Cervical spondylosis

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Skeletal spine

Cervical spondylosis Read More Chronic Spinal injury Bowel incontinence Cervical spondylosis is a disorder in which there is abnormal wear on the cartilage and bones of the neck (cervical vertebrae). See also:
• • •

Neck pain Herniated disk Spinal stenosis

Causes Cervical spondylosis is caused by chronic wearing away (degeneration) of the cervical spine, including the cushions between the neck vertebrae (cervical disks) and the joints between the bones of the cervical spine. There may be abnormal growths or "spurs" on the bones of the spine (vertebrae). These changes can, over time, press down on (compress) one or more of the nerve roots. In advanced cases, the spinal cord becomes involved. This can affect not just the arms, but the legs as well. The major risk factor is aging. By age 60, most women and men show signs of cervical spondylosis on x-ray. Other factors that can make a person more likely to develop spondylosis are:
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Past neck injury (often several years before) Severe arthritis Past spine surgery

Symptoms Symptoms often develop slowly over time, but may start suddenly. More common symptoms are:
• • • • •

Neck pain (may radiate to the arms or shoulder) Neck stiffness that gets worse over time Loss of sensation or abnormal sensations in the shoulders, arms, or (rarely) legs Weakness of the arms or (rarely) legs Headaches, particularly in the back of the head

Less common symptoms are:
• •

Loss of balance Loss of control over the bladder or bowels (if spinal cord is compressed)

Exams and Tests Examination often shows limited ability to bend the head toward the shoulder and rotate the head. Weakness or loss of sensation can be signs of damage to specific nerve roots or to the spinal cord. Reflexes are often reduced. The following tests may be done:
• • • •

CT scan or spine MRI Spine or neck x-ray EMG X-ray or CT scan after dye is injected into the spinal column (myelogram)

Treatment Even if your neck pain does not go away completely, or it gets more painful at times, learning to take care of your back at home and prevent repeat episodes of your back pain can help you avoid surgery. Symptoms from cervical spondylosis usually stabilize or get better with simple, conservative therapy, including:
• • • •

Nonsteroidal anti-inflammatory medications (NSAIDs) Narcotic medicine or muscle relaxants Physical therapy to learn exercises to do at home Cortisone injections to specific areas of the spine

Various other medications to help with chronic pain, including phenytoin, carbamazepine, or tricyclic antidepressants such as amitriptyline

If the pain does not respond to these measures, or there is a loss of movement or feeling, surgery is considered. Surgery is done to relieve the pressure on the nerves or the spinal cord.
CERVICAL SPONDYLITIS Do's § Do regular exercise to maintain neck strength, flexibility and range of motion. § Use firm mattress, thin pillow. § Do turn to one side while getting up from lying down position. § Wear a cervical collar during the day. § Regularly walk or engage in low-impact aerobic activity. § In order to avoid holding the head in the same position for long periods, take break while driving, watching TV or working on a computer. § Use a seat belt when in a car and use firm collar while traveling. § When in acute pain take rest, immobilize the neck, and take medications as directed. Don'ts § Avoid sitting for prolonged period of time in stressful postures. § Avoid running and high-impact aerobics, if you have any neck pain. § Do not lift heavy weights on head or back. § Avoid bad roads, if traveling by two or four wheelers. § Do not drive for long hours; take breaks. § Avoid habit of holding the telephone on one shoulder and leaning at it for long time. § Do not take many pillows below the neck and shoulder while sleeping. § Do not lie flat on your stomach. § In order to turn around, do not twist your neck or the body; instead turn around by moving your feet first. § Do not undergo spinal manipulations if you are experiencing acute pain. What are the bad postures that can worsen cervical spondylitis? 1. 2. 3. 4. 5. The The The The The head held forward from normal position shoulders held up and forward chest bent and rounded pelvic area tilted backwards hips, knees and ankles bent

