Cervical Spondylosis Clinical Presentation

  • Author: Hassan Ahmad Hassan Al-Shatoury, MD, PhD, MHPE; Chief Editor: Consuelo T Lorenzo, MD   more...
 
Updated: Apr 18, 2012
 

History

Common clinical syndromes associated with cervical spondylosis include the following:

  • Cervical pain
    • Chronic suboccipital headache may be present. Mechanisms include direct nerve compression; degenerative disk, joint, or ligamentous lesions; and segmental instability.
    • Pain can be perceived locally, or it may radiate to the occiput, shoulder, scapula, or arm.
    • The pain, which is worse when the patient is in certain positions, can interfere with sleep.
  • Cervical radiculopathy
    • Compression of the cervical nerve roots leads to ischemic changes that cause sensory dysfunction (eg, radicular pain) and/or motor dysfunction (eg, weakness). Radiculopathy most commonly occurs in persons aged 40-50 years. (See images below) A 48-year-old man presented with neck pain and preA 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. An axial, gradient-echo magnetic resonance imaging scan shows moderate anteroposterior narrowing of the cord space due to a ventral osteophyte at the C4 level, with bilateral narrowing of the neural foramina (more prominently on the left side). A 48-year-old man presented with neck pain and preA 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. A T2-weighted sagittal magnetic resonance imaging scan shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.
    • An acute herniated disk or chronic spondylotic changes can cause cervical radiculopathy and/or myelopathy
    • The C6 root is the most commonly affected one because of the predominant degeneration at the C5-C6 interspace; the next most common sites are at C7 and C5.
    • Most cases of cervical radiculopathy resolve with conservative management; few require surgical intervention.
  • Cervical myelopathy
    • Cervical spondylotic myelopathy is the most serious consequence of cervical intervertebral disk degeneration, especially when it is associated with a narrow cervical vertebral canal. (See image below) A 59-year-old woman presented with a spastic gait A 59-year-old woman presented with a spastic gait and weakness in her upper extremities. A T2-weighted sagittal magnetic resonance imaging scan shows cord compression from cervical spondylosis, which caused central spondylotic myelopathy. Note the signal changes in the cord at C4-C5, the ventral osteophytosis, buckling of the ligamentum flavum at C3-C4, and the prominent loss of disk height between C2 and C5.
    • Cervical myelopathy has an insidious onset, which typically becomes apparent in persons aged 50-60 years. Complete reversal is rare once myelopathy occurs.
    • Involvement of the sphincters is unusual at presentation, as based on the patient's perception of symptoms.
    • Five categories of cervical spondylotic myelopathy are described; these are based on the predominant neurologic findings, as follows:
      • Transverse lesion syndrome - Corticospinal and spinothalamic tracts, as well as the posterior columns, are involved.
      • Motor syndrome - This primarily involves the corticospinal or anterior horn cells.
      • Central cord syndrome - Motor and sensory involvement is greater in the upper extremities than the lower extremities. (See also Central Cord Syndrome.)[5]
      • Brown-Séquard syndrome - Unilateral cord lesion with ipsilateral corticospinal tract involvement and contralateral analgesia are present below the level of the lesion. (See also Brown-Sequard Syndrome, in the Physical Medicine and Rehabilitation section, and Brown-Sequard Syndrome, in the Emergency Medicine section.)
      • Brachialgia and cord syndrome - Predominant upper limb pain is present, with some associated long-tract involvement.
  • Less common manifestations
    • Primary sensory loss may be present in a glovelike distribution.
    • Tandem spinal stenosis is a simultaneous cervical and lumbar stenosis resulting from spondylosis. It is a triad of findings: neurogenic claudication, complex gait abnormality, and a mixed pattern of upper and lower motor neuron signs.
    • Dysphagia may be present if the spurs are large enough to compress the esophagus.
    • Vertebrobasilar insufficiency and vertigo may be observed.
    • Elevated hemidiaphragm, caused by spondylotic compression of C3-4 (as noted in a case report), may be another finding.
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Physical

