positive result suggests compression in the
upper cervical spine (C2-C4).
o If the patient exhibits diffuse hyperreflexia, then the jaw jerk may
distinguish an upper cervical cord compression from lesions that are
above the foramen magnum.
• In patients with cervical spondylotic myelopathy, weakness is most commonly
seen in the triceps and/or hand intrinsic muscles, where upper extremity
symptoms typically begin. Wasting of the intrinsic hand musculature is also a
typical finding.
o A thorough examination of patients' hands should be performed. By
having the patient make a fist and release it 20 times in 10 seconds,
impairment or clumsiness may be observed that may suggest cervical
spondylotic myelopathy.
 o The finger escape sign may also be present. To assess this, the
patient holds his or her fingers extended and adducted. If the ulnar
digits drift into abduction and flexion within 30-60 seconds, cervical
spondylotic myelopathy may be present.
• A classic finding with examination of the lower extremities is proximal motor
weakness, most commonly in the iliopsoas, followed by the quadriceps
femoris; distal weakness is a less common finding. The finding of lower
extremity weakness and lower extremity upper motor neuron signs but absent
upper extremity symptoms and signs should trigger a workup for thoracic cord
pathology.
• Examine gait during any neurologic examination whenever possible. Patients
with cervical spondylotic myelopathy typically exhibit a stiff or spastic gait,
especially later in the course of their disease.
• Another helpful sign is the Lhermitte sign.
o This consists of electric shock–like sensations that run down the
center of the patient's back and shoot into the limbs during flexion of
the neck.
o This sign is not specific for cervical spondylotic myelopathy and
classically is attributed to posterior column dysfunction. Other causes
of the Lhermitte sign include multiple sclerosis, tumors, and other
compressive pathology.
• Sensory abnormalities in cervical spondylotic myelopathy have a variable
pattern upon examination.
o Loss of vibratory sense or proprioception in the extremities can occur,
particularly in the feet. Spinothalamic sensory loss may be
asymmetric.
o Diabetes mellitus or other metabolic causes of peripheral neuropathy
can confound the sensory examination. Perform a complete motor
examination. Wasting of the intrinsic hand musculature is a classic
finding in persons with cervical spondylotic myelopathy.

Causes
In addition to age and possibly sex, several risk factors have been proposed for
cervical spondylosis.

o Repeated occupational trauma (eg, carrying axial loads, professional

dancing, gymnastics) may contribute. The role of occupational trauma is
controversial, especially in terms of worker's compensation claims and other
related medicolegal clauses.
o Familial cases have been reported; a genetic cause is possible.
o Smoking also may be a risk factor.
o Conditions that contribute to segmental instability and excessive segmental
motion (eg, congenitally fused spine, cerebral palsy, Down syndrome) may be
risk factors for spondylotic disease. Cervical spondylotic myelopathy may be
responsible for functional declines in patients with athetoid cerebral palsy.
Differential Diagnoses
Amyotrophic Lateral Sclerosis Migraine Variants
Ankylosing Spondylitis Multiple Sclerosis
Arteriovenous Malformations Muscle Contraction Tension Headache
Brainstem Gliomas Polyarteritis Nodosa
Cluster Headache Radial Mononeuropathy
Diabetic Neuropathy Reflex Sympathetic Dystrophy
Median Neuropathy Subarachnoid Hemorrhage
Meningioma Syringomyelia
Metastatic Disease to the Brain Thoracic Outlet Syndrome
Metastatic Disease to the Spine and Related Structures Torticollis
Migraine Headache
Migraine Headache: Neuro-Ophthalmic Perspective
Other Problems to Be Considered
Acromioclavicular pathology
Acute posterior cervical strain
Adhesive capsulitis
Aortic disease
Arachnoiditis
Arteriovenous malformation
Back pain
Bicipital tendonitis - Rotator cuff tears, lateral epicondylitis
Brainstem syndromes
Calcareous tendonitis
Cervical disk syndromes
Cervical lymphadenitis
Cervical rib
Congenital spinal lesion
Diskitis
Double crush syndrome
Epidural abscess
Extrinsic neoplasia (usually metastatic)
Fibrositis syndromes
Frozen shoulder syndromes
Gallbladder disease
Glenohumeral arthritis
Gout (infrequently)
Heart disease
Hyperabduction syndrome
Intervertebral osteoarthritis
Idiopathic brachial plexopathy (neuralgic amyotrophy)
Intrinsic neoplasia
Lung disease
Meningitis
Musculoligamentous injuries to the neck and shoulder
Neoplasms
Neoplasms of the shoulder
Nerve injuries
Occipital neuralgia
Osteomyelitis
Osteoarthritis of apophyseal joints
Paget disease
Pancoast tumor
Pancreatic disease
Peptic ulcer disease
Pharyngeal infections
Posttraumatic facet fracture with narrowing of the foramen
Postural disorders
Psychogenic disorders
Rheumatic fever (infrequently)
Rheumatoid arthritis
Rib-clavicle compression
Rotator cuff tears and tendonitis
Scalene muscle
Septic arthritis
Spinal cord tumors
Sternocleidomastoid tendinitis
Subacromial bursitis
Synovial cysts
Tabes dorsalis
Thoracic disk
Thoracic outlet syndrome
Tropical spastic paraparesis

Workup

Laboratory Studies
Cyanocobalamin (vitamin B-12) levels and a serum rapid plasma reagin may help
distinguish metabolic and infectious causes of myelopathy from cervical spondylotic
myelopathy. Metabolic and infectious conditions may coexist with cervical
spondylosis, and, thus, an abnormal laboratory profile does not exclude cervical
spondylotic myelopathy.

Imaging Studies

• Although plain films of the cervical spine are the least costly and most widely
available imaging modality, the imaging study of choice is MRI.
• Although a narrow spinal canal with a sagittal diameter of 10-13 mm (as
visualized on a plain radiograph) has been associated with a higher incidence
of neurologic deficit and cervical spondylotic myelopathy, this measurement
has become less important with the widespread availability of MRI. MRI
 allows direct visualization of neural structures and allows a more accurate
estimation of the cord space.
• Plain radiography can help assess the contribution of spinal alignment and
degenerative spondylolisthesis to canal stenosis.
• MRI is a noninvasive and radiation-free procedure that provides excellent
imaging of the spinal cord and subarachnoid space and is a sensitive method
for determining involvement of these by extradural pathology.
o MRI allows multiplanar imaging, excellent imaging of the neural
elements, and increased accuracy in diagnosing intrinsic cord disease.
o It may detect pathology in the asymptomatic patient, or the pathology
may be unrelated to the symptoms. In one report, 57% of patients who
were older than 64 years had disk bulging and 26% of patients in this
age group had evidence of cord compression on MRIs.25
o Some spondylotic changes (eg, small lateral osteophytes, midbody
calcific densities) may be overlooked by MRI.
• Overall, the advantages of MRI significantly outweigh its deficiencies, and
thus it has become the standard diagnostic study for spondylotic disease.
o It has been demonstrated to be an accurate imaging modality in
several studies.
o When surgical results were used as the criterion standard, agreement
with MRI findings was found in 74% of cases, agreement with CT
myelography in 84% of cases, and with myelography in 67% of cases.
o In one study, MRI was demonstrated to be 90% sensitive for the
diagnosis of cervical stenosis, while CT myelography and CT scanning
were 100% sensitive.26
• Plain films of the cervical spine are an inexpensive way of assessing
spondylotic disease in symptomatic patients.
o Cervical spine films can demonstrate disk-space narrowing,
osteophytosis, loss of cervical lordosis, uncovertebral joint
hypertrophy, apophyseal joint osteoarthritis, and vertebral canal
diameter.
o The nearly universal presence of spondylotic radiographic changes in
elderly patients (and the similar appearance of a cervical spine film in
a symptomatic patient and an asymptomatic patient) allows the
classification of an individual patient as having mild, moderate, or
severe spondylotic changes.
• CT scanning is another important imaging modality. Superior to MRI in its
definition of bony anatomy, CT scanning better defines the neural foramina.
CT scanning is often used to complement MRI and to provide additional bony
detail to characterize a lesion responsible for neural encroachment.
• Myelography is also useful for demonstrating nerve root lesions. Myelography
demonstrates nerve root take off very well.27 It is particularly useful in patients
under going reoperation.
o Some authors, however, report that CT myelography has a lower rate
of false-positive results compared with conventional myelography.
Some researchers have concluded that CT myelography provides
additional data only when myelography results are positive—negative
 myelography findings followed by CT scanning in the case of
suspected spondylosis is unlikely to show any clinically useful
findings.28
o Recently, dynamic CT myelography has been reported as useful in the
surgical planning for patients with cervical spondylotic myelopathy, in
some cases altering the surgeon's approach on the basis of dynamic
findings.29
o Nevertheless, the exact role for dynamic imaging such as dynamic CT
myelography and dynamic MRI remains to be determined.

