History
The various clinical syndromes seen with cervical spondylosis manifest quite differently.
Intermittent neck and shoulder pain, or cervicalgia, is the most common syndrome seen in clinical practice. [2] This can be a frustrating problem for physicians and patients because often the patient has no associated neurologic signs. When neurologic deficits are present, diagnostic imaging can often help define the cause. When they are not present, however, imaging findings are not usually helpful because the incidence of radiologic abnormalities is quite high in persons in this age group, even in asymptomatic patients.
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A large part of the problem is that the source of pain in this situation is poorly understood. This syndrome is possibly related to compression of the sinovertebral nerves and the medial branches of the dorsal rami in the cervical region. [16]
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The neck pain experienced with cervical spondylosis is often accompanied by stiffness, with radiation into the shoulders or occiput, that may be chronic or episodic with long periods of remission. [2]
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One third of patients with cervicalgia due to cervical spondylosis present with headache, and greater than two thirds present with unilateral or bilateral shoulder pain. A significant amount of these patients also present with arm, forearm, and/or hand pain. [16]
Another poorly understood clinical syndrome seen with cervical spondylosis is chronic suboccipital headache. Although the C1 thru C3 dermatomes are represented on the head and it would seem likely that occipitoatlantal and atlantoaxial degeneration would cause pain in these areas, no contributions to these joints occur from the dorsal rami of C1-C3. In addition, the greater occipital nerve cannot usually be compressed by bony structures. Regardless, headaches can be the dominant symptom in a patient with degenerative cervical disease. The headaches are usually suboccipital and may radiate to the base of the neck and the vertex of the skull. [16]
Perhaps more thoroughly understood than the above-discussed syndromes is radiculopathy associated with cervical spondylosis. The most commonly involved nerve roots are the sixth and seventh nerve roots, which are caused by C5-C6 or C6-C7 spondylosis, respectively. Patients usually present with pain, paresthesias or weakness, or a combination of these symptoms. The vast majority of these patients present without a history of trauma or other recalled precipitated cause. The pain is usually in the cervical region, the upper limb, shoulder, and/or interscapular region. At times, the pain may be atypical and manifest as chest pain (pseudoangina) or breast pain. Usually, the pain is more frequent in the upper limbs than in the neck, although it is frequently present in both areas. [17] Cervical radiculopathy is not usually associated with myelopathy. [2]
Cervical spondylotic myelopathy is the most common cause of nontraumatic paraparesis and tetraparesis. The process usually develops insidiously.
In the early stages, patients often present with neck stiffness. Patients also may present with stabbing pain in the preaxial or postaxial border of the arms. [10] Patients with a high compressive myelopathy (C3-C5) can present with a syndrome of "numb, clumsy hands," for which the patient describes difficulty writing, a loss of manual dexterity, nonspecific and diffuse weakness, and abnormal sensations. [2] Those patients with a lower myelopathy typically present with a syndrome of weakness, stiffness, and proprioceptive loss in the legs. These patients often exhibit signs of spasticity.
Weakness or clumsiness of the hands may be seen in conjunction with weakness in the legs. Motor loss in the hands with relative sparing of the legs, however, is a relatively rare syndrome. Symptoms are commonly asymmetric in the legs.
Loss of sphincter control and urinary incontinence are rare; some patients, however, report urinary urgency, frequency, and/or hesitancy. [2, 10]
Cervical spondylotic myelopathy significantly affects patients' quality of life. A recent study reported that greater than one third of patients with cervical spondylotic myelopathy have anxious or depressed moods related to their decreased mobility. [18]
Another syndrome that may be seen in relation to cervical spondylosis is central cord syndrome. This syndrome typically occurs when an elderly patient experiences an acute hyperextension injury with preexisting acquired stenosis due to ventral osteophytes and infolding of redundant ligamentum flavum, resulting in acute cord compression. Patients usually present with a history of a blow to the forehead. The syndrome consists of greater upper extremity weakness than lower extremity weakness, varying degrees of sensory disturbances below the lesion, and myelopathic findings such as spasticity and urinary retention. [19]
Rarely, dysphagia or airway dysfunction has been reported secondary to cervical spondylosis. [20, 21, 22, 23, 24] Dysphagia may occur when large anterior osteophytes cause mechanical compression of the esophagus or periesophageal inflammation causes motion over the osteophytes. Conservative therapy with anti-inflammatory medications and other modalities has been advocated for mild-to-moderate cases of dysphagia, while surgery has been reserved for more severe cases. [22]
Physical
Examination findings include neck pain, radicular signs, and myelopathic signs. Patients with neck pain from spondylosis often present with neck stiffness. This is a nonspecific sign, and other causes of neck pain and stiffness (eg, myofascial pain, intrinsic shoulder pathology) must be considered and excluded.
If the history is compatible with cervical radiculopathy, carefully search for signs of muscle atrophy in the supraspinatus, infraspinatus, deltoid, triceps, and first dorsal interosseus muscles.
Winging of the scapula also may be present because it can occur with C6 or C7 radiculopathy. Palpate all muscles because this may allow earlier detection of wasting than visualization can provide. If weakness is detected in either 1 myotomal distribution or 2-3 peripheral nerves, peripheral nerve injury can likely be excluded as the cause. Muscle testing is important because muscle findings have more specificity than sensory or reflex findings.