Findings at physical examination may include the following:

  • Spurling sign - Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, causing additional foraminal compromise.
  • Lhermitte sign - This generalized electrical shock sensation is associated with neck extension.
  • Hoffman sign - Reflex contraction of the thumb and index finger occurs in response to nipping of the middle finger. This sign is evidence of an upper motor neuron lesion. A Hoffman sign may be insignificant if present bilaterally.
  • Distal weakness
  • Decreased ROM in the cervical spine, especially with neck extension
  • Hand clumsiness
  • Loss of sensation
  • Increased reflexes in the lower extremities and in the upper extremities below the level of the lesion
  • A characteristically broad-based, stooped, and spastic gait
  • Extensor planter reflex in severe myelopathy
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Causes

  • Age
    • Cervical spondylosis is a disease observed most commonly in elderly individuals.
    • Among persons younger than 40 years, 25% have degenerative disk disease (DDD), and 4% have foraminal stenosis, as confirmed with magnetic resonance imaging (MRI).
    • In persons older than 40 years, almost 60% have DDD, and 20% have foraminal stenosis, as confirmed with MRI.
  • Trauma
    • The role of trauma in spondylosis is controversial.
    • Repetitive, subclinical trauma probably influences the onset and rate of progression of spondylosis.
  • Work activity - Cervical spondylosis is significantly higher in patients who carry loads on their head than in those who do not (see Frequency).
  • Genetics
    • The role of genetics is unclear. However, a retrospective, population-based study by Patel et al shows that genetics may play a role in the development of cervical spondylotic myelopathy (CSM). The study uses The Utah Population Database, which contains over 2 million residents' health and genealogical data, and cross-references it with 10 years of clinical diagnosis statistics from a large tertiary hospital. An abundance of cases showing relatedness, as well as a considerable amount of elevated relative risks to close and distant relatives, advances the idea of an inherited predisposition to CSM.[6]
    • Patients older than 50 years who have normal cervical spine radiographic findings are significantly more likely to have a sibling with normal or mildly abnormal radiographic results.
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Contributor Information and Disclosures
Author

Hassan Ahmad Hassan Al-Shatoury, MD, PhD, MHPE,  Associate Professor, Department of Neurosurgery, Suez Canal University; Co-Director, Center of Research and Development in Medical Education and Health Services Suez Canal University Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Ayman Ali Galhom, MD, PhD  Lecturer (Associated Professor), Department of Neurosurgery, Suez Canal University Faculty of Medicine, Egypt

Ayman Ali Galhom, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Curtis W Slipman, MD  Director, University of Pennsylvania Spine Center; Associate Professor, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Medical Center

Curtis W Slipman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, International Association for the Study of Pain, and North American Spine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD  Physiatrist, Department of Physical Medicine and Rehabilitation, Alegent Health Immanuel Rehabilitation Center

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Additional Contributors

The editors would like to thank Franklin C Wagner, Jr, MD, Former Chief, Division of Spine and Spinal Cord Surgery, Former Professor, Department of Neurosurgery, University of Illinois at Chicago College of Medicine, for his previous association with this article.

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A cervical myelogram shows advanced spondylotic changes and multiple compression of the spinal cord by osteophytes.
A 59-year-old woman presented with a spastic gait and weakness in her upper extremities. A T2-weighted sagittal magnetic resonance imaging scan shows cord compression from cervical spondylosis, which caused central spondylotic myelopathy. Note the signal changes in the cord at C4-C5, the ventral osteophytosis, buckling of the ligamentum flavum at C3-C4, and the prominent loss of disk height between C2 and C5.
A T2-weighted cervical magnetic resonance imaging scan shows obliteration of the subarachnoid space as a result of spondylotic changes.
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. An axial, gradient-echo magnetic resonance imaging scan shows moderate anteroposterior narrowing of the cord space due to a ventral osteophyte at the C4 level, with bilateral narrowing of the neural foramina (more prominently on the left side).
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. A T2-weighted sagittal magnetic resonance imaging scan shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.
 
 
 
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