muscular problem or by trapped nerve between vertebrae. Routine activity like traveling. Cervical Spondylosis can come from a number of disorders and diseases of any structures in neck. Many a time reference to a specialist also may not prove fruitful. Mobility of the spine is dependent on several small joints. A thorough knowledge of the structure and functioning of the neck has become essential to understand and hence successfully treat cervical spondylosis. Neck pain can be caused by an injury. and thus helps fighting this. This will be explained later along with measures to avoid their deleterious effects. etc. Cervical spondylosis may be caused by one or more of several complaints. Inappropriate working or sleeping posture can also be the cause.Treating the patient for a single factor like a spur seen on X-ray or a slipped disc in the neck seen on a myelogram or CT scan need not always completely alleviate the patient's suffering.Neck pain is one of the most common problems that one encounters in day to day life. Most people will experience neck pain at some point in their life. Biochemical engineering has helped us to understand the dynamics of the functioning of the various joints of the cervical spine and thus their role in production of the pain. the derangement of the functioning of one of which. It is probably as common as common cold. With the . It has also been possible to study the effects on the spine of external influences like concussion. There are several theories about why many people suffer neck pain. It is very important to attempt to ascertain the facts that can cause it. household work. Cervical Spondylosis is more frequently seen in women than men. A very common mistake is to perceive the cause of illness as a singular factor. hyper flexion. though general measures should always be taken to avoid it. no specific reason for cervical spondylosis can be found. A knowledge of such aggravating factors would prove beneficial and ensure a successful therapy. hypertension. office jobs though in themselves quite innocuous are potential harbingers of serious damage to the neck which results in prolonged cervical spondylosis. For most people. can cause neck pain and reduced movements.

nterior strong and solid portion of each vertebra is known as its Behind this the bone tends to be thinner and more delicate. embracing the spinal cord by forming a circle. It is known as vertebral disc and is made up of elastic fibres and is compressible. A hard knob is formed at the meeting of two ae behind known as the spinous process. e front. xample. are known as laminae. human beings walk on two legs. Similarly the spinous process of last cervical vertebra is ongest and strongest because it has to anchor muscles and the ligaments g from the head. unction Of The Spine e animals. its mechanism of functionaing is complex and boimechanics of ovements are very gentle and graceful. The cervical spine is made up ven seperate bones called vertebrae and the functioning of the spine -operative effort of the vertebrae. It forms rms on either side. two on either side of the ne. each vertebra has wn functions to perform and hence the shape of each vertebra varies. The spine is called upon to . the joint between the skull and the top of the spine is pivot joint. the skull has to rotate to look at the back. a disc of soft elastic but strong tissue of about 8mm ness is interposed between two vertebrae. To provide this y movement.L in k B a r 0 STRUCTURE AND FUNCTION OF CERVICAL SPINE natomy an cervical spine is an excellent example of engineering and manship. This knob can be felt under kin oints vertebra has at its back four joints. They are known as intervertebral joints. In addittion. one above and one below. ession of several disc can produce a smooth curved in half or one of a circle.

This is a l configuration of each human being. What is treatment for Cervical Spondylosis? 1. During various movements of the neck pinal cord is well protected.Do's and Dont's Medical Treatment Usually Analgesics and muscle relaxants are advised . seven. our spine is provided with curves so that it can last.Medical 2.Relaxation 4. At their exit from the canal the nerve roots must not be essed or pinched during normal movements of the neck.e. ome people have long necks and some have very short necks.mit weight of the body to the ground.Ergonomics 5. In the cal spine the convexity is at the level of disc between fifth and cervical vertebrae.Physiotherapy 3. broad shoulders make the neck broader and shorter. It is the law of physics that if eight is transmitted alona a straight line the stress is maximum. cervical spine has a constant number of vertebrae i. The bodies of the vertebrae do unction of transmission of weight. aminae of consecutive vertebrae from the spinal canal protects the from external injurious forces. s been mentioned earlier that laminae coming from each side of the bra surround the spinal cord and meet at the back. Surgical Treatment If the medical treatment and . roots come out from the spinal cord at each lever of the vertebrae on ither side. In more severe cases the orthopaedic doctor may suggest cortisone injections near the joints of the vertebral bodies to ease the swelling of the nerves and relieve pain.