Other Tests

• Electrodiagnostic studies are useful in many patients.

o Electromyography (EMG) can help diagnose cervical radiculopathy
and, occasionally, identify cervical spondylotic myelopathy.
o EMG is useful in the study of radiculopathy because it demonstrates a
close correlation with neuroimaging and operative findings.
o It also provides an anatomic distribution of abnormalities, thus
facilitating the differential of cervical radiculopathy from other similar
causes of radicular symptoms.
o EMG can help determine how long a lesion has been present. When
using modern imaging techniques such as MRI, EMG can help clarify
whether a lesion observed on imaging is the cause of nerve root
pathology.
o In a patient with cervical spondylotic myelopathy, EMG can exclude
specific syndromes of peripheral neuropathy rather than confirm
cervical spondylotic myelopathy.
• Somatosensory evoked potentials and cortical motor evoked potentials also
may help evaluate spinal cord dysfunction, especially in timing intervention for
the asymptomatic or minimally symptomatic patient with early cervical
spondylotic myelopathy.

Histologic Findings
Histologic findings associated with cervical spondylotic myelopathy are greatest at
the site of maximal compression. Changes in the gray matter range from consistent
motor-neuron loss and ischemic changes in surviving neurons to necrosis and
cavitation. Frequently, involvement of white matter is minimal, although it varies in
degree. White matter changes, when they occur, are generally seen in the ventral
inner portion of the dorsal column or in the lateral columns bordering the gray matter,
with the anterior columns being only slightly damaged. Nongliotic necrosis is
frequently described. Wallerian degeneration of posterior columns cephalad to the
site of compression and of corticospinal tracts caudal to site of compression is
frequent. Widespread proliferation of small, thickened, and hyalinized intermedullary
blood vessels is frequently reported.

Many of these findings are similar to a pathological model of vascular occlusion.

Extensive infarction of gray and white matter is associated with anteroposterior
compression ratios of less than 20%.11,7 Based on a cadaveric study, the critical
degree of anteroposterior compression necessary to induce histopathologic changes
in the spinal cord has been suggested to be 30%.30

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eMedicine Specialties > Neurology > Headache and Pain

