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Cervical Spondylosis Treatment & Management

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

Rehabilitation Program

Physical Therapy

See the list below:

  • Immobilization of the cervical spine is the mainstay of conservative treatment for patients with severe cervical spondylosis with evidence of myelopathy. Immobilization limits the motion of the neck, thereby reducing nerve irritation. Soft cervical collars are recommended for daytime use only, but they are unable to appreciably limit the motion of the cervical spine. More rigid orthoses (eg, Philadelphia collar, Minerva body jacket) can significantly immobilize the cervical spine (see Special Concerns). The patient's tolerance and compliance are considerations when any of the braces are used. A program of isometric cervical exercises may help to limit the loss of muscle tone that results from the use of more restrictive orthoses. Molded cervical pillows can better align the spine during sleep and provide symptomatic relief for some patients.
  • Mechanical traction is a widely used technique. This form of treatment may be useful because it promotes immobilization of the cervical region and widens the foraminal openings. However, traction in the treatment of cervical pain was not better than placebo in 2 randomized groups.
  • The use of cervical exercises has been advocated in patients with cervical spondylosis. Isometric exercises are often beneficial to maintain the strength of the neck muscles. Neck and upper back stretching exercises, as well as light aerobic activities, also are recommended. The exercise programs are best initiated and monitored by a physical therapist.
  • Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (eg, moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).
  • Manual therapy, such as massage, mobilization, and manipulation, may provide further relief for patients with cervical spondylosis. Mobilization is performed by a physical therapist and is characterized by the application of gentle pressure within or at the limits of normal motion, with the goal of increasing the ROM. Manual traction may be better tolerated than mechanical traction in some patients. Manipulation is characterized by a high-velocity thrust, which is often delivered at or near the limit of the ROM. The intention is to increase articular mobility or to realign the spine. Contraindications to manipulative therapy include myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability, and vertebrobasilar insufficiency.

Occupational Therapy

Patients with upper extremity weakness often lose their ability to perform activities of daily living (ADL), vocational activities, or recreational activities. Lifestyle modifications may involve an evaluation of workplace ergonomics, postural training, neck-school therapy (supervised, small-group therapy), stress management, and vocational assistance. Disability can be improved with specific strengthening exercises of the upper extremities, special splinting to compensate for weakness, and the use of assistive devices that allow the patient to perform previously impossible activities.

Recreational Therapy

The recreational therapist can use recreational and community activity to accomplish the following:

  • Help the patient maintain his/her physical strength, social skills, and motivation
  • Assist the patient and family in adjusting to the disability
  • Decrease the patient's atypical behaviors
  • Increase the patient's independence
  • Reinforce other therapies
  • Provide community integration
  • Further evaluate the level of functioning in cases of severe disability caused by cervical spondylosis
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Medical Issues/Complications

Cervical spondylosis may result in complications (see Mortality/Morbidity), including the following:

  • Cervical myelopathy
  • Paraplegia
  • Tetraplegia
  • Recurrent chest infection
  • Pressure sores
  • Recurrent urinary tract infection
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Surgical Intervention

Indications for surgery include the following:

  • Progressive neurologic deficits
  • Documented compression of the cervical nerve root and/or spinal cord
  • Intractable pain

The aims of surgery are to relieve pain and neuronal structure compression, as well as, in select cases, to achieve stabilization.

Approaches for surgery are anterior or posterior.

Anterior approaches include the following[14, 15] :

  • Diskectomy without bone graft
  • Diskectomy with bone graft
  • Cervical instrumentation

Posterior approaches include the following[1, 16] :

  • Decompressive laminectomy and foraminotomy
  • Hemilaminectomy
  • Laminoplasty [17]

Data from the AOSpine North America Cervical Spondylotic Myelopathy Study show the majority of complications due to surgical treatment of CSM are treatable. Complications that do arise are often associated with greater age, increased operative time, and use of combined anterior-posterior procedures.[18]

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Consultations

Consultations with the following specialists may be helpful:

  • Psychologist or psychiatrist
  • Pain management specialist
  • Neurologist
  • Neurosurgeon and/or orthopedic spinal surgeon
  • Urologist
  • Internist
  • Occupational therapist
  • Physical therapist
  • Recreational therapist
  • Social worker
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Other Treatment

Injection

Cervical, zygapophyseal, intra-articular steroid injection can be helpful for active synovitis. The facet injections can be diagnostic and therapeutic. Mechanical facet pain is better evaluated with facet joint nerve blocks. Long-term relief can often be accomplished with a rhizotomy procedure. Cervical epidural block might be beneficial in cervical spondylosis, especially if an inflammatory component is present. Epidural and selective nerve root blocks can be diagnostically and therapeutically helpful in cases of radiculopathy. Trigger-point injections may be helpful.

Treatment of bowel and bladder dysfunction

Some patients with bowel dysfunction may benefit from a daily suppository, enema, or oral laxative. The administration should be followed by digital stimulation so that the patient's defecation occurs at a predictable time. Evaluate bladder incontinence with urodynamic studies. Pharmacologic intervention is possible in some patients, but many individuals need an intermittent catheterization program and control of fluid intake. An indwelling catheter is occasionally required if the patient does not have the dexterity to comply with a catheter program.

Rehabilitative nursing

A nurse should be involved in the educational process regarding the development of an effective bowel and/or bladder program and the prevention of pressure sores.

Psychosocial support

Patients with significant disability often react with fear, anxiety, or depression. Postoperative depression is significantly associated with pain intensity, pain interference, and pain-related disability. Results of one study of depression and negative affect among spinal surgery patients suggest postoperative screening for depression and treating depression to improve functional outcomes after spine surgery.[19] Referral to a psychologist or psychiatrist for psychotherapy, pharmacotherapy, and/or family counseling may be indicated.

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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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