Diagnosis and Management of Cervical Spondylosis Treatment & Management
- Author: Sandeep S Rana, MD; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS more...
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. 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.  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. 
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 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. 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.
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.
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.
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 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. 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.
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.
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. 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. 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. Additionally, long-term results with laminoplasty have been reported with fewer late complications then laminectomy. Nevertheless, some authorities advocate laminectomy.[2, 46] Laminectomy combined with lateral mass fusion may yield excellent results without progression to spinal instability or kyphosis.[47, 48, 49]
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%.[50, 51] 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, 52, 46]
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.
Artificial cervical disks were approved by the US Food and Drug Administration (FDA) in 2007 and are now being offered as an alternative to spinal fusion in some selected patients. Replacement with an artificial disk can potentially preserve natural neck motion and thereby reduce stress and prevent degeneration of adjoining cervical disks. A study comparing artificial cervical disk replacement with cervical fusion concluded that patients who had undergone artificial cervical disk replacement had faster recovery than their counterparts. Currently, artificial cervical disk replacement is only offered for 1 level disk disease. Artificial disk replacement at 2 level disease is being performed in Europe but is considered investigational in the United States.
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.
Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine (Phila Pa 1976). 1988 Jul. 13(7):831-7. [Medline].
McCormack BM, Weinstein PR. Cervical spondylosis. An update. West J Med. 1996 Jul-Aug. 165(1-2):43-51. [Medline].
Wilkinson M. The morbid anatomy of cervical spondylosis and myelopathy. Brain. 1960 Dec. 83:589-617. [Medline].
Hoff JT, Wilson CB. The pathophysiology of cervical spondylotic radiculopathy and myelopathy. Clin Neurosurg. 1977. 24:474-87. [Medline].
Rosomoff HL, Fishbain D, Rosomoff RS. Chronic cervical pain: radiculopathy or brachialgia. Noninterventional treatment. Spine (Phila Pa 1976). 1992 Oct. 17(10 Suppl):S362-6. [Medline].
Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001 Nov-Dec. 9(6):376-88. [Medline].
Fehlings MG, Skaf G. A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury. Spine (Phila Pa 1976). 1998 Dec 15. 23(24):2730-7. [Medline].
Young WF. Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction in older persons. Am Fam Physician. 2000 Sep 1. 62(5):1064-70, 1073. [Medline].
McCormick WE, Steinmetz MP, Benzel EC. Cervical spondylotic myelopathy: make the difficult diagnosis, then refer for surgery. Cleve Clin J Med. 2003 Oct. 70(10):899-904. [Medline].
Young WF, Weaver M, Mishra B. Surgical outcome in patients with coexisting multiple sclerosis and spondylosis. Acta Neurol Scand. 1999 Aug. 100(2):84-7. [Medline].
al-Mefty O, Harkey HL, Marawi I, et al. Experimental chronic compressive cervical myelopathy. J Neurosurg. 1993 Oct. 79(4):550-61. [Medline].
Henderson FC, Geddes JF, Vaccaro AR, Woodard E, Berry KJ, Benzel EC. Stretch-associated injury in cervical spondylotic myelopathy: new concept and review. Neurosurgery. 2005 May. 56(5):1101-13; discussion 1101-13. [Medline].
Moore AP, Blumhardt LD. A prospective survey of the causes of non-traumatic spastic paraparesis and tetraparesis in 585 patients. Spinal Cord. 1997 Jun. 35(6):361-7. [Medline].
Holt S, Yates PO. Cervical spondylosis and nerve root lesions. Incidence at routine necropsy. J Bone Joint Surg Br. 1966 Aug. 48(3):407-23. [Medline].
Rahim KA, Stambough JL. Radiographic evaluation of the degenerative cervical spine. Orthop Clin North Am. 1992 Jul. 23(3):395-403. [Medline].
Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. 1992 Jul. 23(3):381-94. [Medline].
Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994 Mar. 75(3):342-52. [Medline].
Stoffman MR, Roberts MS, King JT Jr. Cervical spondylotic myelopathy, depression, and anxiety: a cohort analysis of 89 patients. Neurosurgery. 2005 Aug. 57(2):307-13; discussion 307-13. [Medline].
Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg. 1954 Nov. 11(6):546-77. [Medline].
Kaye JJ, Dunn AW. Cervical spondylotic dysphagia. South Med J. 1977 May. 70(5):613-4. [Medline].
Umerah BC, Mukherjee BK, Ibekwe O. Cervical spondylosis and dysphagia. J Laryngol Otol. 1981 Nov. 95(11):1179-83. [Medline].