Cervical Spondylosis, Diagnosis and Management: Treatment & Medication
Author: Sandeep S Rana, MD, Clinical Associate Professor of Neurology, Drexel
University College of Medicine
Contributor Information and Disclosures
Updated: Aug 14, 2009
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Overview
Differential Diagnoses & Workup
Treatment & Medication
Follow-up
Multimedia
References
Keywords
 Treatment
Medical Care
A brief discussion of the natural history of symptomatic cervical spondylosis is necessary
before discussing therapeutic intervention.
Cervical radiculopathy usually resolves without intervention. The long-term prognosis in
cervical spondylotic myelopathy is less clear. Some patients experience a progressive
decline, while most have long periods of stability of symptoms with intermittent
exacerbations.
One study noted that 79% of patients with neck pain and/or referred pain syndromes and
cervical spondylosis improved or became asymptomatic by the 15-year follow-up
point.31 Medical treatments for cervical spondylosis include neck immobilization,
pharmacologic treatments, lifestyle modifications, and physical modalities (eg, traction,
manipulation, exercises). No carefully controlled trials have compared these modalities;
therefore, these therapies are often initiated based on a clinician's preference or specialty.
Comparing the efficacy of these treatments against no treatment is difficult.
Neck immobilization (with a soft collar, Philadelphia collar, rigid orthoses, Minerva
jacket, or a molded cervical pillow for support) is a common, nonoperative treatment for
neck pain and/or suboccipital pain syndromes caused by spondylosis and cervical
radiculopathy.
Despite widespread use, soft collars are largely believed to work by placebo effect
because they do not appreciably limit motion of the cervical spine. They have not been
demonstrated to change long-term outcomes. If worn properly, a soft collar maintains
relative flexion. The collar should be worn as long as possible during the day. However,
patient comfort is key.
As symptoms improve, the collar can be worn only during strenuous activity. Eventually,
it can be discontinued. More rigid collars and devices may better limit motion of the
cervical spine, but they may reduce muscle tone and cause neck stiffness from disuse.
Implement a daily cervical exercise program to limit loss of muscle tone.
Pharmacologic treatment includes several options.
NSAIDs are the mainstay of pharmacologic treatment. They are effective in reducing the
biologic effects of inflammation and pain. Their use should be monitored for adverse
effects such as gastropathy, renal toxicity, hypertension, liver abnormalities, and
bleeding. Selective inhibitors of cyclooxygenase-2 (COX-2) such as celecoxib can lower
the risk of gastrointestinal toxicity, but recent studies have raised concerns of the
association of this class of drugs with higher cardiovascular events, particularly at higher
doses.
Patients who experience more chronic pain symptoms may benefit from tricyclic
antidepressants (TCAs). Common side effects include dry mouth, sedation, urinary
retention, constipation, and cardiac conduction blocks.
Muscle relaxants such as carisoprodol and cyclobenzaprine may also be beneficial in
patients with a spasm in the neck muscles (which can be related to spondylotic changes).
Opioids could be considered in patients who have moderate-to-severe pain due to
significant structural spondylosis, whose who are poor surgical candidates, and those who
have failed nonopioid agents. For patients who are at risk for NSAID toxicity,
particularly the geriatric population, opioids are reasonable alternatives.32 However,
opioids should be avoided if there is history of substance abuse or mood disorder.
Steroid use is controversial. In some patients with severe radiculopathy, a high-dose oral
steroid taper may rapidly reduce pain and shorten the course of symptoms. Some patients
with progressive cervical spondylotic myelopathy also may benefit. Epidural steroid
injections may help patients with radicular symptoms. Patients who present within 8
hours of an acute central cord injury (which can be caused partly by ventral osteophytes)
may benefit from high doses of methylprednisolone.
No placebo controlled trials have studied gabapentin in cervical spondylosis, but based
on its efficacy in controlling neuropathic pain, it is often being used off label for chronic
pain associated with cervical spondylosis.
Lifestyle modifications (eg, neck schools, instruction in body mechanics, relaxation
techniques, postural awareness, ergonomics and/or workplace modifications) may
alleviate symptoms.
Neck school is a form of small group therapy that provides techniques to patients who are
willing to actively work toward recovery. It may be of limited clinical value.
Instruction in body mechanics focuses on low-load concepts. These include avoiding
forward bending and rotation of the neck, avoiding prolonged extension of the neck,
avoiding prolonged sitting or standing, and selecting the proper chair.
Workplace modifications and ergonomics serve to reduce strenuous neck positions during
work and leisure.
Physical modalities are among the oldest treatments used for spine-related disorders.
Cervical mechanical traction, commonly used for cervical radiculopathy, in addition to
cervical joint distraction, may loosen adhesions within the dural sleeves, reduce
compression and irritation of discs, and improve circulation within the epidural space.
Studies regarding its efficacy are conflicting, with intermittent traction probably being
more effective than static traction. Initially, a weight of 10 lb is recommended, eventually
increasing to 20 lb as tolerated.
It can be used at home 2-3 times daily for 15 minutes at a time. It is contraindicated in
patients who have myelopathy, a positive Lhermitte sign, or rheumatoid arthritis with
atlantoaxial subluxation. A retrospective study found that cervical traction provided
symptomatic relief in 81% of the patients with mild-to-moderately severe cervical
spondylosis syndromes.33
Manipulation, most commonly practiced by chiropractors and osteopathic physicians,
was described as early as 4000 years ago. It remains a popular treatment for back pain.
Techniques vary and include low-velocity, high-amplitude manipulation; high-velocity,
low-amplitude manipulation (eg, thrusting or impulse manipulation); and nonthrusting
maneuvers. Studies have reported conflicting results, and few well-controlled studies
specifically concerning the treatment of cervical spondylosis symptoms have been
published.
Contraindications to cervical manipulation include vertebral fractures, dislocations,
infections, malignancy, spondylolisthesis, myelopathy, various rheumatologic and
connective-tissue disorders, and the presence of objective signs of nerve root
compromise. The most feared complication of cervical manipulation, vertebrobasilar
artery dissection, is rare and almost impossible to predict despite multiple proposed risk
factors.
Exercises designed for cervical pain include isometric neck strengthening routines, neck
and shoulder stretching and flexibility exercises, back strengthening exercises, and
aerobic exercises. Controlled trials regarding the efficacy of these routines are lacking.
Other commonly used modalities for pain include heat, cold, acupuncture, massage,
trigger-point injection, transcutaneous electrical nerve stimulation, and low-power cold
laser. Most of the passive modalities used for degenerative disease of the cervical spine
are performed by physical therapists and are most efficacious in combination.
Surgical Care
Surgical care for cervical spondylosis involves anatomic correction of the degenerative
pathologic entities that compress a nerve root or the spinal cord.
Indications for surgery include intractable pain, progressive neurologic deficits, and
documented compression of nerve roots or of the spinal cord that leads to progressive
symptoms. Surgery has not been proven to help neck pain and/or suboccipital pain.
Several approaches to the cervical spine have been proposed. The approach selected is
determined based on the type and location of pathology and the surgeon's preference.
Cervical radiculopathy traditionally has been approached either via the anterior approach,
which was first described by Robinson and Smith in 1955, or the posterolateral approach,
during which a "keyhole" foraminotomy is performed.
The anterior approach allows excellent access to midline disease and visualization of
pathology without manipulation of neural elements. Robinson and Smith proposed that
the anterior approach coupled with fusion using an iliac crest bone graft (autograft)
arrests progressive spondylotic spurring, causes existing osteophytes to eventually regress
as a result of spinal stability promoted by fusion, decompresses and enlarges the neural
foramen and spinal canal by the distraction of the disk space, and minimizes surgical
manipulation of the contents of the spinal canal, thereby minimizing complications
More recently, use of allografts, which could be in form of bone graft obtained from
cadavers, or ventral cervical plating have become more popular as they eliminate
morbidity of harvesting the graft.34 Success of fusion is higher with autografts due to the
presence of endogenous morphogenetic proteins that are present in the harvested bones
and help with osteoinduction. Research is being performed on the use of recombinant
human morphogenetic proteins to improve success of fusion with allografts.35
When performed with fusion, anterior cervical diskectomy (ACD) yields good-to-
excellent results in almost 90% of patients when no other level of spondylosis is present.
When adjacent levels of spondylosis were demonstrated, only 60% of patients had good-
to-excellent results.
ACD without fusion has been used based on the nonexistent correlation between
successful fusion and clinical outcome and the significant incidence of pseudoarthrosis
following ACD and fusion (10-20%). The advantage of this procedure is the lack of bone
graft–related complications and decreased manipulation and dissection of the cervical
tissues. Patients who do not undergo fusion often report a shorter postoperative hospital
stay and an earlier return to daily activities.
ACD without fusion almost inevitably is followed by disk-space collapse. This procedure
does not accomplish disk-space distraction and does not mechanically open the neural
foramina. It does not promote stabilization of the motion segment to promote resorption
of osteophytes. As a result, most surgeons choose ACD with fusion for patients with
cervical radiculopathy when taking an anterior surgical approach. Instability of the
cervical spine is rarely reported following ACD with or without fusion, but the incidence
of postoperative neck pain is higher without fusion.
The posterolateral approach to cervical radiculopathy has similar results to the anterior
approach when used for the proper indications. This approach is associated with greater
initial postoperative discomfort but avoids the possibility of graft dislodgment and
damage to neck structures. It is best used for nerve root decompression, when the
pathologic entity is a lateral spondylotic spur or soft disk. In this approach, a keyhole
foraminotomy is made by removing the medial third of the facet joint and the most lateral
aspects of the lamina at the involved level and side. The underlying lateral aspect of the
ligamentum flavum is then removed to visualize the nerve root. The nerve root is
unroofed posteriorly, superiorly, and inferiorly so that it lies free and without tension.
The impact of facetectomies on the stability of the cervical spine has been questioned.
Bilateral 50% facetectomies have been demonstrated to expose the nerve by 3-5 mm
without a notable effect on stability. Bilateral facetectomies of 70% reduced the ability of
the spine to withstand stresses, while increasing the exposure of the nerve root. In all
likelihood, maintenance of the interspinous and most of the interlaminar ligaments is
important for preserving stability in patients undergoing foraminotomy.
Surgical intervention for cervical spondylotic myelopathy is controversial.
In 1992, a thorough review of the literature pertaining to surgery for cervical spondylotic
myelopathy concluded that the chances for improvement after surgery for cervical
spondylotic myelopathy were approximately 50%. The conclusion was that large
multicenter trials are needed to determine the benefit of surgery and to establish criteria
for the operation/approach of operation. Also noted was that diagnostic errors still occur,
namely with amyotrophic lateral sclerosis and multiple sclerosis.36
Risks of surgery are another concern. The older literature reviewed by Rowland has been
criticized because of uncertainty as to whether nonspondylotic causes of myelopathy
were excluded prior to surgery. With current early intervention strategies tailored to the
pathophysiology of myelopathy, final outcomes clearly exceed expectant outcomes.
Rowland noted in his proposed trial guidelines that patients with rapid progression of
myelopathy may be allowed access to surgery without a trial of conservative therapy.
In the United States, cervical immobilization with a collar or brace is the most commonly
used therapy for cervical spondylotic myelopathy. Studies demonstrate conflicting results
regarding efficacy of this treatment.
Researchers have reported that symptomatic patients may deteriorate neurologically
during bracing; thus, surgery is usually recommended in patients with moderate-to-severe
disability or frank myelopathy. Because of the possible progressive character of cervical
spondylotic myelopathy, some advocate a more aggressive approach to the disease to
strive for improved outcomes.
The natural history of cervical spondylotic myelopathy is highly variable. The older
literature notes the natural course of cervical spondylotic myelopathy to be that of
progressive disability and deterioration in neurologic function. Nurick, however, noted
that a period of initial deterioration occurs, followed by a clinical plateau that lasts for
several years, during which disability does not worsen for those with mild cervical
spondylotic myelopathy. He noted that older patients deteriorate more frequently and,
thus, advocates surgery for those older than 60 years and for those with progressive
decline in neurologic function.37
Another factor that must be taken into consideration is that patients with cervical
spondylotic myelopathy may be at risk for significant spinal cord injury, even with minor
trauma. This argument, in addition to improved surgical outcomes in those with
decreased duration of symptoms, has been used as an argument supporting surgery.
Nevertheless, a recent Cochrane review found the natural course of cervical spondylotic
myelopathy to be highly variable for patients with mild-to-moderate symptoms, in whom
the review noted the disease to often remain static and symptoms to occasionally
improve.38 Similarly, for mild-to-moderate cervical spondylotic myelopathy, a 3-year
prospective randomized trial found no significant difference between patients who were
treated surgically and those who were treated conservatively.39
Excellent results have been demonstrated for patients undergoing surgical intervention.
One prospective trial of 503 patients undergoing conservative management for cervical
spondylotic myelopathy versus surgery reported that patients treated surgically had better
outcomes than those treated medically and that medical treatment did not significantly
alter neurologic outcomes.40
Accurately prognosticating the course of disability for any given individual with cervical
spondylotic myelopathy is difficult. Once moderate signs and symptoms develop,
however, surgical intervention is likely to be beneficial over further medical treatment.
The primary goal of surgery for cervical spondylotic myelopathy is decompression of the
spinal cord.41 Traditionally, for cervical laminectomy, a posterior approach has been the
treatment of choice. During the previous 20 years, laminectomy has increasingly been
recognized as not appropriate for all patients. Neurologic deterioration, which has been
reported after laminectomy, has been attributed to the development of spinal instability
and kyphotic deformities. Laminectomy also is unable to address ventral osteophytic
overgrowth via a posterior approach. Through an anterior cervical approach, one can
directly remove osteophytes, disk material, and even vertebral bodies, if necessary, to
decompress the cord. With interposition of bone grafts and, in some instances, cervical
plates (ie, instrumentation), neck instability can be prevented.
The sagittal alignment of the cervical spine is important in choosing an approach for
decompressing the cervical cord in cervical spondylotic myelopathy.
Preoperative lordotic alignment of the cervical spine is necessary in order to maintain
maximal benefit from posterior decompression. This is because of both the direct
decompression of the cord achieved by surgical removal of compressive elements (eg,
ligamentum flavum, bone) and the indirect decompression achieved ventrally by
posterior drift of the spinal cord.
Fixed local or global kyphosis, therefore, may be a relative contraindication for posterior
decompression.42 In the case of kyphosis, general insufficiency of the anterior column is
caused by degenerative changes in diskoligamentous structures, leading to neutralization
or inversion of the physiologic cervical lordosis. Because of kyphosis, the cord shifts
forward and is compressed by anterior osteophytes.
In cases of combined anterior compression and posterior bulging of the ligamentum
flavum causing narrowing of the vertebral canal, a combined anteroposterior approach
may be recommended.
The posterior approach (often advocated by Japanese surgeons) is also accepted as a
standard decompression procedure in patients who have more than 3 segments of stenotic
changes. The anterior approach involves an extensive resection.
Laminoplasty (a modern approach) and its variants preserve the lamina to avoid
excessive scar formation and to reduce the incidence of postlaminectomy kyphosis.
Excellent laminoplasty results have been reported for the treatment of multilevel cervical
spondylotic myelopathy.43 Additionally, long-term results with laminoplasty have been
reported with fewer late complications then laminectomy.44 Nevertheless, some
authorities advocate laminectomy.2,45 Laminectomy combined with lateral mass fusion
may yield excellent results without progression to spinal instability or kyphosis.46,47,48
The anterior approach is advocated for cervical spondylotic myelopathy when identifiable
anterior compression or kyphotic deformity is present. This approach is more frequently
used in the United States because ventral compression is more common. Myelopathy due
to osteophytes confined to 1-2 levels is treated using ACD and fusion with removal of the
osteophytes. In severe cases, extensive decompression is performed using multilevel
vertebrectomies (corpectomy) and reconstruction with bone graft and instrumentation.
Recent series have reported clinical improvement rates ranging from 80-94%.49,50
Neither the anterior nor posterior approach has been demonstrated superior to the other,
provided the appropriate procedure is performed for the proper clinical indication.2,51,45
Minimally invasive surgical techniques are being developed for management of cervical
spondylosis causing foraminal or central canal stenosis manifesting as radiculopathy,
myelopathy or both. In these cases, dorsal laminoforaminotomy can be performed with
minimally invasive techniques using microendoscope and tubular retractor system.
Typically, these cases are performed with electromyographic and somatosensory evoked
potential monitoring. The goal of these techniques is to minimize injury to surrounding
tissue, which leads to better outcomes with less pain.52
Of note, the number of geriatric patients seeking surgical treatment for cervical
spondylotic myelopathy is steadily increasing. One study demonstrated that corrective
surgical techniques could be performed in patients older than 70 years, with acceptable
risk of morbidity and reasonable expectation for clinical improvement.53
Medication
The goal of pharmacotherapy is to reduce pain and inflammation.
Nonsteroidal anti-inflammatory drugs
Used most commonly for the relief of mild to moderate pain. Although the effects of
NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC
for initial therapy. Other options include naproxen and diclofenac.

