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Cervical Spondylosis Clinical Presentation

  • Author: Hassan Ahmad Hassan Al-Shatoury, MD, PhD, MHPE; Chief Editor: Dean H Hommer, MD  more...
 
Updated: May 23, 2016
 

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.)[6]
      • 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

See the list below:

  • Age
    • Cervical spondylosis is an accumulation of degenerative changes 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.[7]
    • 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

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

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

Disclosure: Nothing to disclose.

Chief Editor

Dean H Hommer, MD Chief, Department of Pain Management, Brooke Army Medical Center

Dean H Hommer, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Healthcare Executives, American College of Sports Medicine, American Institute of Ultrasound in Medicine, American Society of Interventional Pain Physicians, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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, North American Spine Society

Disclosure: Nothing to disclose.

Acknowledgements

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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