Sobol SM, Rigual NR. Anterolateral extrapharyngeal approach for cervical osteophyte-induced dysphagia. Literature review. Ann Otol Rhinol Laryngol. 1984 Sep-Oct. 93(5 Pt 1):498-504. [Medline].
Farooqi NA, Doran M, Buxton N. Cervical osteophytes: a cause of potentially life-threatening laryngeal spasms. Case report. J Neurosurg Spine. 2006 May. 4(5):419-20. [Medline].
Kanbay M, Selcuk H, Yilmaz U. Dysphagia caused by cervical osteophytes: a rare case. J Am Geriatr Soc. 2006 Jul. 54(7):1147-8. [Medline].
Teresi LM, Lufkin RB, Reicher MA, et al. Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology. 1987 Jul. 164(1):83-8. [Medline].
Brown BM, Schwartz RH, Frank E, Blank NK. Preoperative evaluation of cervical radiculopathy and myelopathy by surface-coil MR imaging. AJR Am J Roentgenol. 1988 Dec. 151(6):1205-12. [Medline].
Alexander JT. Natural history and nonoperative management of cervical spondylosis. In: Menezes AH, Sonntag VKH, et al. Principles of Spinal Surgery. Vol 1. 1996:547-557.
Penning L, Wilmink JT, van Woerden HH, Knol E. CT myelographic findings in degenerative disorders of the cervical spine: clinical significance. AJR Am J Roentgenol. 1986 Apr. 146(4):793-801. [Medline].
Yamazaki T, Suzuki K, Yanaka K, Matsumura A. Dynamic computed tomography myelography for the investigation of cervical degenerative disease. Neurol Med Chir (Tokyo). 2006 Apr. 46(4):210-5; discussion 215-6. [Medline].
Song T, Chen WJ, Yang B, et al. Diffusion tensor imaging in the cervical spinal cord. Eur Spine J. 2011 Mar. 20(3):422-8. [Medline].
Iwabuchi M, Kikuchi S, Sato K. Pathoanatomic investigation of cervical spondylotic myelopathy. Fukushima J Med Sci. 2004 Dec. 50(2):47-54. [Medline].
Gore DR, Sepic SB, Gardner GM, Murray MP. Neck pain: a long-term follow-up of 205 patients. Spine (Phila Pa 1976). 1987 Jan-Feb. 12(1):1-5. [Medline].
AGS Panel on Persistent Pain in Older Persons. The management of of persistent pain in older persons. J Am Geriatr Soc. 2002. 50(Suppl 6):S205-S224.
Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy. Am J Phys Med Rehabil. 1999 Jan-Feb. 78(1):30-2. [Medline].
Kaiser MG, Haid RW, Subach BR, Barnes B, Rodts GE Jr. Anterior cervical plating enhances arthrodesis after discectomy and fusion with cortical allograft. Neurosurgery. Feb-2002. 50:229-236.
Baskin DS, Ryan P, Sonnta V, Westmark R, Wedmayer MA. A prospective, randomized, controlled cervical fusion study using recombinant human bone morphogentic protein-2 with the CORNERSTONE-SR allograft ring and the ATLANTIS anterior cervical plate. Spine. 2003. 28:1219-1225.
Rowland LP. Surgical treatment of cervical spondylotic myelopathy: time for a controlled trial. Neurology. 1992 Jan. 42(1):5-13. [Medline].
Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain. 1972. 95(1):101-8. [Medline].
Fouyas IP, Statham PF, Sandercock PA. Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy. Spine (Phila Pa 1976). 2002 Apr 1. 27(7):736-47. [Medline].
Kadanka Z, Mares M, Bednaník J, et al. Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study. Spine (Phila Pa 1976). 2002 Oct 15. 27(20):2205-10; discussion 2210-1. [Medline].
Sampath P, Bendebba M, Davis JD, Ducker TB. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976). 2000 Mar 15. 25(6):670-6. [Medline].
Ma X, Zhao XF, Zhao YB. [A clinical study on different decompression methods in cervical spondylosis]. Zhonghua Wai Ke Za Zhi. 2009 Apr 15. 47(8):607-9. [Medline].
Lee JY, Sharan A, Baron EM, et al. Quantitative prediction of spinal cord drift after cervical laminectomy and arthrodesis. Spine (Phila Pa 1976). 2006 Jul 15. 31(16):1795-8. [Medline].
Wang MY, Shah S, Green BA. Clinical outcomes following cervical laminoplasty for 204 patients with cervical spondylotic myelopathy. Surg Neurol. 2004 Dec. 62(6):487-92; discussion 492-3. [Medline].