Ibuprofen (Motrin, Advil, Haltran, Nuprin)

Inhibits inflammatory reactions and pain by decreasing activity of COX, which results in
prostaglandin synthesis.
Dosing
Interactions
Contraindications
Precautions
Adult
200-800 mg PO q6-8h while symptoms persist, not to exceed 3.2 g/d
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Probenecid may increase concentrations and possibly toxicity; may decrease effect of
loop diuretics when administered concurrently; PT may increase when an NSAID is
administered concurrently with anticoagulants; monitor patient for bleeding and obtain a
PT before administering an NSAID concomitantly with these types of medications;
instruct patient to watch for signs and symptoms of bleeding; may increase serum lithium
levels and risk of methotrexate toxicity
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do
not administer to patients in whom aspirin, iodides, or other NSAIDs have induced
symptoms of asthma, rhinitis, urticaria, nasal polyps, angioedema, bronchospasm, and
other symptoms of allergic or anaphylactoid reactions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and
hepatic function; caution in patients with anticoagulation abnormalities or who are
receiving anticoagulant therapy

Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)

Relieves mild to moderate pain; inhibits inflammatory reactions and pain, probably by
decreasing activity of COX, which results in decreased prostaglandin synthesis.
Dosing
Interactions
Contraindications
Precautions
Adult
250-500 mg PO bid; may increase to 1.5 g/d for limited periods, not to exceed 1.25 g/d
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs;
conversely, effects of loop diuretics may decrease when administered concurrently with
naproxen; PT may increase when naproxen is administered concurrently with
anticoagulants; monitor PT closely and instruct patients to watch for signs and symptoms
of bleeding; concurrent administration with phenytoin may increase pharmacologic and
toxic effects of phenytoin
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity
Dosing
Interactions
Contraindications
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal
papillary necrosis may occur; increases risk of acute renal failure in patients with
preexisting renal disease or compromised renal perfusion; WBC counts rarely decrease
and usually return to normal in ongoing therapy; discontinuation of therapy may be
necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs;
caution in patients with anticoagulation defects or who are receiving anticoagulant
therapy

Diclofenac (Voltaren)
Has analgesic, antipyretic, and anti-inflammatory activity; inhibits inflammatory
reactions and pain, probably by decreasing activity of COX, which results in
prostaglandin synthesis.
Dosing
Interactions
Contraindications
Precautions
Adult
25 mg PO bid/tid; if well-tolerated, increase daily dose by 25 or 50 mg at weekly
intervals until satisfactory response obtained or until total daily dose of 150-200 mg is
reached; doses greater than this generally do not increase effectiveness
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Probenecid may increase concentrations and possibly toxicity of NSAIDs; effect of loop
diuretics may be decreased when administered concurrently; coadministration with
anticoagulants may prolong PT; consider effects on platelet function and gastric mucosa;
monitor PT and patients closely; instruct patients to watch for signs and symptoms of
bleeding; NSAIDs may increase serum lithium levels and risks of methotrexate toxicity
(eg, stomatitis, bone marrow suppression, nephrotoxicity)
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; because of potential cross-sensitivity to other NSAIDs, do
not administer to patients with hypersensitivity to aspirin, iodides, or other NSAIDs
Dosing
Interactions
Contraindications
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Potential exists for cross-hypersensitivity to aspirin, phenylacetic acid, and other
NSAIDs; caution in patients with bleeding tendencies or on anticoagulants; acute renal
insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary
necrosis may occur; patients with preexisting renal disease or compromised renal
perfusion are at greatest risk of acute renal failure; low WBC counts occur rarely; if low
WBC counts occur, they are transient and usually return to normal while with ongoing
therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further
evaluation and may require discontinuation
Corticosteroids
Used for potent anti-inflammatory activity and relieve inflammation associated with
cervical radiculopathy.

Prednisone (Sterapred)
Decreases inflammation by suppressing migration of PMN leukocytes and reversing
increased capillary permeability.
Dosing
Interactions
Contraindications
Precautions
Adult
5-60 mg/d PO or divided bid/qid; taper over 2 wk as symptoms resolve; injection into an
inflamed joint may provide temporary relief from pain, stiffness, and swelling
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Clearance may decrease when used concurrently with estrogens; when used concurrently
with digoxin, may increase digitalis toxicity secondary to hypokalemia; phenobarbital,
phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing
prednisone dose); monitor patients for hypokalemia when administering concurrently
with diuretics
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; diabetes; mental illness; hypothyroidism; cirrhosis; viral,
fungal, or tubercular skin lesions
Dosing
Interactions
Contraindications
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals
Precautions
Caution in patients with hyperthyroidism, cirrhosis, nonspecific ulcerative colitis,
osteoporosis, peptic ulcer, diabetes, and myasthenia gravis; adrenal crisis may occur if
glucocorticoids are withdrawn abruptly; hyperglycemia, edema, osteonecrosis, peptic
ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression,
myopathy, and infections are possible complications

Methylprednisolone (Adlone, Medrol, Solu-Medrol, Depo-Medrol, Depopred)

Decreases inflammation by suppressing migration of PMN leukocytes and reversing
increased capillary permeability.
Dosing
Interactions
Contraindications
Precautions
Adult
2-60 mg/d PO in 1-4 divided doses, followed by gradual reduction to lowest level that
maintains clinical response
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia;
estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease
levels (adjust dose); monitor patients for hypokalemia when administering medication
concurrently with diuretics
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
Precautions
Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis,
euphoria, psychosis, growth suppression, myopathy, and infections are possible
complications
Tricyclic antidepressants
A complex group of drugs that has central and peripheral anticholinergic effects and
sedative effects. They block the active reuptake of norepinephrine and serotonin.

Amitriptyline (Elavil)
Increases synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting
their reuptake at presynaptic neuronal membrane; useful as an analgesic for certain
chronic and neuropathic pain.
Dosing
Interactions
Contraindications
Precautions
Adult
30-100 mg/d PO hs
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Because drug metabolized by P-450 2D6 system, other drugs that inhibit this enzyme
system (eg, cimetidine, quinidine) may increase levels; phenobarbital may decrease
effects; blocks uptake and prevents hypotensive effects of guanethidine; may interact
with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; MAOIs in past 14 d
Dosing
Interactions
Contraindications
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with cardiac conduction disturbances and those with a history of
hyperthyroidism or renal or hepatic impairment; because of pronounced effects in
cardiovascular system, avoid in older patients

Nortriptyline (Aventyl hydrochloride, Pamelor)

Effective in treatment of chronic pain; by inhibiting reuptake of serotonin and/or
norepinephrine at the presynaptic neuronal membrane, it increases their synaptic
concentration; additional pharmacodynamic effects (eg, desensitization of adenyl cyclase,
down-regulation of beta-adrenergic receptors and serotonin receptors) appear to be
involved.
Dosing
Interactions
Contraindications
Precautions
Adult
25 mg PO tid/qid, not to exceed 150 mg/d
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Cimetidine may increase levels when used concurrently; may increase PT in patients
stabilized with warfarin
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; patients diagnosed with narrow-angle glaucoma; MAOIs
in past 14 d
Dosing
Interactions
Contraindications
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal or hepatic impairment, cardiac conduction disturbances, or
a history of hyperthyroidism
Cyclooxygenase 2 inhibitors
Although increased cost can be a negative factor, incidence of costly and potentially fatal
GI bleeding is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing
analysis of cost avoidance of GI bleeding will further define populations that most benefit
from COX-2 inhibitors.

Celecoxib (Celebrex)
Inhibits primarily COX-2, which is considered an inducible isoenzyme induced during
pain and inflammatory stimuli; inhibition of COX-1 may contribute to NSAID GI
toxicity; at therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI
toxicity may be decreased; seek lowest dose for each patient.
Dosing
Interactions
Contraindications
Precautions
Adult
200 mg/d PO; alternatively, 100 mg PO bid
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Coadministration with fluconazole may cause increase in celecoxib plasma
concentrations because of inhibition of celecoxib metabolism; coadministration with
rifampin may decrease celecoxib plasma concentrations
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac
function, hypertension, and conditions predisposing to fluid retention; caution in severe
heart failure and hyponatremia because may deteriorate circulatory hemodynamics;
NSAIDs may mask usual signs of infection; caution in presence of existing controlled
infections; evaluate symptoms and signs suggesting liver dysfunction or in abnormal LFT
results
Muscle relaxants
Reduce associated cervical muscle spasm.

