Cervical Spondylosis

Intervertebral disks lose hydration and elasticity with age, and these losses lead to cracks and fissures. The surrounding ligaments also lose their elastic properties and develop traction spurs. The disk subsequently collapses as a result of biomechanical incompetence, causing the annulus to bulge outward. As the disk space narrows, the annulus bulges, and the facets override. This change, in turn, increases motion at that spinal segment and further hastens the damage to the disk. Annulus fissures and herniation may occur. Acute disk herniation may complicate chronic spondylotic changes.

As the annulus bulges, the cross-sectional area of the canal is narrowed. This effect may be accentuated by hypertrophy of the facet joints (posteriorly) and of the ligamentum flavum, which becomes thick with age. Neck extension causes the ligaments to fold inward, reducing the anteroposterior (AP) diameter of the spinal canal.

As disk degeneration occurs, the uncinate process overrides and hypertrophies, compromising the ventrolateral portion of the foramen. Likewise, facet hypertrophy decreases the dorsolateral aspect of the foramen. This change contributes to the radiculopathy that is associated with cervical spondylosis. Marginal osteophytes begin to develop. Additional stresses, such as trauma or long-term heavy use, may exacerbate this process. These osteophytes stabilize the vertebral bodies adjacent to the level of the degenerating disk and increase the weight-bearing surface of the vertebral endplates. (See images below) The result is decreased effective force on each of these structures.

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 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.

Degeneration of the joint surfaces and ligaments decreases motion and can act as a limiting mechanism against further deterioration. Thickening and ossification of the posterior longitudinal ligament (OPLL) also decreases the diameter of the canal.[4, 5, 6]

The blood supply of the spinal cord is an important anatomic factor in the pathophysiology. Radicular arteries in the dural sleeves tolerate compression and repetitive minor trauma poorly. The spinal cord and canal size also are factors. A congenitally narrow canal does not necessarily predispose a person to myelopathy, but symptomatic disease rarely develops in individuals with a canal that is larger than 13 mm.

Frequency

United States

Cervical spondylosis is a common condition that is estimated to account for 2% of all hospital admissions. It is the most frequent cause of spinal cord dysfunction in patients older than 55 years. On the basis of radiologic findings, 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the cervical spine.

Evidence from a 2009 report indicated that cervical spondylosis with myelopathy was the most common primary diagnosis (36%) among elderly US patients admitted to the hospital for surgical treatment of a degenerative cervical spine between 1992 and 2005.[7] The study, which looked at 156,820 hospital admissions for elderly Medicare beneficiaries, also determined that fusion was the most common procedure (70%) performed in these patients for cervical spine degeneration, with 58% of the fusions being anterior.

International

Investigators in a study involving Ghanaians reported, "out of 225 patients who carried loads on their head, 143 (63.6%) had cervical spondylosis, and of the 80 people who did not carry load on their head, 29 (36%) had cervical spondylosis."

Mortality/Morbidity

The course of cervical spondylosis may be slow and prolonged, and patients may either remain asymptomatic or have mild cervical pain. Long periods of nonprogressive disability are typical, and in a few cases, the patient's condition progressively deteriorates.

Morbidity ranges from chronic neck pain, radicular pain, diminished cervical range of motion (ROM), headache,[8] myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis and/or sphincteric dysfunction (eg, difficulty with bowel or bladder control) in advanced cases. The patient may eventually become chair bound or bedridden.

A retrospective cohort study by Lin et al suggested that cervical spondylosis increases the risk for migraine headaches. The investigators found the overall incidence of migraines in persons with cervical spondylosis to be 5.16 per 1000 people annually, compared with 2.09 per 1000 people annually in controls. The adjusted hazard ratio for migraine in cervical spondylosis was reported to be 2.03. In cervical spondylosis patients with myelopathy, the incidence of migraine was 2.19 times greater than in controls.[9]

A study by Woodworth et al suggested that cervical spondylosis leads to cortical thinning and atrophy in the brain, with resultant increases in neurologic symptoms and pain. Using high-resolution T1-weighted structure magnetic resonance imaging (MRI), the investigators reported that in patients with cervical spondylosis, changes were seen in parts of the brain associated with sensorimotor function and pain processing, including cortical thinning in the superior frontal gyrus, anterior cingulate, and precuneus and volume reduction in the putamen.[10]

Race

No apparent correlation between race and cervical spondylosis exists.