Tension in neck and shoulder muscle.Soft collar is used during night times to prevent awkward position of the neck during sleep. Physical Relaxation: The whole body is relaxed by free suitable and comfortable positions. and the condition is severe.. Shortwave Diathermy . Relaxation Relaxation is essential part of treatment. For eg.Firm collar steadies the neck and relieve pain. It is removed when the pain subsides. so that the muscles are freed from tension and the pain is relieved. Physiotherapy The goal of physiotherapy treatment is to relieve pain. Motivation is given to maintain the erect posture: Collars . Cervical Traction . Mental Relaxation.Simple postural exercises can be taught to correct the faulty position of the neck. Relaxation can be done in two ways: Physical Relaxation. pain.. .physiotherapy fails. and enhance movements of the neck. Firm Collar . especially during traveling or work. The warmth obtained from the shortwave diathermy current relaxes the muscle and the pain is relieved.Traction is a mechanical device.A disc or heating pad is placed over the back of the neck. where the nerves are affected.Two types of collars can be prescribed: Soft Collar . position of relaxation . Decompression of the nerve is done to relieve the nerve which is compressed by the bones and the disc.when you are lying flat on your back. anxiety are all relieved by relaxation. Posture correction . which supports the head and chin. surgery may be required. It is used to relieve the nerve compression by a bone.

tables etc. chairs. The pillow should be firm and thin This position will allow relaxation for your body while lying down. Avoid bad roads. Feet supported on stool or low bench Arm. thin pillow or butterfly shaped pillow Do not lie flat on your stomach. neck and shoulder are supported by high backed chair. if travelling by two or four wheelers Do not sit for prolonged period of time in stressful postures Do use firm collars while traveling Do not lift heavy weights on head or back Do not turn from your body but turn your body moving your feet first Do turn to one side while getting up from lying down Do the exercises prescribed regularly Do use firm mattress.One pillow under the head One cushion for the shoulder and One under knees. with a small pillow at lower back. resting on arm of chair or pillow Ergonomics Ergonomics concentrates on the architectural design of furnitures like desk. Do's and Dont's If you are prone to cervical spondylosis. . The design of the furniture should be such that it should support the body structure without causing any undue strain to the muscles of the back and neck . Relaxation while sitting. The head.

How is Cervical Spondylosis diagnosed? .

side of neck will be stiff and painful.Bad posture .Injury 2. Muscle weakness The muscles responsible for maintaining the neck in erect position can become weak. Limitation of movement The neck movements are limited.What are the symptoms of Cervical Spondylosis? Pain Neck pain Shoulder pain Headache Muscle tightness The muscles covering the regions like back of neck shoulder . elbow. if the spinal cord is affected. Referred pain There may be no pain felt over the neck but referred pain maybe present in arm. What are the causes of Cervical Spondylosis? 1. there will be loss of balance and also loss of bladder and bowel control. thumb and fingers. but flexing the neck down is possible. Sensory loss The bones of the neck applies pressure over the nerves passing through them and can causes loss of sensation in the arm or fingers. Extending the neck up is difficult and restricted due to pain and stiffness. Loss of bladder and bowel control In extremely severe cases.

Bad posture Incorrect posture adapted by habit or due to poor skeletal set up in the neck predisposes abnormal tear of the neck joints. knees and ankles are bent.Thick necks with hump at the back . An example is awkward positions adapted while sleeping. Life style The various styles of activity adapted in daily life can cause strain or tear of the structures of the neck and lead to cervical spondylosis. The pelvic area is tilted backwards. The shoulders are held up and forward.Life style Injury cervical spondylosis can be caused by previous injury.Occupational strain 4. The chest is bent and rounded. Body type Body type also predisposes cervical spondylosis . ligaments and the structures surrounding the joints. The hips.3. The physical strain. Occupational strain The physical discomfort. which arises through an occupation is occupational stress. These cause abnormal tear of joints.Body type 5. repeated fractures or dislocations of the joints of neck. What is bad posture that can cause cervical spondylosis ? The head is held forwards from normal position. intensity of work and duration of working hours all constitutes the occupational strain.