Carisoprodol (Soma)
Short-acting medication that may have depressant effects at spinal cord level.
Dosing
Interactions
Contraindications
Precautions
Adult
350 mg PO tid/qid
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Increases toxicity of alcohol, CNS depressants, MAOIs, clindamycin, and phenothiazines
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity, acute intermittent porphyria
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment

Cyclobenzaprine (Flexeril)
Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic
origins, influencing both alpha and gamma motor neurons; structurally related to TCAs
and thus carries some of same liabilities.
Dosing
Interactions
Contraindications
Precautions
Adult
20-40 mg/d PO divided bid/qid; not to exceed 60 mg/d
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Coadministration with MAOIs and TCAs may increase toxicity; may have additive effect
when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and
barbiturates may be enhanced
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity; MAOIs within last 14 d
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
Precautions
Caution in angle-closure glaucoma and urinary hesitance
Opiates
For use in short-term management of acute pain.

Hydrocodone and acetaminophen (Vicodin, Lortab, Norcet, Margesic, Lorcet-HD)

Drug combination indicated for moderately severe to severe pain.
Dosing
Interactions
Contraindications
Precautions
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
Not established
Dosing
Interactions
Contraindications
Precautions
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases
with CNS depressants or TCAs
Dosing
Interactions
Contraindications
Precautions
Documented hypersensitivity, high-altitude cerebral edema, or elevated ICP
Dosing
Interactions
Contraindications
Precautions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans;
may use if benefits outweigh risk to fetus
Precautions
Tab contains metabisulfite, which may cause hypersensitivity; caution in patients
dependent on opiates because this substitution may result in acute opiate withdrawal
symptoms; caution in severe renal or hepatic dysfunction

Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)

Drug combination indicated for relief of moderately severe to severe pain.
Dosing
Interactions
Contraindications
Precautions
Follow-up

Patient Education
For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and
Head Center. In addition, see eMedicine's patient education articles Vertebral
Compression Fracture and Neck Strain.

Miscellaneous

Medicolegal Pitfalls

• The role of cervical spondylosis in postautomobile accident cervical whiplash

syndrome has been a controversial medicolegal area.
• In 1973, Verbiest warned clinicians to be wary of patients who present after
minor trauma with symptoms attributable to cervical spondylosis, especially
when legal and/or compensatory matters were involved.
• In one series of 648 patients with ruptured cervical disks, only one patient
was noted to experience a typical hyperextension injury as a result of a rear-
end car collision.54
• Repetitive trauma has been implicated (eg, in those carrying baskets on their
heads), but the cause-and-effect relationship for auto accidents or other
infrequently occurring trauma has not been demonstrated.

Special Concerns
Cervical diskography is a controversial tool used to assess patients with nonradicular
or nonmyelopathic symptoms (eg, neck pain and suboccipital pain attributable to
cervical spondylosis). It is particularly controversial because some authorities claim
that diskography is a useful tool, while others remain skeptical because of a high rate
of false-positive results.
 • The technique involves the injection of a small amount of contrast into the
disk space. A positive study result occurs when a patient's symptoms are
reproduced by the injection. Some authors also use relief of the symptoms
(elicited by local injection of anesthetic) as corroborative evidence of
diskogenic pain. The morphology of the disk after contrast injection is
important to some authorities, while others discount it as a meaningless
entity.
• Regardless, most advocates recommend it as a test of final resort once MRI
or myelography results are demonstrated to be within normal limits.
• In theory, the test can localize the pathologic disk responsible for a patient's
symptoms. One study reported that 70% of patients who underwent surgical
intervention based on diskography studies experienced excellent or good
results

There is a strong tendency for the symptoms of cervical spondylosis to subside spontaneously,
though they may persist for several months and the structural changes are clearly permanent.

Treatment is thus aimed at assisting natural resolution of temporarily inflamed or edematous

soft tissues.

In mild cases physiotherapy may be recommended (radiant heal, short wave diathermy,
massage, traction or exercises).

In the more severe cases judicious use of a close-fitting cervical collar for supporting the neck
(it should be worn for 1-3 months depending on progress) and rest to the neck is advisable.

In the exceptional cases in which the spinal cord is constricted, decompression from front or
by laminectomy may be required and thereafter it may be advisable to fuse the affected
segments of the spinal column by a bone-grafting operation.

Physiotherapy

Once the neck problem is diagnosed, treatment can be decided.

In most neck conditions, pressure on the neck causes pain and pain causes muscle spasms,
setting up a cycle. The best way to break the cycle and stop the pain is to relieve both
pressure and spasms. There are various approaches to achieve each of these goals. Many of
them require daily applications, so they must be done by the patient at home.

Relief of pressure:

Lying down is perhaps the simplest way to relieving the neck of its heavy load. Bed rest gives
the muscles a chance to recover. The duration of bed rest should be advised by the
physiotherapist.

Not only is spinal molding a relaxing way to start and end your body, it also reshapes your
spine into its natural curves. Begin by lying on the floor or g on a firm mattress with rolled-up
towels under your neck and low back. Your legs may be straight or bent. Lie in this position for
15-20 minutes.

Cervical collar helps the neck muscles support the head, it also reduces neck mobility. The
therapist may prescribe wearing of a cervical collar for the acute phase of neck problems and
the duration of wearing it. The collar should fit snugly around the neck and be long enough to
support the chin. Men can minimize irritation from the collar by shaving frequently.

Extension and flexion is especially helpful when you feel your neck and back stiffen. While
sitting, place your hands on your knees and push down. Slowly arch your back and bend your
back backward. Then slowly slump forward. Repeat this exercise 10 times.

Side bends increase your side-to-side flexibility. Start by placing your fingers together and
pointing your elbows outward. Bend at the waist, tilting your body to one side as far as you
can. Then bend your head and neck in the same direction. Repeat on your other side. Repeat
this exercise 10 times.

This exercise increases the flexibility of your entire spine. To begin, place your fingers together
and point your elbows outward. Slowly and gently twist at your waist, rotating your head and
neck to the same side

Cervical
Spondylosis

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Pronunciations
arthritis

cervical spondylosis

computed tomography

methocarbamol

myelitis

myelopathy
 Cervical Spondylosis
. Repeat toward the other sid

(Neck Osteoarthritis)
What is it?

Cervical spondylosis is a condition of the neck which results in pain and stiffness. It is an
age related condition in which the discs and vertebrae degenerate or suffer from ‘wear
and tear’. In a normal vertebral segment the bones are adequately separated by a full
size disc, the ligaments are nicely aligned and the cartilage covering the bone ends is
defect free. The effects of degeneration result in a narrowed joint space, thinned discs,
worn cartilage and tightened ligaments. When the joints become closer together the
pressure on the ends of the bones becomes greater leading to further wear. The body
responds by increasing the surface area of the joint ends by laying down new bone along
the edges of the joints. These projections of new bone are called osteophytes and they
are often responsible for nerve root compression which can lead to cervical radiculopathy
(trapped nerves).

Causes

Degeneration generally increases with age, is more common in men than women and
changes can start by the age of 30. It is thought that approximately 95% of men and
women over the age of 70 will show signs of cervical spondylosis. Certain posture types
can increase the likelihood of developing wear and tear symptoms earlier. As with many
conditions, education, postural awareness and preventative treatment can reduce the
symptoms.

Treatment

Following a thorough examination and assessment of the presenting problem, advice and
treatment may include the following:

• Advice regarding activity modification and reducing aggravating factors

• Electrotherapy i.e. Interferential / TENS to control pain
• Soft tissue mobilisation to restore normal tissue feel and function
• Joint mobilisations to the neck, upper back, shoulder and elbow if appropriate to
improve neck range of movement
• Acupuncture to reduce pain, normalise tissue tone and improve blood flow
• Individually tailored exercise programme to stretch, strengthen and mobilise
appropriate areas including postural re-education
e. Repeat this exercise 10 ti Spondylosis
From Wikipedia, the free encyclopedia

Jump to: navigation, search

This article does not cite any references or sources. Please help improve this article
by adding citations to reliable sources. Unsourced material may be challenged and
removed. (December 2007)
Not to be confused with spondylitis, spondylolysis, or spondylolisthesis.

Spondylosis

Classification and external resources

ICD-10 M47.

ICD-9 721

OMIM 184300

12323
DiseasesDB

000436
MedlinePlus

neuro/564
eMedicine

[1]
MeSH

Spondylosis is degenerative arthritis of the joints between the centra of the

spinal vertebrae. In this condition the interfacetal joints are not involved. If
severe, it may cause pressure on nerve roots with subsequent pain or
paresthesia in the limbs.

When the space between two adjacent vertebrae narrows, compression of a

nerve root emerging from the spinal cord may result in radiculopathy (sensory
and motor system disturbances, such as severe pain in the neck, shoulder, arm,
back, and/or leg, accompanied by muscle weakness). Less commonly, direct
pressure on the spinal cord (typically in the cervical spine) may result in global
weakness, gait dysfunction, loss of balance, and loss of bowel and/or bladder
control. The patient may experience a phenomenon of shocks (paresthesia) in
hands and legs because of nerve compression and lack of blood flow. If
vertebrae of the neck are involved it is labelled cervical spondylosis. Lower back
spondylosis is labeled lumbar spondylosis.