Sex

Both sexes are affected equally. Cervical spondylosis usually starts earlier in men than in women.

Age

Symptoms of cervical spondylosis may appear in persons as young as 30 years but are found most commonly in individuals aged 40-60 years. Radiologic spondylotic changes increase with patient age; 70% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine.

A retrospective study by Wang et al of 1276 cases of cervical spondylosis found an aging-related increase in the incidence of the condition—including bulge or herniation at C3-C4, C4-C5, C5-C6, and C6-C7—in patients up to age 50 years and a decrease in the condition’s incidence with aging in patients older than 50 years, with the decrease particularly seen after age 60 years. Additionally, an aging-related increase in the incidence of hyperosteogenesis and spinal stenosis was found prior to age 60 years, with a decrease in incidence seen after age 60 years.[11]

Cervical spondylosis usually starts earlier in men than in women. When cervical spondylosis develops in a young individual, it is almost always secondary to a predisposing abnormality in one of the joints between the cervical vertebrae, probably as a result of previous mild trauma.

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).
    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.

  • 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.

  • 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.

See the list below:

• Usually, no specific findings are present.

• Other findings may include those related to an underlying etiologic or pathogenetic disorder that initiates the spondylotic changes.

See the list below:

• Plain cervical radiography is routine in every patient with suspected cervical spondylosis.

  • This examination is valuable in evaluating the uncovertebral and facet joints, the foramen, intervertebral disk spaces, and osteophyte formation.

  • In select circumstances, flexion-extension views may be needed to detect instability.

• Myelography, with computed tomography (CT) scanning, was previously considered to be the imaging test of choice for assessing spinal and foraminal stenosis. However, with advances in MRI and CT scanning technology, myelography is now performed in selected patients.[15]

  • Because myelography method is invasive, most physicians depend on MRI in diagnosing cervical spondylosis.[15]

  • Myelography adds anatomic information in evaluating spondylosis.

  • Myelography may be especially useful in visualizing the nerve root takeoff.

  • CT scanning, with or without intrathecal dye, can be used to estimate the diameter of the canal.

  • CT scans may demonstrate small, lateral osteophytes and calcific opacities in the middle of the vertebral body.

• MRI is a considerable advance in the use of imaging to diagnose cervical spondylosis. It offers the following advantages:

  • Direct imaging in multiple planes

  • Better definition of neural elements

  • Increased accuracy in evaluating intrinsic spinal cord diseases

  • Noninvasiveness

  • Myelogramlike images

• High–signal-intensity lesions can be seen on magnetic resonance images of spinal cord compression; this finding indicates a poor prognosis.

• False-positive and false-negative MRI results occur frequently in patients with cervical radiculopathy; therefore, MRI results and clinical findings should be used when interpreting root compression.[3]

A study by Banaszek et al indicated that diffusion tensor imaging (DTI) can demonstrate spinal cord impairment in patients with early stage cervical spondylosis before such impairment is visible on plain MRI scans. The study involved 132 symptomatic patients with varying degrees of cervical spondylosis, as well as 25 control subjects. Examining spinal segments from C2/C3 to C5/C6, the investigators found significant differences in fractional anisotropy values between the control subjects and the patients with cervical spondylosis, including early stage patients who did not yet show spinal cord compression on plain MRI scans. According to the investigators, the mean fractional anisotropy values were significantly associated with the anteroposterior diameter of the spinal canal and with space available for the spinal cord index.[16]

See the list below:

• Electromyography is useful in evaluating radiculopathy caused by spondylosis when the diagnosis of radiculopathy is in question, but it may have only limited value in assessing myelopathy.

• In myelopathy, somatosensory evoked potential (SSEP) responses are delayed or have a low amplitude.[17]

• Cortical motor evoked potentials (MEP) may be more sensitive than SSEPs in evaluating spinal cord dysfunction.[18, 19]

• As an invasive procedure, cervical diskography is not commonly used in the evaluation of cervical spondylosis.

• Urodynamic studies may be helpful in evaluating bladder incontinence (see Other Treatment).

Thinning and fragmentation of the articular cartilage may be observed. The normal smooth, white articular surface becomes irregular and yellow. Continued loss of articular cartilage leads to exposure of areas of subchondral bone, which appear as shiny foci on the articular surface (eburnation). Fibrosis, increased bone formation, and cystic changes frequently occur in the underlying bone. Loss of articular cartilage stimulates new bone formation, usually in the form of nodules (osteophytes) at the bone edges.