These are roughly circular and between each vertebra is a 'disc'. It is a common cause of neck pain in older people. neck. Nerves from the spinal cord come out from between the vertebrae to take and receive messages to various parts of the body. What is the cervical spine? The spine is made up of many bones called vertebrae.) . and are attached to. is protected by the spine. The nerves coming from the spinal cord in the cervical region go to the shoulder. surgery may be an option. Strong ligaments attach to the vertebrae. Symptoms tend to wax and wane. The spinal cord. and upper chest. The cervical (neck) spine is the upper part of the spine. These give extra support and strength to the spine. various parts of the spine. Treatments include neck exercises and painkillers. The discs are made of strong 'rubber-like' tissue which allows the spine to be fairly flexible. In severe cases. arm.. (The muscles and most ligaments are not shown in the diagram for clarity. Cervical Spondylosis Post your experience See others (298 there) Cervical spondylosis is a 'wear and tear' of the vertebrae and discs in the neck.Long backs These body types are more prone to cause strain or tear of the neck tisues. Various muscles also surround. which contains the nerves that come from the brain.

What is cervical spondylosis? Cervical spondylosis is a cause of neck pain. However. and becomes more common with increasing age. we all develop a degree of degeneration in the vertebrae and discs as we become older. It tends to develop after the age of 30. cervical spondylosis is a term used if the degree . To an extent. The underlying cause is the age-related degeneration ('wear & tear') of the vertebrae and discs in the neck region.

some people develop chronic (persistent) pain. kidney failure. continue with normal activities. particularly after a night's rest. This is caused by irritation of a nerve which goes to the arm from the spinal cord in the neck. Movement of the neck may make the pain worse. It is now known that if you wear a collar for long periods it may cause the neck to 'stiffen up'. Headaches from time to time. four times a day. Some people with asthma. high blood pressure. Medicines Painkillers are often helpful. and nerves may become irritated by these degenerative changes which can cause troublesome symptoms. As far as possible. ligaments. The headaches often start at the back of the head just above the neck and travel over the top to the forehead. They include ibuprofen which you can buy at pharmacies or get on prescription. Numbness. or tolfenamic need a prescription. . Other types such as diclofenac. than is expected for a given age. or heart failure may not be able to take anti-inflammatory painkillers. As the 'discs' degenerate. The pain sometimes spreads down an arm to a hand or fingers. pins and needles or weakness may occur in part of the arm or hand. This may spread to the base of the skull and shoulders. The pain tends to wax and wane with flare-ups from time to time.of degeneration is more severe. What are the symptoms of cervical spondylosis Symptoms can vary from mild to severe. Symptoms include: • • • • Pain in the neck. and causes more symptoms. some people have worn a neck collar for long periods when a flare-up of neck pain developed. Some people find that these work better than paracetamol. In the past. Some neck stiffness. The nearby muscles. For an adult this is two 500 mg tablets. Sometimes the vertebrae develop small. You need only take them when symptoms flare-up. Therefore. • • Paracetamol at full strength is often sufficient. try to keep your neck as active as possible. rough areas of bone on their edges. You may have a flare up of symptoms if you over-use your neck. What are the treatments for cervical spondylosis? Exercise your neck and keep active Aim to keep your neck moving as normally as possible. or if you sprain a neck muscle or ligament. naproxen. over many years they become thinner. However. Anti-inflammatory painkillers. Tell a doctor if these symptoms occur as they may indicate a problem with a 'trapped nerve'.