Contents
[hide]

• 1 Treatment
• 2 Surgery
• 3 See also
• 4 References

• 5 External links

[edit] Treatment

"Treatment is usually conservative in nature; the most commonly used

treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), physical
modalities, and lifestyle modifications. Alternative therapies such as osteopathic
manipulative medicine (OMM), massage, trigger-point therapy, chiropractic and
acupuncture may be utilized to control pain and maintain musculoskeletal
function in some people. Surgery is occasionally performed. Many of the
treatment modalities for cervical spondylosis have not been subjected to
rigorous, controlled trials. Surgery is advocated for cervical radiculopathy in
patients who have intractable pain, progressive symptoms, or weakness that fails
to improve with conservative therapy. Surgical indications for cervical
spondylosis with myelopathy (CSM) remain somewhat controversial, but "most
clinicians recommend operative therapy over conservative therapy for moderate-
to-severe myelopathy." (Baron, M.E.) Physical therapy may be effective for
restoring range of motion, flexibility, and core strengthening. Decompressive
therapies (i.e. manual mobilization, mechanical traction) may also help alleviate
pain. However, physical therapy cannot "cure" the degeneration, and some
people view that strong compliance with postural modification is necessary to
realize maximum benefit from decompression and flexibility rehabilitation.
Understanding anatomy is the key to conservative management of spondylosis.

[edit] Surgery

There are many different surgical procedures to correct spinal deformity. The
vertebrae can be approached by the surgeon from the front, side, or rear.
Portions of a disc may be removed. To prevent further dislocation, fusion of two
vertebrae may be done by taking pieces of bone from the patient's hip and
inserting them between the two vertebrae which are fused together and secured
by screws.
[edit] See also

• Spinal disc herniation

• Laminectomy

[edit] References

• Thomas, Clayton L. (1985). Taber's Cyclopedic Medical Dictionary. F.A. Davis

Company, Philadelphia, Pennsylvania. ISBN 0-8036-8309-X.
• Baron, M.E. (2007) Cervical Spondylosis: Diagnosis and Management.
http://www.emedicine.com

mes.
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 Review

Cervical spondylosis with spinal cord

encroachment: should preventive surgery be
recommended?
Donald R Murphy1,2,3 , Christopher M Coulis4,5 and Jonathan K Gerrard6
1
Rhode Island Spine Center, 600 Pawtucket Ave, Pawtucket, RI 02860-6059, USA
2
Department of Community Health, Alpert Medical School of Brown University, Box G-A,
Providence, RI 02912, USA
3
Department of Research, New York Chiropractic College, 2360 State Rte. 89, Seneca Falls, New
York 13148, USA
4
Shoreline Spine & Pain Associates, PC, 2415 Boston Post Rd, Guilford, CT 06437, USA
5
Clinical Sciences, University of Bridgeport, College of Chiropractic,126 Park Avenue, Bridgeport,
CT 06604, USA
6
Aquarius Chiropractic, #210-179 Davie Street Vancouver, V6Z 2Y1, USA
author email corresponding author email

Chiropractic & Osteopathy 2009, 17:8doi:10.1186/1746-1340-17-8

The electronic version of this article is the complete one and can be found online at:
http://www.chiroandosteo.com/content/17/1/8

Received: 25 April 2009

Accepted: 24 August 2009

Published: 24 August 2009

© 2009 Murphy et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is properly cited.

Abstract

Background
It has been stated that individuals who have spondylotic encroachment on the cervical spinal
cord without myelopathy are at increased risk of spinal cord injury if they experience minor
trauma. Preventive decompression surgery has been recommended for these individuals. The
purpose of this paper is to provide the non-surgical spine specialist with information upon
which to base advice to patients. The evidence behind claims of increased risk is investigated
as well as the evidence regarding the risk of decompression surgery.

Methods
A literature search was conducted on the risk of spinal cord injury in individuals with
asymptomatic cord encroachment and the risk and benefit of preventive decompression
surgery.

Results
Three studies on the risk of spinal cord injury in this population met the inclusion criteria. All
reported increased risk. However, none were prospective cohort studies or case-control
studies, so the designs did not allow firm conclusions to be drawn. A number of studies and
reviews of the risks and benefits of decompression surgery in patients with cervical
myelopathy were found, but no studies were found that addressed surgery in asymptomatic
individuals thought to be at risk. The complications of decompression surgery range from
transient hoarseness to spinal cord injury, with rates ranging from 0.3% to 60%.

Conclusion
There is insufficient evidence that individuals with spondylotic spinal cord encroachment are at
increased risk of spinal cord injury from minor trauma. Prospective cohort or case-control
studies are needed to assess this risk. There is no evidence that prophylactic decompression
surgery is helpful in this patient population. Decompression surgery appears to be helpful in
patients with cervical myelopathy, but the significant risks may outweigh the unknown benefit
in asymptomatic individuals. Thus, broad recommendations for decompression surgery in
suspected at-risk individuals cannot be made. Recommendations to individual patients must
consider possible unique circumstances.

Background

Degenerative changes in the cervical spine are part of the normal aging process and are
nearly ubiquitous in older people [1]. They are generally asymptomatic [2,3]. Spondylosis,
with the development of osteophytes, occurs as part of the degenerative process. This can
lead to the development of clinical symptoms in some individuals if the osteophytes impinge
on neural structures such as the nerve root or spinal cord. If this encroachment occurs in the
lateral recess or lateral canal it can lead to radiculopathy. If it occurs in the central canal it can
cause myelopathy. However, encroachment in either of these regions can also be
asymptomatic with regard to myelopathy [1,4]. For example, Matsumoto, et al [1] assessed
497 asymptomatic subjects and found posterior disc protrusion with compression of the spinal
cord in 7.6%. While this figure was presented in the abstract of the paper, no details were
provided as to how this compression was measured. However, the figure was similar to that of
Teresi, et al [5] who found cord compression on MRI in 7 of 100 asymptomatic subjects. Cord
compression without myelopathy has also been found on CT myelography [6].

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction
in older individuals and usually develops insidiously [7]. However, it has been reported to
develop after trauma [8-15]. Some authors have suggested that individuals who have
asymptomatic spondylotic encroachment on the cervical spinal cord are at increased risk of
acute myelopathy if they experience minor trauma such as a fall or motor vehicle collision
[16,17]. This has led some surgeons to recommend decompression surgery for the purpose of
preventing this trauma-induced myelopathy in presumed susceptible individuals [18,19]. For
example, Epstein [18] stated "Patients under 65 years of age, if mildly symptomatic or at risk
for quadriplegia with even mild trauma, may warrant early decompression". However, he did
not provide evidence-based recommendations as to how to determine risk of quadriplegia or
the level of risk that would warrant surgery in the absence of frank myelopathy.

The authors, all non-surgical spine specialists, have had patients consult them for second
opinion after being recommended this type of surgery. Each of these patients was
asymptomatic with regard to cervical myelopathy (though they had neck pain), but cervical
MRI had revealed cervical spondylosis which encroached on, and compressed, the spinal cord.
It was reported in each of these cases that the surgeon making the recommendation did so
based on the view that the spinal cord encroachment placed the patient at risk of spinal cord
injury if he or she were to experience even relatively minor trauma. These patients expressed
a desire for a non-surgical opinion as to whether such surgery is truly advisable. This is
apparently a frequent enough occurrence in the experience of other spine specialists to have
warranted a "Curve/Countercurve" piece in a recent issue of Spine Line, a publication of the
North American Spine Society [19].

Evidence-based medicine calls for the clinician to provide counseling and treatment that is
based on the best available evidence, combined with clinical experience and patient preference
[20-22]. The purpose of this review is to investigate whether the scientific literature can be
used to inform the surgical and non-surgical spine specialist regarding how to advise patients
who have spondylotic encroachment on the cervical spinal cord in the absence of frank
myelopathy.

Methods

The following databases were searched up to May 31, 2008: Medline, Cinahl, Embase and
MANTIS. Searches of the authors' own libraries were also conducted. Finally, citation searches
of relevant articles and texts were conducted manually. The search terms used for the
database searches can be found in table 1.

Table 1. Search terms

The search yielded 1881 citations. Relevant papers were retrieved and reviewed by two
independent reviewers. Studies that were deemed relevant were those that investigated the
risk of spinal cord injury from minor trauma in patients with pre-existing spondylotic central
canal encroachment and those that reported on outcomes and complications to cervical
decompression surgery, with or without fusion. Case reports and small case series were
excluded. Also excluded were studies reporting risk of spinal cord injury resulting from major
trauma and studies involving individuals who had narrowing of the central canal from sources
other than degenerative changes. In cases in which systematic reviews of the literature were
found, the individual studies included in the reviews were not reviewed separately, unless this
was necessary to clarify information that was not readily apparent from the systematic review.

