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Cervical Spondylosis, Diagnosis and Management: Differential Diagnoses & Workup

Author: Sandeep S Rana, MD, Clinical Associate Professor of Neurology, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Aug 14, 2009

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.
    • MRI allows multiplanar imaging, excellent imaging of the neural elements, and increased accuracy in diagnosing intrinsic cord disease.
    • 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
    • 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.
    • It has been demonstrated to be an accurate imaging modality in several studies.
    • 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.
    • 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.
    • Cervical spine films can demonstrate disk-space narrowing, osteophytosis, loss of cervical lordosis, uncovertebral joint hypertrophy, apophyseal joint osteoarthritis, and vertebral canal diameter.
    • 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.
    • 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
    • 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
    • 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.
    • Electromyography (EMG) can help diagnose cervical radiculopathy and, occasionally, identify cervical spondylotic myelopathy.
    • EMG is useful in the study of radiculopathy because it demonstrates a close correlation with neuroimaging and operative findings.
    • It also provides an anatomic distribution of abnormalities, thus facilitating the differential of cervical radiculopathy from other similar causes of radicular symptoms.
    • 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.
    • 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

More on Cervical Spondylosis, Diagnosis and Management

Overview: Cervical Spondylosis, Diagnosis and Management
Differential Diagnoses & Workup: Cervical Spondylosis, Diagnosis and Management
Treatment & Medication: Cervical Spondylosis, Diagnosis and Management
Follow-up: Cervical Spondylosis, Diagnosis and Management
Multimedia: Cervical Spondylosis, Diagnosis and Management
References
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Further Reading

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Keywords

cervical spondylosis, cervical spondylosis treatment, cervical degenerative joint disease, cervical spine, cervical degenerative disk disease, cervical osteoarthritis, cervical spondylotic myelopathy, CSM, disk degeneration, degenerative cervical disease, osteophytic bars, cervical radiculopathy, neck pain, shoulder pain, cervicalgia, chronic suboccipital headache, paresthesias, pseudoangina, breast pain, nontraumatic paraparesis, nontraumatic tetraparesis, numbness, clumsy hands, loss of manual dexterity, difficulty with writing, central cord syndrome, Tinel sign, Spurling sign, Babinski sign, Hoffman sign, pectoralis muscle reflex, spastic gait, Lhermitte sign

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Contributor Information and Disclosures

Author

Sandeep S Rana, MD, Clinical Associate Professor of Neurology, Drexel University College of Medicine
Sandeep S Rana, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

William J Nowack, MD, Associate Professor, Epilepsy Center, Department of Neurology, University of Kansas Medical Center
William J Nowack, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Electroencephalographic Association, American Medical Informatics Association, and Biomedical Engineering Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Howard A Crystal, MD, Professor, Departments of Neurology and Pathology, State University of New York Downstate; Consulting Staff, Department of Neurology, University Hospital and Kings County Hospital Center
Howard A Crystal, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association
Disclosure: Medivations Honoraria Consulting

 
 
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