However. heat. and walk 'like a model'.• • A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Physiotherapy. Try not to stoop when you sit at a desk. surgery may be an option to relieve the symptoms Physiotherapy . The physiotherapists skill are required by the health care team in most disciplines of medicine including surgery. or pins and needles develop in an arm or hand. numbness. have lots to drink and eat foods with plenty of fibre. orthopedics. pressed on or 'trapped' which can cause persistent severe pain or other symptoms in an arm such as muscle weakness. Chronic neck pain is also sometimes associated with anxiety and depression which may also need to be treated. and surgery. disability. Therapies such as traction. Other pain relieving techniques may be tried if the pain becomes chronic (persistent). degeneration. etc. may be tried when you have a flare-up of pain. rehabilitation and sports medicine. In some cases special x-rays and scans may be advised to look for the exact site of the problem. cold. Other advice • • • A good posture may help. Constipation is a common side-effect from codeine. vascular surgery. inflammation. In some cases. the evidence that these help is not strong. etc. Purpose of physiotherapy : The purpose of physiotherapy is to decrease body dysfunctions reduce pain caused either by trauma. weakness. obstetrics. Brace your shoulders slightly backwards. A muscle relaxant such as diazepam is sometimes prescribed for a few days during a flare-up of pain if your neck muscles become tense and make the pain worse. A firm supporting pillow seems to help some people when sleeping. physical disorder. To prevent constipation. dysfunction. What may be most helpful is the advice a physiotherapist can give on neck exercises to do at home. pediatrics. treatment advice and instructions to any person in connection with movement. gynecology. healing and pain from trauma and disease. cardiothoracic. dermatology.Other Courses And Institutes Physiotherapy means physiotherapeutic system of medicine which includes examination. manipulation. Treatment may vary and you should go back to see a doctor if: • • the pain becomes worse. ENT. Codeine is often taken in addition to paracetamol. The various conditions in which physiotherapy useful are as . bodily malfunction. neurology. Sit upright. a nerve may become irritated. In some cases.

extremities and abdomen. spina-bifida. To treat such diseases scientifically. physiotherapy arrests the progress of disease as in cervical spondylosis. pneumothorax but also surgical procedures involving spine. 4) In degenerative disease of spine. rheumatoid. 6) In hemiplegia or paraplegia physiotherapy greatly helps the patient to gradually increase his mobility. pelvis. He maintains the fitness of sports person and provide first aid in case of various sport injuries. To be able to recognize and referred patients for the timely intervention of other healthcare professional specialized in the area of investigation and skilled treatment. 3. 2) In joints and soft tissue injury rapid repair of damaged tissue occurs with quick reduction of pain and swelling. Must be capable of under taking further study and advancing the knowledge and be able with further training to undertake teaching. It also has a major role to play congenital disease of spine like spina-bifida. physical and mental conditions affecting health. 2. It allows for regain of full joint movements and muscles power after healing of a fracture. clubfoot. Take steps to prevent such diseases. To produce the physiotherapists with basic knowledge and skill. chronic obstructive lungs disease. To enable them to recognize the disease. Scope of Physiotherapy : Physical therapists practice in: • Hospitals • Nursing homes • Residential homes/ Rehabilitation centers • Private offices/Private practices/Private clinics . It is also useful in gynecological problems like incontinence. 8) It easies labour and return to normal after delivery. 5. 9) Sort medicine. muscular dystrophy etc. 5) Chest physiotherapy has a vital role to play in medical and surgical conditions like bronchial asthma.follows: 1) Management of a fracture and return to normal function is possible with simple methods of physiotherapy. 3) Restoration of full joint movements with reduction of pain and deformity is possible various kinds of joint diseases like osteoarthritis. 4. 7) In children physiotherapy is assuming real importance in children with cerebral palsy. The aims of the physiotherapy education : 1. pelvis inflammatory disease.A physiotherapist is mandatory for any sport event. research and practice. arthritis juvenile arthritis etc. traumatic. 6. Suitable arthroses are also provided for giving support to spine. prolepses of uterus.