Kaminsky SB, Clark CR, Traynelis VC. Operative treatment of cervical spondylotic myelopathy and radiculopathy. A comparison of laminectomy and laminoplasty at five year average follow-up. Iowa Orthop J. 2004. 24:95-105. [Medline].
Grob D. Surgery in the degenerative cervical spine. Spine (Phila Pa 1976). 1998 Dec 15. 23(24):2674-83. [Medline].
Kumar VG, Rea GL, Mervis LJ, McGregor JM. Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery. 1999 Apr. 44(4):771-7; discussion 777-8. [Medline].
Houten JK, Cooper PR. Laminectomy and posterior cervical plating for multilevel cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament: effects on cervical alignment, spinal cord compression, and neurological outcome. Neurosurgery. 2003 May. 52(5):1081-7; discussion 1087-8. [Medline].
Huang RC, Girardi FP, Poynton AR, Cammisa Jr FP. Treatment of multilevel cervical spondylotic myeloradiculopathy with posterior decompression and fusion with lateral mass plate fixation and local bone graft. J Spinal Disord Tech. 2003 Apr. 16(2):123-9. [Medline].
Chagas H, Domingues F, Aversa A, Vidal Fonseca AL, de Souza JM. Cervical spondylotic myelopathy: 10 years of prospective outcome analysis of anterior decompression and fusion. Surg Neurol. 2005. 64 Suppl 1:S1:30-5; discussion S1:35-6. [Medline].
Chibbaro S, Benvenuti L, Carnesecchi S, et al. Anterior cervical corpectomy for cervical spondylotic myelopathy: experience and surgical results in a series of 70 consecutive patients. J Clin Neurosci. 2006 Feb. 13(2):233-8. [Medline].
Macdonald RL, Fehlings MG, Tator CH, et al. Multilevel anterior cervical corpectomy and fibular allograft fusion for cervical myelopathy. J Neurosurg. 1997 Jun. 86(6):990-7. [Medline].
Santiago P, Fessler RG. Minimally Invasive Surgery for the Management of cervical spondylosis. Neurosurgery. Jan-2007. 60:S1-160-165.
Heller JG, Sasso RC, Papadopoulos SM, et al. Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial. Spine (Phila Pa 1976). 2009 Jan 15. 34(2):101-7. [Medline].
Razack N, Greenberg J, Green BA. Surgery for cervical myelopathy in geriatric patients. Spinal Cord. 1998 Sep. 36(9):629-32. [Medline].
Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to 1972. Clin Neurosurg. 1973. 20:9-17. [Medline].
Whitecloud TS 3rd, Seago RA. Cervical discogenic syndrome. Results of operative intervention in patients with positive discography. Spine (Phila Pa 1976). 1987 May. 12(4):313-6. [Medline].
Bracken MB, Shepard MJ, Collins WF Jr, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg. 1992 Jan. 76(1):23-31. [Medline].
Chesnut RM, Abitbol JJ, Garfin SR. Surgical management of cervical radiculopathy. Indication, techniques, and results. Orthop Clin North Am. 1992 Jul. 23(3):461-74. [Medline].
Chiles BW 3rd, Leonard MA, Choudhri HF, Cooper PR. Cervical spondylotic myelopathy: patterns of neurological deficit and recovery after anterior cervical decompression. Neurosurgery. 1999 Apr. 44(4):762-9; discussion 769-70. [Medline].
Clarke E, Robinson PK. Cervical myelopathy: a complication of cervical spondylosis. Brain. 1956 Sep. 79(3):483-510. [Medline].
Clements DH, O'Leary PF. Anterior cervical discectomy and fusion. Spine (Phila Pa 1976). 1990 Oct. 15(10):1023-5. [Medline].
Connor PM, Darden BV 2nd. Cervical discography complications and clinical efficacy. Spine (Phila Pa 1976). 1993 Oct 15. 18(14):2035-8. [Medline].
Cull R, Whittle I. The nervous system. Munro J, Edwards CS. Macleod's Clinical Examination. 1995. 201-256.
Denno JJ, Meadows GR. Early diagnosis of cervical spondylotic myelopathy. A useful clinical sign. Spine (Phila Pa 1976). 1991 Dec. 16(12):1353-5. [Medline].
Dillin W, Booth R, Cuckler J, Balderston R, Simeone F, Rothman R. Cervical radiculopathy. A review. Spine (Phila Pa 1976). 1986 Dec. 11(10):988-91. [Medline].
Dillin W, Uppal GS. Analysis of medications used in the treatment of cervical disk degeneration. Orthop Clin North Am. 1992 Jul. 23(3):421-33. [Medline].