Results

Risk of Spinal Cord Injury from Minor Trauma

Five studies [9-11,13,23] were excluded because they assessed younger individuals in whom
degenerative spondylotic change would not be expected. One study that excluded subjects
with cervical spondylosis was also excluded from the present study [24]. Three studies were
excluded because all of the subjects [25,26] or more than half [12] had major trauma
(fracture and/or dislocation). One study was excluded because it looked at rate of recovery
and not incidence or risk [27]. Two studies met the inclusion criteria [14,15].

Regenbogen, et al [14] retrospectively reviewed the medical records of 88 patients over age
40 with spinal cord injury resulting from trauma and compared them with a group of 35 young
adults (16–36 years) with spinal cord injury. Of the 88 older patients, 25 had no bony or
ligamentous injury and another 17 had "subtle" signs of bony or ligamentous injury. In
contrast, only one of the 35 younger patients had developed spinal cord injury without severe
bony or ligamentous injury. All 25 patients with no bony injury were evaluated with
radiographs and 16 with pantopaque myelography. All patients imaged with myelography had
signs of "moderate to severe" spondylosis. Katoh, et al [15] reported on 27 patients with
ossification of the posterior longitudinal ligament who sustained minor trauma ("such as
tumbling, slipping or jumping from small steps") to the cervical spine. Thirteen of these
patients developed new myelopathy, 7 experienced deterioration of pre-existing myelopathy
and 7 experienced no neurologic sequelae. Eighteen of the 19 patients with a narrow central
canal (<10 mm) developed neurologic deterioration, whereas this occurred in only two of the
eight patients with a wider canal (10 mm or greater).

Benefits and Risks of Surgery in the Cervical Spine in Asymptomatic

Spinal Cord Encroachment
The search did not reveal any studies on the outcome of surgery in asymptomatic or
presumed "at risk" subjects. It did reveal a number of review papers [28-34] that included
most of the studies found in the search. The most common surgical procedures used in this
patient population are discectomy, laminectomy with or without foraminotomy or fusion,
circumferential decompression with fusion, laminoplasty and corpectomy. Each has its own
indications and contraindications as well as complications. These are provided in Table 2.
Potential complications to these surgical procedures include injury to the spinal cord, nerve
roots, sympathetic ganglia, recurrent laryngeal nerve, or vertebral artery, CSF leakage,
infection and pseudoarthrosis (Table 2).

Table 2. Surgical procedures for cervical spondylotic myelopathy

Discussion

The role of preventive surgery in patients with asymptomatic cervical spinal cord
encroachment has been a point of controversy amongst surgeons. Riew, in a point-
counterpoint piece, [19] argued that the risk of myelopathy in patients with asymptomatic
encroachment on the cervical spine is not worth the risk of surgery. Combining data from the
Paralyzed Veterans of America, National Library of Medicine, and the US Census, he estimated
the "worst case scenario" risk of myelopathy in this patient population to be 1:2100. He
argued that even if the risk of serious complication from surgical decompression was 1:1000,
this would be twice the risk of myelopathy after trauma [19]. As has been pointed out in the
present paper, however, the studies Riew cited on which he based the assumption of risk were
of inadequate design to assess true risk [25,26]. However, this point only strengthens his
recommendation against surgery in this population. Others [18] have argued that because of
the potentially catastrophic nature of spinal cord injury after trauma, decompression surgery is
appropriate in this patient population. The purpose of this study is to assess the evidence
regarding this risk and attempt to compare what is known about this risk with what is known
about the risk of surgery. It is hoped that all spine clinicians can take an evidence-based
approach to counseling patients with this condition.

All studies that related to the risk of spinal cord injury in patients with asymptomatic
encroachment located in the search were case reports, case series or retrospective cross-
sectional studies. None were case-control or prospective cohort studies. Thus, while it can be
said that there may be an association between the presence of asymptomatic cord
encroachment and spinal cord injury after trauma, no firm conclusions can be drawn about
causation. Case-control or prospective cohort studies would be necessary to make this
determination [35]. Also, in the majority of cases the size of the central canal was measured
with radiographs. Recent evidence indicates poor correlation between radiographically-
determined central canal size and that determined by MRI [36]. Because the studies were of
inadequate design to assess risk and used inadequate measurement methods, the present
authors did not feel that it was of benefit to undergo a formal critical appraisal of the studies.

Bednarik, et al [37,38] have studied risk factors for the development of CSM in individuals
with asymptomatic spondylotic cord compression using a prospective cohort design. In their
initial study of 66 subjects with this condition who were followed for 2–8 years [37], they
found that 13 subjects (19.7%) developed symptomatic CSM. The only risk factors for the
progression to CSM in this cohort were symptomatic radiculopathy at baseline,
electromyographic (EMG) evidence of anterior horn lesion at baseline and abnormal
somatosensory evoked potentials (SSEP) at baseline. In a more recent publication with a
larger sample size (n = 199) and longer follow period (2–12 years, median 44 months) [38]
they found that 45 subjects (22.6%) developed symptomatic CSM. Baseline symptomatic
radiculopathy, EMG evidence of anterior horn cell lesion and abnormal SSEP were found to be
risk factors for the development of CSM during the follow up period. There was a tendency
toward increased risk in males vs females and in those with abnormal motor evoked
potentials, but these did not reach statistical significance (p = 0.072 and p = 0.112,
respectively). Factors in their model that were not found to increase risk of the development
of CSM were age, type of compression (spondylosis, disc herniation or the combination of
both), number of stenotic levels, decreased cross sectional area of the spinal canal, decreased
Pavlov ratio and hyperintense signal within the spinal cord on T2-weighted MRI image. They
did not include exposure to trauma in their analysis, however, when re-analyzing the data
they found relatively few exposures to trauma and that these had no impact on development
of CSM (Bednarik J, personal communication 26th June 2008).

In all the surgical studies found in the search, the subjects had symptomatic myelopathy. No
outcome studies were found that included asymptomatic subjects thought to be at risk. Thus,
the role surgery plays in preventing spinal cord injury in asymptomatic subjects thought to be
at risk is not known. It is also not known whether the complication rate of decompression
surgery in patients with asymptomatic cord encroachment would be the same as in those with
myelopathy. However, as the reported postsurgical complications generally relate to the
surgery itself and not to the myelopathy (see Table 1), it is not likely that the complication
rate would be substantially different in asymptomatic individuals as compared to symptomatic
individuals.

Based on this review of the literature, it remains to be determined whether an individual with
cervical spinal cord encroachment, without signs or symptoms of myelopathy, is at increased
risk of spinal cord injury after trauma. It also remains to be determined what the magnitude is
of any increased risk. This determination would require population-based case-control or,
preferably, prospective cohort studies. With these designs, bias can be minimized and
statistical conclusions can be drawn regarding risk [35]. Until such studies have been
performed, it cannot be stated with certainty that individuals with the findings discussed here
are at increased risk of trauma-induced myelopathy.

Because of this, there is currently no substantial evidence upon which to base a

recommendation for prophylactic decompression surgery in this patient population. However,
evidence-based medicine calls for recommendations to be individually directed and to take into
account scientific evidence combined with clinical experience and patient preference [20-22].
There may be individual variations in a particular case, such as severe canal encroachment,
low signal change within the spinal cord on T1 weight images with high signal on the T2
weighted images (which has been found to correlate with poor surgical outcome) [39],
ossification of the posterior longitudinal ligament or persistent engagement in high-risk
activities, which may influence one's recommendation. Also it may be advisable for the non-
surgical spine specialist to counsel patients who have asymptomatic cord encroachment to
avoid high-risk activities, particularly those that could involve high-acceleration extension
injury. Given the fact that post-traumatic myelopathy has been reported to be associated with
falls in the elderly [40], it would be reasonable for elderly patients with this finding to be
provided prevention strategies, including exercises for improved balance, in order to lessen
the likelihood of falling [41].

Conclusion

Asymptomatic cervical spondylotic spinal cord encroachment is fairly common. It has been
said that individuals with this finding are at increased risk of severe myelopathy if they
experience minor trauma. In some cases, prophylactic decompression surgery has been
recommended. However, there is no good evidence that these individuals are at increased risk
and, given the potentially serious complications of surgery, the evidence does not allow for
firm and broad recommendations to be made regarding prophylactic surgery. Population-
based case-control or prospective cohort studies are needed to determine whether the
magnitude of any risk in this patient population justifies surgical intervention.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

DRM conceived of the research idea, supervised the literature search and data extraction
process and was the principle writer of the manuscript. CMC and JKG conducted the literature
searches and were involved in data extraction. All authors reviewed and made editorial
changes in the manuscript. All authors read and approved the final manuscript.

