Understanding cervical spondylosis with/without radiculopathies

1. CERVICAL SPONDYLOSIS
BY : PHILANS COSMOS ANKRAH

3. Neck pain is a common complaint and tends to occur
with increasing frequency after the age of 30. Most
episodes of neck pain are short-lived and tend to
respond to nonoperative management
(Watson, 1993).
KEY POINT

4.  Definition
 Brief anatomy
 Prevalence
 Pathogenesis
 Symptoms and complications
 Diagnosis and Imaging studies
 Physical examination
 Prognosis
 Treatment
CONTENT

5. Arthritis of C/ Spine
Cervical spondylosis is a disorder caused by abnormal wear on cervical
vertebrae with degeneration and mineral deposits in the attachments of
the cervical vertebrae, causing pain and weakness in the neck and arm,
and changes in sensation.
DEFINITION

6.  Cervical aspect: There are seven cervical vertebrae-- the atlas(C1), the axis(C2), and
cervical vertebrae numbers three through seven. (C3-C7).
 There is no disc between the atlas and the axis.
 The 7th spinous process is the longest.
 Cervical vertebrae have transverse foramina that differ from other vertebrae.
BRIEF ANATOMY OF THE NECK

8. Transverse foramen
Vertebral foramen
Odontoid process
(dens) of axis
Transverse
ligament of atlas
Atlas (C1)
Axis (C2)
Spinous
process
Anterior arch of atlas
Posterior arch of C1

9. CERVICAL PLEXUS
• The cervical plexus is formed by the ventral
rami of the C1-C4 spinal nerves. These
nerves supply the muscles and skin of the
head, neck, shoulder, and chest.
BRIEF ANATOMY OF THE NECK

10. BRACHIAL PLEXUS
• The brachial plexus is composed C5, C6, C7, C8
and T1 spinal nerves.
• Those include a radial nerve, a median nerve, a
ulnar nerve.
① The radial nerve: C5-C8,T1 of spinal nerves.
② The Ulnar nerve: C8 and T1 of spinal nerves.
③ The median nerve: C5-C8,T1 of spinal nerves
BRIEF ANATOMY OF THE NECK

11. MUSCLES OF THE NECK
Scalene muscles: Middle scalene, Anterior
scalene, Posterior scalene.
Sternocleidomastoid
Semispinalis capitis
Splenius capitis
Levator scapulae
Trapezius
Supra- and infra-hyoid muscles
BRIEF ANATOMY OF THE NECK

12.  In the United States, Prevalence of neck and referred shoulder/brachial pain has been reported to
be 9%.
o In a series of 205 patients who present with neck pain and were managed nonoperatively, 79% were
noted to be asymptomatic or improved at a minimum follow-up of 10 years. Radiographically, 25%
of patients in their fifth decade have been shown to have degenerative changes in one or more discs.
o By the seventh decade, this number increases to over 75% (Lewis et al., 2007).
 Little literature exists to authoritatively state epidemiological study results of cervical spondylosis in
Ghana.
 In TQMH, Cervical spondylosis has been among the top five cases presented at the physiotherapy
department since 2008
PREVALENCE

13. 1. Intervertebral disc herniation:
• Injury
• degenerative changes.
2. Degeneration of cervical vertebrae: occurs as a natural consequence of the normal
aging process with a resulting decrease in the water content of the disc.
• Osteophytosis of the vertebral bodies.
• Hypertrophy of the facets and laminal arches.
3. ligamentous and segmental instability.
PATHOGENESIS

14. DISC AGEING
• Decrease in volume
• loss of disc height
• protrusion of central disc into vertebral body
• decrease in height+ bulging of annulus
• changes in disc tissue microstructure/composition
PATHOGENESIS

15. Neck pain (may radiate to the arms or shoulder)
Loss of sensation or abnormal sensations of the shoulders, arms, or
(rarely) legs
Weakness of the arms or (rarely) legs
Neck stiffness that progressively worsens
Loss of balance
Headaches, particularly in the back of the head
Loss of control of the bladder or bowels (if spinal cord is compressed)
SYMPTOMS

16. CERVICAL RADICULOPATHY
Herniation or degeneration of an intervertebral disc
1. C5-6 (C6 nerve root affected).
• Pain will radiate to the shoulder or lateral arm and dorsal
forearm.
• Anesthesia and paresthesias may be present in the thumb
and index finger.
• Weakness, if present, will involve the biceps and wrist
extensors.
• The brachioradialis or biceps reflex is often decreased or
absent.
CLINICAL MANIFESTATIONS

17. CLINICAL MANIFESTATIONS
CERVICAL RADICULOPATHY
Herniation or degeneration of an intervertebral disc
2. C6-7 (C7 nerve root affected).
• The pain distribution is similar to that of a C7 radiculopathy.
• Anesthesia and parestheias, when present, involve the index and mid fingers.
• Weakness, if present, is noted in the triceps, wrist flexors, and finger extensors.
• The triceps reflex may be reduced.