Durufle A, Petrilli S, Le Guiet JL, et al. Cervical spondylotic myelopathy in athetoid cerebral palsy patients: about five cases. Joint Bone Spine. 2005 May. 72(3):270-4. [Medline].
Ebara S, Yonenobu K, Fujiwara K, Yamashita K, Ono K. Myelopathy hand characterized by muscle wasting. A different type of myelopathy hand in patients with cervical spondylosis. Spine (Phila Pa 1976). 1988 Jul. 13(7):785-91. [Medline].
Firooznia H, Ahn JH, Rafii M, Ragnarsson KT. Sudden quadriplegia after a minor trauma. The role of preexisting spinal stenosis. Surg Neurol. 1985 Feb. 23(2):165-8. [Medline].
Goodridge AE, Feasby TE, Ebers GC, Brown WF, Rice GP. Hand wasting due to mid-cervical spinal cord compression. Can J Neurol Sci. 1987 Aug. 14(3):309-11. [Medline].
Haerer AF. Examination in cases of suspected hysteria and malingering. DeJong's The Neurologic Examination. 5th ed. 1992. 744.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine (Phila Pa 1976). 1999 Apr 15. 24(8):785-94. [Medline].
Irvine DH, Foster JB, Newell DJ, Klukvin BN. Prevalence of cervical spondylosis in a general practice. Lancet. 1965 May 22. 14:1089-92. [Medline].
Jumah KB, Nyame PK. Relationship between load carrying on the head and cervical spondylosis in Ghanaians. West Afr J Med. 1994 Jul-Sep. 13(3):181-2. [Medline].
Kaiser JA, Holland BA. Imaging of the cervical spine. Spine (Phila Pa 1976). 1998 Dec 15. 23(24):2701-12. [Medline].
LaBan MM, Taylor RS. Manipulation: an objective analysis of the literature. Orthop Clin North Am. 1992 Jul. 23(3):451-9. [Medline].
Lam M. Headache. Adler SN, et al. A Pocket manual of Differential Diagnosis. 1994. 303-304.
LaRocca H. Cervical spondylotic myelopathy: natural history. Spine (Phila Pa 1976). 1988 Jul. 13(7):854-5. [Medline].
Lees F, Turner J. Natural history and prognosis of cervical spondylosis. BMJ. 1963. 2:1603.
Nakano KK. Neck pain. Kelley WN, Harris ED, Ruddy S, Sledge CB. Textbook of Rheumatology. 1985. 471-490.
Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K. Myelopathy hand. New clinical signs of cervical cord damage. J Bone Joint Surg Br. 1987 Mar. 69(2):215-9. [Medline].
Papadopoulos SM, Hoff JT. Anatomical treatment of cervical spondylosis. Clin Neurosurg. 1994. 41:270-85. [Medline].
Raynor RB, Pugh J, Shapiro I. Cervical facetectomy and its effect on spine strength. J Neurosurg. 1985 Aug. 63(2):278-82. [Medline].
Robinson R, Smith G. Anterolateral cervical disc removal and interbody fusion for cervical disc syndrome. Bull Johns Hopkins Hosp. 1955. 96:223.
Saunders R. Corpectomy for cervical spondylotic myelopathy. Menezes AH, Sonntag VH, et al. Principles of Spinal Surgery. 1996. Vol. 1: 559-569.
Schellhas KP, Smith MD, Gundry CR, Pollei SR. Cervical discogenic pain. Prospective correlation of magnetic resonance imaging and discography in asymptomatic subjects and pain sufferers. Spine (Phila Pa 1976). 1996 Feb 1. 21(3):300-11; discussion 311-2. [Medline].
Tan JC, Nordin M. Role of physical therapy in the treatment of cervical disk disease. Orthop Clin North Am. 1992 Jul. 23(3):435-49. [Medline].
Verbiest H. Chapter 23. The management of cervical spondylosis. Clin Neurosurg. 1973. 20:262-94. [Medline].
Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine (Phila Pa 1976). 1989 Mar. 14(3):253-7. [Medline].
Watson JC, Broaddus WC, Smith MM, Kubal WS. Hyperactive pectoralis reflex as an indicator of upper cervical spinal cord compression. Report of 15 cases. J Neurosurg. 1997 Jan. 86(1):159-61. [Medline].
Yoo K, Origitano TC. Familial cervical spondylosis. Case report. J Neurosurg. 1998 Jul. 89(1):139-41. [Medline].
Yoss RE, Corbin KB, Maccarty CS, Love JG. Significance of symptoms and signs in localization of involved root in cervical disk protrusion. Neurology. 1957 Oct. 7(10):673-83. [Medline].