References

Physical Exam for Cervical Spondylosis

- Signs and Symptoms: (see C-spine Exam)

- pain is earlly symptom, which may be ischemic in origin;

- Myelopathy:
- characterized by weakness (upper > lower extremity);
- ataxic broad based suffling gait, sensory changes;
- rarely urinary retention;
- myelopathy hand:
 - finger escape sign (small finger spontaneously abducts due to
weak intrinsics) indicating cervical myelopathy;
- upper motor neuron findings such as hyper-reflexia, clonus, or
Babinski's sign may be present;
- funicular pain, characterized by central burning and stinging with or
w/o (Lhermitte's phenomenon - radiatineg lightening like sensations
down back w/ neck flexion) may also be present w/ myelopathy;

- Radiculopathy:
- can be associated with myelopathy;
- can involve one or multiple roots, and symptoms include neck, shoulder,
and arm pain, paresthesias, and numbness;
- findings may overlap because of intraneural intersegmental
connections of sensory nerve roots;
- lower nerve root at a given level is usually affected;
- Spurling's Manuever:
- mechanical stress, such as excessive vertebral motion, may exacerbate symptoms;
- gentle neck hyperextension with the head tilted toward the affected side will narrow the
size of the neuroforamen and may exacerbate the symptoms or produce radiculopathy;
- Shoulder Abduction Relief Test:
- significant relief of arm pain with shoulder abduction;
- this sign is more likely to be present w/ soft disc herniation,
whereas, the test is likely to be negative with radiculopathy
caused by Spondylosis (osteophyte compression);
Surgical Indications:
- intractable pain;
- progressive neurological deficit;
- severe deltoid or wrist extensor weakness;
- myelopathy or pending myelopathy;

- Surgical Treatment:
- anterior approach: & fusion;
- fusion of one or more levels is performed by countersinking iliac crest bone graft between vertebral
bodies;
- requires discectomy, removal of posterior osteophytes, and removal of the bony sclerotic bed of the
vertebral body;
- stability of bone graft is achieved by initial distraction of soft tissues as graft is inserted;
- once, distractive force is removed the graft will be held firmly between vertebral bodies;
- note: to maintain stability the posterior longitudinal ligament should be left intact, if possible;
- in most cases of cervical spondylosis involving one or two levels, the pathology will be anterior and
will be reflecting clinically as myelopathy, anterior cord syndrome, or central cord syndrome;
- when the primary pathology is mostly anterior, generally the anterior approach should be anterior;
- the one exception to this may be the rheumatoid C-spine;
- posterior approach:
- full laminectomy is required;
- removal of the spinous process & lamina on each side at multiple levels;
- facet joints:
- resection of > 25 % of facet can result in cervical instability;
- if destabilizing facet resection is needed in order to decompress cord, posterior arthrodesis
should be done;
- laminaplasty:
- may be indicated for multi-level disease;

Pathoanatomy of Cervical Spondylosis

- Pathoanatomy:
- osteophytosis occurs as result of breakdown in the out annular fibers of annulus fibrosis;
- disk material stretching & displacing these fibers, causing stress at ligamentous attachments
leading to formation of osteophytes;
- osteophytes collects initially extend horizontally;
- later on osteophytes extend vertically from edges of vertebra, sometimes bridging disk space;
 - involves the disc, two facet joints & two false uncovertebral joints (Lushka);
- cervical cord becomes impinged when diameter of canal (normally about 17 mm) is reduced to less than
13 mm;
- hyperextension:
- cord increases in diameter and it & roots are pinched between discs and adjacent spondylitic
bars anteriorly, and hypertrophic facets and infolded ligamentum flavum posteriorly;
- hyperflexion:
- cord narrows and the neural structures are tethered anteriorly across discs or spondylitic bars;
- radiculopathy:
- spondylotic changes in the foramina primarily from chondro-osseous spurs of the joints of Luschka
may restrict motion and may lead to nerve root compression;
- soft disc herniation:
- is usually posterolateral, between posterior edge of uncinate process & lateral edge of
posterior longitudinal ligament, resulting in acute radiculopathy;
- myelopathy:
- central herniation;
- spondylotic bars with a congenitally narrow canal;

- Apophyseal Joints:
- show early irregularity and blurring of the joint surfaces;
- joint space narrowing and eventual spurring and sclerosis;
- lateral view & oblique view:
- allows evaluation of facet joints;
- determine if osteophytes of apophyseal joints project medially into foramina canal;
- specifically, osteophytes arising from the ventral portion of superior articular process
may cause symptomatic foraminal narrowing;
- rarely osteophytes may also project anteriorly and impinge upon vertebral artery, resulting in arterial
insufficiency;
- loss of disk height leads to reduced neuroforaminal volume, rendering root more susceptible to
compression;

- Joints of Luschka:
- joints give rise to bony spurs or ridges -osteophytes- as can main fascet
joints & edges of vertebral bodies adjacent to intervertebral disc;
- this is symphysis type of articulation between vertebral bodies;
- exiting nerve root on each side travels between these joints, & can be
compressed by osteophytes extending into intervertebral foramen
from any or all three of sources mentioned;

Differential Dx of C-Spine Pathology

- Myelopathy: Diff Dx:

- Myopathic Disorders
- Stroke / TIA;
- Multiple Sclerosis
- Amyotrophic Lateral Sclerosis
- Thoracic Outlet Syndrome;
- Pancoast Tumors
- Reflex Sympathetic Dystrophy
- Brachial Neuritis (upper & lower motor neurons, sensation is Nl);
- Spinal Cord Tumor
- Syringomyelia
- Subacute Combined Degeneration
- Cervical Disc Herniation
- Cerebral hemisphere lesion
- Low pressure hydrocephalus
- Herpes Zoster;
 - Subacromial Impingement;
- Thoracic Outlet Syndrome;

Electromyography
- See:
- Nerve Injury:
- Nerve Menu
- outside links:
- The Expert Electromyographer
- EMG Table of Contents:

- EMG Findings in Specific Conditions:

- Normal Study:
- normal insertional activity;
- silent rest activity;
- biphasic and triphasic potentials;
- complete interference;
- Neuropraxia
- normal insertional activity;
- silent rest activity;
- no biphasic and triphasic potentials;
- interference: none
- Axonotmesis:
- increased insertional activity;
- rest activity: fibrillations & positive sharp waves;
- no biphasic and triphasic potentials;
- interference: none
- Neurotmesis
- increased insertional activity;
- rest activity: fibrillations & positive sharp waves;
- no biphasic and triphasic potentials;
- interference: none
- Axonal Neuropathies:
- increased insertional activity;
- rest activity: fibrillations & positive sharp waves;
- no biphasic and triphasic potentials;
- interference: incomplete;
- Demyelinating Neuropathies
- normal insertional activity;
- silent rest activity;
- no biphasic and triphasic potentials;
- interference: incomplete;
- Anterior Horn Disease
- increased insertional activity;
- rest activity: fibrillations & positive sharp waves;
- large polyphasic contractions;
- Myopathic Disorders
- Neuropathic Disorders
- Peripheral Neuropathy

- Indications for EMG:

- EMG studies are highly sensitive, but results are nonspecific;
- to evaluate motor neuron dysfunction;
- confirme & extension of clinical examination;
- useful in localizing level of specific lesion, distinguishing between partial and complete lesions,
differentiating primary muscle
 or nerve pathology, & evaluating malingerers;
- useful for diff dx & in presence of coexisting disease;
- radiculopathy due to dz of C-spine, diffuse peripheral neuropathy, or proximal median neuropathy can
pose clinical questions that electrodiagnostic testing can answer;
- no other test has a higher diagnostic accuracy in patients w/ final diagnosis of carpal tunnel
syndrome;

- Technique:
- small needle is inserted into muscle to record electrical activity of several neighboring motor units;

- Specific Measurements:
- Rest Activity:
- S wave:
- occurs when action potentials travel from the point of stimulation of peripheral nerve to the spinal
cord and back to the muscle;
- another factor that may lead to normal EMG in presence of compressive radiculopathy is overlapping
motor innervation of single muscle;
- Nerve Entrapment:
- Motor Conduction Latency:
- Sensory latency:
- F wave:
- F wave is often measured to supplement routine nerve conduction studies because the F wave
permits evaluation of the proximal segments of peripheral nerves;
- F waves are valuable in evaluating disorders involving the nerve roots, plexuses and the proximal
segments of peripheral nerves;
- determine of F wave latencies is particularly valuable in evaluating patients with demyelinating
paolyradiculopathies;
- Number of motor units under voluntary control;
- Duration and Amplitude of each Motor Unit Potential;

Cervical Spondylosis :

In case of intense pain in the neck due, to cervical spondylosis associated with painful or

painless weakness in the arm stoppage of neck movement is immediately required. There

is a lot of vibrations and jerks in the neck during travelling and it is advisable to stop

travelling and stay away from office /institution /academy for a few days. A cervical collar

is advisable to restrict undue movements of the neck. Whenever there is pain in the

joints, the muscles encircling that joint become tight and reduce the mobility of the joint

as a protective mechanism. When the tension in the muscle becomes too much, they

generate pain; Heat is the best agent to relax the muscles. Many gadgets and home

remedies can be used, i.e., hot water bags, electrical heating pads, infrared lamps etc.

The more preferable heat treatments are short wave diathermy (WD) and ultrasound

heat. They provide deep penetrating heat.

 Traction (cervical) is quite effective when a slipped disc presses a nerve root. Traction

increases the intervertebral disc space and therefore the pressure of disc on the nerve

root is released. Traction can be intermittent or steady traction kept up for some time. If

traction fails to reduce pain in 24 to 48 hours, there is little reason to insist on the use of

traction any further.

http://www.wheelessonline.
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