Physical therapy

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

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

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[20, 21, 22] :

• Diskectomy without bone graft

• Diskectomy with bone graft

• Cervical instrumentation

Posterior approaches include the following[4, 23] :

• Decompressive laminectomy and foraminotomy

• Hemilaminectomy

• Laminoplasty[24, 25]

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.[26]

A literature review by Ma et al indicated that in patients with cervical spondylosis, treatment with anterior cervical diskectomy and fusion (ACDF) was associated with a lower overall success rate and a higher visual analog scale score than was treatment with cervical arthroplasty. However, the mean duration of surgery was shorter with diskectomy/fusion.[27]

A study by Lim et al, using the American College of Surgeons National Surgical Quality Improvement Program database, reported that in patients with cervical spondylosis undergoing ACDF, instrumentation can be safely employed. The investigators found that 30-day rates of complications, unplanned reoperation, and readmission did not significantly differ between patients who underwent ACDF with instrumentation and those treated with ACDF without instrumentation.[28]

In a retrospective study of elderly patients with cervical spondylosis who were treated with primary one- to two-level anterior cervical spine fusion, Puvanesarajah et al found that major medical complications or mortality are more likely to occur in patients aged 80 years or above than in those aged 65-79 years. Patients aged 80 years or older also had significantly higher rates of dysphagia, aspiration pneumonitis, and reintubation. However, the investigators state that carefully selected patients in this age group could potentially benefit substantially from the surgery.[29]

A retrospective study by Passias et al indicated that in patients with morbid obesity, bariatric surgery is associated with improved cervical and lumbar pathology. The investigators reported that by 180 days post surgery, half of the study’s patients who had been diagnosed with cervical or lumbar pathology had stopped seeking inpatient care for the spinal condition. For individuals with cervical spondylosis, that diagnosis no longer applied to (cumulatively) 46%, 70%, 83%, and 94% of them at 90-, 180-, 360-, and 720-day follow-up (respectively).[30]

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

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.[31] Referral to a psychologist or psychiatrist for psychotherapy, pharmacotherapy, and/or family counseling may be indicated.

The goal of pharmacotherapy is to reduce morbidity and prevent complications.

Class Summary

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment of cervical spondylosis. If one class seems to be ineffective after a 2-week trial, a formulation from another class may be tried. The most commonly used NSAIDs are ibuprofen, acetylsalicylic acid, naproxen, indomethacin, meloxicam, and piroxicam.

Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)

Relieves mild to moderately severe pain and inhibits inflammatory reactions, probably by decreasing the activity of the enzyme cyclooxygenase, thus inhibiting prostaglandin synthesis.

Ibuprofen (Ibuprin, Advil, Motrin)

NSAID from propionic acid derivatives group. Effective inhibitor of cyclo-oxygenase, which is responsible for biosynthesis of prostaglandins. Rapidly absorbed after oral administration. Half-life in plasma is about 2 h. Ibuprofen passes slowly into the synovial spaces and may remain there in higher concentration as the concentration in plasma declines. Excretion is rapid and complete (mainly excreted in urine as metabolites or conjugates).

Indomethacin (Indocin, Indochron E-R)

Rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. Indomethacin inhibits prostaglandin synthesis.

Piroxicam (Feldene)

Decreases the activity of cyclooxygenase, which in turn inhibits prostaglandin synthesis; piroxicam's effects decrease the formation of inflammatory mediators.

Aspirin (Anacin, Ascriptin, Bayer Aspirin)

Treats mild to moderately severe pain and headache. The drug inhibits prostaglandin synthesis, which prevents the formation of platelet-aggregating thromboxane A2; aspirin acts on the heat-regulating center of the hypothalamus and vasodilates peripheral vessels to reduce fever. By inhibiting prostaglandin synthesis, aspirin may also inhibit key steps in the inflammation process.

Meloxicam (Mobic, Vivlodex)

Meloxicam has anti-inflammatory effects systemically and can reduce the effect of local inflammatory mediators.

Class Summary

Corticosteroids have potent anti-inflammatory properties. These medications can be given as a brief tapered course of oral treatment.