Perform a detailed sensory and reflex examination in every patient who presents with a history suggestive of cervical spondylosis. Note that radicular findings often do not adhere strictly to textbook dermatomal charts. Patients often experience more pain proximally in their limbs, while, distally, paresthesias dominate.
Look for physical evidence of other causes of radiculopathy-type symptoms (eg, tenderness lateral to the neck in the supraclavicular fossa, Tinel sign).
The neck compression test (Spurling test or sign), if positive, is useful when assessing a patient for cervical radiculopathy.
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This test is best performed by having the patient actively extend his or her neck, laterally flex, and rotate to the side of the pain while sitting. Next, use careful compression by slight axial loading. This maneuver works by narrowing the ipsilateral neural foramina during flexion and rotation, while the initial extension causes posterior disk bulging.
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While this maneuver has a low sensitivity for cervical radiculopathy, it has a specificity of nearly 100%. Other useful tests are the axial manual traction test and the shoulder abduction test.
In cervical spondylotic myelopathy, the most typical examination findings are suggestive of upper motor dysfunction, including hyperactive deep tendon reflexes, ankle and/or patellar clonus, spasticity (especially of the lower extremities), the Babinski sign, and the Hoffman sign.
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The Hoffman sign is a reflex contraction of the thumb and index finger after nipping the middle finger. Although this sign is usually present with corticospinal tract dysfunction, unlike the Babinski sign, it can also be present in generalized hyperreflexic states and in neurosis. It also may be found (usually bilaterally and incomplete) in persons without cervical spondylotic myelopathy.
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Thus, this sign is only valuable if it is associated with other upper motor neuron–related findings. The Hoffman sign is best elicited by positioning the patient's hand at rest and then stabilizing the proximal phalanx between the examiner's index and middle finger; with the examiner's thumb, the patient's distal middle finger is flicked downward. The sensitivity of this examination maneuver may be increased by examining the patient during multiple full flexions or extensions of the neck (dynamic Hoffman sign).
Another occasionally useful test is the pectoralis muscle reflex.
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This is elicited by tapping the pectoralis tendon in the deltopectoral groove, which causes adduction and internal rotation of the shoulder if hyperactivity is present. A positive result suggests compression in the upper cervical spine (C2-C4).
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If the patient exhibits diffuse hyperreflexia, then the jaw jerk may distinguish an upper cervical cord compression from lesions that are above the foramen magnum.
In patients with cervical spondylotic myelopathy, weakness is most commonly seen in the triceps and/or hand intrinsic muscles, where upper extremity symptoms typically begin. Wasting of the intrinsic hand musculature is also a typical finding.
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A thorough examination of patients' hands should be performed. By having the patient make a fist and release it 20 times in 10 seconds, impairment or clumsiness may be observed that may suggest cervical spondylotic myelopathy.
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The finger escape sign may also be present. To assess this, the patient holds his or her fingers extended and adducted. If the ulnar digits drift into abduction and flexion within 30-60 seconds, cervical spondylotic myelopathy may be present.
A classic finding with examination of the lower extremities is proximal motor weakness, most commonly in the iliopsoas, followed by the quadriceps femoris; distal weakness is a less common finding. The finding of lower extremity weakness and lower extremity upper motor neuron signs but absent upper extremity symptoms and signs should trigger a workup for thoracic cord pathology.
Examine gait during any neurologic examination whenever possible. Patients with cervical spondylotic myelopathy typically exhibit a stiff or spastic gait, especially later in the course of their disease.
Another helpful sign is the Lhermitte sign.
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This consists of electric shock–like sensations that run down the center of the patient's back and shoot into the limbs during flexion of the neck.
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This sign is not specific for cervical spondylotic myelopathy and classically is attributed to posterior column dysfunction. Other causes of the Lhermitte sign include multiple sclerosis, tumors, and other compressive pathology.
Sensory abnormalities in cervical spondylotic myelopathy have a variable pattern upon examination.
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Loss of vibratory sense or proprioception in the extremities can occur, particularly in the feet. Spinothalamic sensory loss may be asymmetric.
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Diabetes mellitus or other metabolic causes of peripheral neuropathy can confound the sensory examination. Perform a complete motor examination. Wasting of the intrinsic hand musculature is a classic finding in persons with cervical spondylotic myelopathy.
Causes
In addition to age and possibly sex, several risk factors have been proposed for cervical spondylosis.
Repeated occupational trauma (eg, carrying axial loads, professional dancing, gymnastics) may contribute. The role of occupational trauma is controversial, especially in terms of worker's compensation claims and other related medicolegal clauses.
Familial cases have been reported; a genetic cause is possible.
Smoking also may be a risk factor.
Conditions that contribute to segmental instability and excessive segmental motion (eg, congenitally fused spine, cerebral palsy, Down syndrome) may be risk factors for spondylotic disease. Cervical spondylotic myelopathy may be responsible for functional declines in patients with athetoid cerebral palsy.
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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. T2-weighted sagittal MRI shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.
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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. Axial gradient echo MRI 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).
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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. Axial CT scan at C5-6 demonstrates a large ventral osteophyte (see arrow). In addition, uncinate process hypertrophy is present bilaterally and the right neural foramen is narrowed.
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T2-weighted sagittal MRI of a 59-year-old woman who presented with a spastic gait and weakness in her upper extremities showing 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.
