Cervical Spondylosis Clinical Presentation

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 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).

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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. 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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  • 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 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.

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  • 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.) ^[12]

    • 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 - A case-control study by Yang et al indicated that the presence of cervical spondylosis correlates with the subsequent development of peripheral vertigo. The investigators found that 19.49% of patients with peripheral vertigo had prior cervical spondylosis, compared with 16.06% of controls, with the odds of previous cervical spondylosis in individuals with peripheral vertigo being 1.285. These odds rose to 1.442 in persons aged 45-64 years. ^[13]

  • Elevated hemidiaphragm, caused by spondylotic compression of C3-4 (as noted in a case report), may be another finding.

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 flexion.

• 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

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. ^[14]

  • 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.