Cervical Spondylosis

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Cervical spondylosis comprises a broad spectrum of progressive degenerative alterations that affect all cervical spine components (i.e., intervertebral discs, facet joints, joints of the Luschka, ligaments flava, and laminae). It is a normal part of the aging process and occurs in the majority of individuals after the fifth decade. This chronic degenerative process in the cervical spine affects the intervertebral discs and facet joints and may develop into disc herniation, osteophyte formation, vertebral body degeneration, spinal cord compression, or cervical spondylotic myelopathy. When neural structures are compressed, cervical spondylosis manifests as neck pain and stiffness, which may be accompanied by radicular symptoms. Neck discomfort is a frequent complaint, second only to low back pain in the frequency of occurrence. This disorder is linked with a large burden of sickness, disability, and economic cost. Although aging is the major cause the location and pace of degeneration, as well as the severity of symptoms and functional impairment, vary from person to person.

Epidemiology

Evidence of spondylotic change is frequently found in many asymptomatic adults, with evidence of some disc degeneration in:

  • 25% of adults under the age of 40,
  • 50% of adults over the age of 40, and
  • 85% of adults over the age of 60

Asymptomatic adults showed significant degenerative changes at 1 or more levels

  • 70% of women and 95% of men at age 65 and 60 were affected
  • The most common evidence of degeneration is found at C5-6 followed by C6-7 and C4-5″.

Risk Factor

  • Age, gender and occupation.
  • The prevalence of cervical spondylosis is similar for both sexes, although the degree of severity is greater for males.
  • Repeated occupational trauma may contribute to the development of cervical spondylosis.
  • Increased incidence in patients who carried heavy loads on their heads or shoulders and in dancers and gymnasts.
  • In about 10% of patients, cervical spondylosis is due to congenital bony anomalies, blocked vertebrae, malformed laminae that place undue stress on adjacent intervertebral discs.

Clinical presentation

1 Non-specific neck discomfort – spinal column-localized pain
2 Cervical radiculopathy – symptoms with a dermatomal or myotomal distribution, which are often experienced in the arms. There may be numbness, discomfort, or function loss.
3 Cervical myelopathy – a collection of symptoms and results resulting from intrinsic spinal cord injury. With concomitant physical findings, numbness, coordination and gait problems, grip weakness, and bowel and bladder symptoms may be observed.

Depending on the stage of the disease process and the place of neurological compression, symptoms might vary. The patient may be asymptomatic despite the presence of spondylosis on imaging[10], and vice versa. On radiographs of the cervical spine, many individuals over the age of 30 have comparable anomalies, making it difficult to distinguish between normal aging and disease.

Pain is the symptom most often mentioned. According to McCormack et al. intermittent neck and shoulder pain is the most prevalent symptom seen in clinical practice. Pain most often occurs in the cervical area, upper extremity, shoulder, and/or interscapular region with cervical radiculopathy. In certain circumstances, the pain may be unusual and appear as chest or breast discomfort, however, it is most often experienced in the upper extremities and neck. Chronic suboccipital headache may be a clinical condition in individuals with cervical spondylosis, which may radiate to the base of the neck and the top of the head.

Frequently reported symptoms of paraesthesia, muscular weakness, or a combination thereof, suggest radiculopathy.

In certain instances, dysphagia or airway dysfunction has been described in association with central cord syndrome and cervical spondylosis.

Examination

Patient history should include pain chronology, radiation, aggravating variables, and inciting events. Symptomatic cervical spondylosis often appears as one of three syndromes:

Axial neck pain

1) Complain of stiffness and soreness in the cervical spine, which is worse while standing and eased by bed rest.
2 ) Neck hyperextension and side-bending aggravate discomfort.
3 ) In upper and lower cervical spine illness, patients may experience radiating pain into the ear or occiput against the superior trapezius or periscapular muscles.
4 ) Atypical cervical angina symptoms include jaw or chest discomfort.

Cervical radiculopathy

  1. Radicular symptoms might include unilateral or bilateral neck discomfort, arm pain, scapular pain, paraesthesia, and arm or hand weakness.
  2. Head tilt toward the afflicted side or hyperextension and side-bending worsen the pain.

Cervical Myelopathy

  1. Insidious onset, with or without neck discomfort (frequently absent)
  2. Can cause hand weakness and clumsiness, preventing fine motor skills (e.g., buttoning a shirt, tying shoelaces, picking up small objects)
  3. Unexplained gait instability and falls
  4. Incontinence is infrequent and appears late in disease development

Managment

Exercise, mobilization, and manipulation alone have limited proof.
Mobilization and/or manipulations combined with exercises help subacute or chronic mechanical neck discomfort with or without headache.
Proprioceptive, strengthening, endurance, or coordination activities are more beneficial than standard pharmacological care.

  • Treatment involves rehabilitative exercises, proprioceptive re-retraining, manual treatment, and posture instruction.
  • 2018 research comparing isometric and dynamic exercises found that short-term physiotherapy helps alleviate cervical spondylosis. Dynamic exercises are preferred than isometric ones.
  • Philadelphia Panel’s 2001 meta-analysis found  Physical therapies such as cervical traction, heat, cold, therapeutic ultrasound, massage, and TENS lacked evidence for treating acute or chronic neck discomfort.
    In individuals with radicular discomfort, cervical traction may relieve nerve root compression from foraminal stenosis.
    Myofascial trigger points may cause neck, shoulder, and upper arm discomfort.
  • High-velocity, low-amplitude thrust or non-thrust manipulation is manual treatment. Manual therapy may reduce discomfort, improve function, enhance range of motion, and treat thoracic hypomobility. 
  • Therapists may use prone, supine, or seated positions for thoracic spine thrust manipulation. Cervical traction might widen the neural foramen and relieve neck tension. 
  • Non-thrust manipulation includes prone PA glides. Retractions, rotations, ULTT1 lateral glides, and PA glides are cervical spine methods. Techniques are selected depending on patient responsiveness and symptom centralization. 
  • Postural education covers sitting and standing spine alignment.
  • Ultrasound is ineffective and thermal treatment merely gives symptomatic relief
  • Soft tissue mobilization was conducted on the upper quarter muscles with the upper extremities in abduction and external rotation to pre-load neural structure
  • Home exercises include cervical retraction, extension, deep cervical flexor strengthening, scapular strengthening, and chest muscular stretching by isometric contraction of flexor and extensor muscles.
  • Education: Cervical spondylosis has a diverse natural history and is difficult to avoid since it’s part of aging. The patient should be trained to maintain excellent neck strength and flexibility, lead an active and healthy lifestyle, and prevent neck injuries (e.g., good ergonomics, avoiding extended neck extension, suitable equipment for contact sports, safe tackling technique, and seatbelt usage in cars.

Summary

1 Cervical spondylosis is a normal part of ageing, affecting 95% of 65-year-olds. Most individuals are asymptomatic but may develop neck discomfort, cervical radiculopathy, or cervical myelopathy.
2 Cervical spondylosis is the most frequent spine dysfunction in the elderly. Symptoms vary on the pathologic stage and region of neural compression.

3 Step-by-step therapy is needed. Neck discomfort without neurologic symptoms usually resolves between days to weeks without treatment. If problems continue, use NSAIDs and physical therapy. Patients experiencing axial neck discomfort, cervical radiculopathy, or moderate cervical myelopathy should work with a physical therapist before having surgery.

4 Treatment includes supervised isometric exercises, proprioceptive reeducation, manual therapy, and posture education.