18. Chronic neck pain
Progressive loss of muscle function or feeling
Permanent disability (occasional)
Inability to retain feces (fecal incontinence) or urine (urinary
incontinence)
COMPLICATIONS

19. 1) Age: the most cases are over 40 years old, and men more than
women.
2) Pain in the neck, headache (back of head), shoulder, or
radiating pain in the arm or fingers.
3) Numbness or tingling in the arm or fingers or thumb.
4) Dizziness.
5) Loss of balance.
6) Dry eyes, visual disturbances (eg, blurred vision, diplopia)
7) Tinnitus.
8) Disturbed concentration and memory
9) X-ray, MRI, CT: will find particular problem.
POINTS OF DIAGNOSIS

20. • A spine or neck x-ray shows abnormalities that
indicate cervical spondylosis.
• A CT scan or spine MRI confirms the diagnosis.
• A Cervical myelogram (x-ray or CT scan after injection
of dye into the spinal column) may be recommended
to clearly identify the extent of injury.
• MRI
• An EMG may also be recommended.
IMAGING

21. PLAIN X-RAYS.
• A plain x-ray series should include an anterior/posterior view, a
lateralview, and oblique views.
• Degeneration can often be noted within the disc spaces and the facet
joints.
• There are often osteophytes noted along the area of the disc space, and
foraminal narrowing can be noted on oblique views.
• Instability has been defined as greater than 3-5 mm of translation or 11
degrees of angulation between adjacent vertebral segments.
IMAGING STUDIES

22. Cervical spondylosis involves loss of disc space height.
• As a result of the degeneration within the disc and the decreased
intervertebral height, altered spinal biomechanics ensue, with
osteophytes forming along the area of the disc space as well as
posteriorly along the facet joints.
• This can be associated with nerve root and spinal cord compression.
IMAGING STUDIES

23. IMAGING STUDIES

25. Examination should include inspection of the symmetry of the paraspinal muscles as
well as the trapezius and shoulder musculature.
Any signs of atrophy must be noted.
Strength and range of motion of the shoulder should be tested, as well as examination
for focal tenderness within the shoulder(to help rule out the shoulder as a source of
potential pain or to define coexistent shoulder disease.)
Special tests (Zito, 2006)
PHYSICAL EXAMINATION

26. SPECIAL TESTS
1. Cervical movement: Flexion 35-45°; Extension 35-45°; Lateral bending
45°; Rotation 60-80°.
2. Spurling test.
3. Jackson test.
4. Compression test.
5. Traction test.
6. Percussion test
7. Tension arm test
PHYSICAL EXAMINATION

27. Tension arm test Percussion head test

28. Jackson test  TRACTION TEST

29.  Most patients with cervical spondylosis will have some chronic
symptoms, but they generally respond to non-operative interventions
and do not require surgery.
PROGNOSIS

30. Conservative care
• Is the primary treatment of patients with neck pain, with or without
radicular symptoms.
• Lifestyle modifications should be instituted to avoid activities that tend
to create or aggravate neck and arm symptoms.
PHYSIOTHERAPY…
TREATMENT

31. Conservative care (cont’d)
A. Typical activities to modify
Posture
Neck weight bearing
TREATMENT

32. Conservative care
B- Use of medications
• anti-inflammatory medications help decrease the
amount of inflammation and provide pain relief.
• In cases of severe pain, mild narcotics may be useful.
• Muscle relaxants may also help decrease the amount of
spasm and allow or increase more comfortable periods
of rest.
• Short courses of steroids are sometimes needed to
control the inflammatory process.
TREATMENT

33.  Conservative care
C- Physical therapy
 useful in the treatment of neck and radicular arm pain.
 Modalities including
 traction,
 ultrasound,
 Electrotherapy and/or diathermy can give pain relief.
 Once the patient’s symptoms have begun to decrease, an exercise regimen can be added taking note that this does not
exacerbate the neck or arm pain symptoms
 Stretches, Active ROM exercises along with some isometric exercises can help regain the strength and flexibility of the
neck.
 Massage
 Dry needling
TREATMENT

34. Cervical traction

35. Cervical traction

36. Cervical collar kinesiotape

38. Surgery
INDICATIONS;
 failure of conservative therapy
 increasing neurologic deficit
 cervical myelopathy that is progressive
Only a small percentage of patients with cervical spine problems eventually
require surgery. However, if considered necessary the surgical procedure is
either an anterior cervical discectomy and fusion or a posterior
laminoforaminotomy.
TREATMENT

39. STANDING

40. WRONG RIGHTWRONG

41. SITTING POSTURE

45. SITTING POSTURE

47. POOR SLEEPING POSITION

48. GOOD SLEEPING POSITION

49. EVEN BETTER

50. POOR SLEEPING POSITION

51. GOOD SLEEPING POSITION

52. EVEN BETTER

53. SOME GOOD AND BAD POSTURES

54.  Watson DH and Trott PH (1993) Cervical headache. An investigation of natural
head posture and upper cervical flexor muscle performance. Cephalagia13:272-
284
 Zito G, Jull G and Story I (2006) Clinical tests of musculoskeletal dysfunction in
the diagnosis
 Lewis, M., James, M., Stokes, E., Hill, J., Sim, J., Hay, E., & Dziedzic, K. 2007, “An
economic evaluation of three physiotherapy treatments for non-specific neck
disorders alongside a randomized trial”, Rheumatology.(Oxford), vol. 46, no. 11,
pp. 1701-1708
 Kendall FB, McCreary EK. Muscle Testing and Function. 4th ed. Baltimore, MD:
Williams & Watkins; 1993: 215-226, 284-293.
References