Prednisone (Deltasone, Orasone, Sterapred)

Glucocorticoid steroid used to treat a variety of inflammatory conditions. Prednisone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Dosages may be adjusted for individual sensitivities and associated medical conditions.

Class Summary

Muscle relaxants are used to treat muscle spasm, which may play a role in patient discomfort.

Methocarbamol (Robaxin)

Skeletal muscle relaxant used in conjunction with other therapies to treat pain and discomfort associated with musculoskeletal conditions. Reduces nerve impulse transmission from spinal cord to skeletal muscle.

Class Summary

These agents are useful in select cases of chronic pain.

Amitriptyline (Elavil)

Antidepressant with sedative effects. The mechanism of action is unknown. Amitriptyline is not an MAOI and does not act primarily by stimulating CNS.

See the list below:

• Obtaining a thorough history and physical examination is required to assess the following:

  • Status of the cervical spine

  • Function of the genitourinary, musculoskeletal, gastrointestinal, vascular, respiratory, and integumentary systems

  • Nutritional, psychological, and vocational aspects of independent living and healthy living habits

• Laboratory studies may be indicated.

  • Tests can be used to determine the patient's overall state of health and the complete blood picture.

  • Urinalysis and an assessment of renal function may be performed.

• Physical therapy is recommended (see Physical Therapy).

• Occupational therapy is often beneficial (see Occupational Therapy).

• The following specialists may be consulted as needed:

  • Social worker

  • Psychologist

  • Recreational therapist

  • Orthopedist

  • Neurologist or neurosurgeon

  • Urologist

  • Internist

See the list below:

• In general, patients with uncomplicated cervical spondylosis and mild disability can be followed up on an outpatient basis.

• Patients with severe disability are better examined in the hospital.

See the list below:

• Medications may include the following:

  • NSAIDs - Acetylsalicylic acid, naproxen, ibuprofen, indomethacin, mefenamic acid, piroxicam

  • Corticosteroids - Oral prednisone or single IM injection

  • Muscle relaxants - Cyclobenzaprine, methocarbamol, and baclofen

  • Narcotic agents

  • Antidepressants - Doxepin, amitriptyline

See the list below:

• The patient may need to be transferred or referred to a facility in which the following specialists are available:

  • Occupational therapist - The therapist can help to modify the patient's home or work environment. Early referral is indicated to minimize deconditioning caused by further immobility or inactivity.

  • Physical therapist

  • Neurosurgeon

  • Recreational therapist

  • Psychologist

See the list below:

• Patients may apply the following measures to help prevent cervical spondylosis or its complications:

  • Avoid high-impact exercise (eg, running, jumping).

  • Maintain cervical ROM with daily ROM exercise.

  • Maintain neck muscle strength, especially neck extensor strength.

  • Avoid holding the head in 1 position for a long period (for example, while driving or watching TV).

  • Avoid prolonged neck extension.

  • Be careful when performing physical activities that are done infrequently; such activities can trigger a flare in symptoms.

• If the patient has only morning stiffness, a long, hot shower every morning may help.

• Cervical spondylosis is difficult to prevent because it is a part of the normal aging process. Individuals may reduce their risk by maintaining good neck strength and flexibility along with leading an active and healthy lifestyle. Preventing neck injuries (eg, using proper equipment in contact sports, headrest and seatbelt use in automobiles) also may reduce the risk of developing this condition.

See the list below:

• Cervical myelopathy - Can cause disabilities, which are categorized as follows (see image below):

  • Grade 0 - Root signs and symptoms, with no evidence of cord involvement, are observed.

  • Grade I - Signs of cord involvement are present, but the patient's gait is normal.

  • Grade II - Mild gait involvement is present, and the patient may be employed.

  • Grade III - Gait abnormality prevents the patient's employment.

  • Grade IV - Ambulation is possible only with assistance.

  • Grade V - The patient is chair-bound or bedridden.

• Paraplegia

• Tetraplegia

• Recurrent chest infection

• Pressure sores

  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.

See the list below:

• Cervical spondylosis is a slowly progressive, chronic joint disability, especially when it is associated with neuronal compression.

• Cervical spondylotic myelopathy is the most serious consequence.

• High – signal-intensity lesions can be seen on magnetic resonance images of spinal cord compression; this finding indicates a poor prognosis.

See the list below:

• For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education article Shoulder and Neck Pain.