several syndromes. Clinically. hypertrophy of the ligamentum flavum. Frequently. thus creating various clinical syndromes.) physical therapy duration:. 2) Master in physiotherapy (M.Process of admission: Through entrance test. Commencement of the course: The course will commence from the 1st April. shopping malls) Courses : 1) Bachelor of physiotherapy/ B. but most clinicians recommend operative therapy over conservative therapy for moderate-to-severe myelopathy. Background Cervical spondylosis is a common degenerative condition of the cervical spine. Surgery is advocated for cervical radiculopathy in patients who have intractable pain.Sc. and lifestyle modifications. Surgery is occasionally performed.T.4 and 1 /2 year (including Internship) Eligibility for admission: . These include neck and shoulder pain.O • Public settings( e. suboccipital pain and headache. It is most likely caused by age-related changes in the intervertebral disks.Inter Science with Biology with 50% marks. both overlapping and distinct. controlled trials. the most commonly used treatments are nonsteroidal anti-inflammatory drugs (NSAIDs). and ossification of the posterior longitudinal ligament occur. Cardiothroacic and Rehabilitation. nerves.g. only a small percentage of patients with radiographic evidence of cervical spondylosis are symptomatic. are seen.P. However. progressive symptoms. Eligibility: B. Entrance test will be held in April or May. . and cervical spondylotic myelopathy (CSM). mechanical stresses result in osteophytic bars. or weakness that fails to improve with conservative therapy. (Hons. Many of the treatment modalities for cervical spondylosis have not been subjected to rigorous. which form along the ventral aspect of the spinal canal. Spondylotic changes are often observed in the aging population.Age: not less than 17 years. spinal cord). Treatment is usually conservative in nature. associated degenerative changes in the facet joints. As disk degeneration occurs. radicular symptoms.P. Surgical indications for cervical spondylotic myelopathy remain somewhat controversial.G.• Out-patient clinics • Community health care centers/ Primary health care centers • Fitness centers/ Health clubs • Occupational health centers • Special schools • Senior citizen centers • Sports centers • Teaching • Foreign countries • Companies • N. (4 and 1/2year) Speciality: Neurology.T) Duration: 2 years . Sports. physical modalities. Orthopedic/ Musculoskeletal. every year. All can contribute to impingement on pain-sensitive structures (eg.

7. This results in the central annular lamellae buckling inward while the external concentric bands of the annulus fibrosis bulge outward. with minimal white matter involvement—a pattern consistent with ischemic insult. spinal cord ischemia. Age-related hypertrophy of the ligamentum flavum and thickening of bone may result in further narrowing of the cord space. resulting in it being stretched over ventral osteophytic bars.7. During flexion. Initially.9 Dynamic factors relate to the fact that normal flexion and extension of the cord may aggravate spinal cord damage initiated by static compression of the cord. a condition often seen in certain Asian populations.1 Nerve root irritation also may occur as intervertebral discal proteoglycans are degraded.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. they fragment.10 Spinal cord ischemia also most likely plays a role in cervical spondylotic myelopathy. During extension. This condition can be an additional contributing source of severe anterior cord compression. hypertrophy of the uncinate process occurs. the spinal cord lengthens. Pathophysiology Cervical spondylosis is the result of disk degeneration. often encroaching on the ventrolateral portion of the intervertebral foramina.2. with reduction of the ventral cerebrospinal fluid sleeve. most prominent between C4 and C7. this starts in the nucleus pulposus.1. pinching the cord between the ligaments and the anterior osteophytes. the cervical cord space becomes narrowed. forming osteophytic bars that extend along the ventral aspect of the spinal canal and.2 These most likely stabilize adjacent vertebrae. can occur with cervical spondylosis. patients with congenitally narrowed spinal canals (10-13 mm) are predisposed to developing cervical spondylotic myelopathy.8 Additionally.6 Cervical spondylotic myelopathy occurs as a result of several important pathophysiological factors. thus.6. which are hypermobile as a result of the lost disk material. As ventral osteophytes develop. Histopathologic changes seen in persons with cervical spondylotic myelopathy frequently involve gray matter. the ligamentum flavum may buckle into the cord. Ischemia most likely occurs at the level of impaired microcirculation. encroach on nervous tissue. These are static-mechanical. This causes increased mechanical stress at the cartilaginous end plates at the vertebral body lip.11 . and stretch-associated injury. Subperiosteal bone formation occurs next. and collapse.5 Ossification of the posterior longitudinal ligament.4 In addition. dynamic-mechanical. T2-weighted sagittal MRI shows ventral osteophytosis.3. in some cases. As disks age. degenerative kyphosis and subluxation are fairly common findings that may further contribute to cord compression in patients with cervical spondylotic myelopathy. lose water.

When they are not present. which can cause localized axonal injury to the cord.15 Age See Sex. greater than 70% of men and women are affected. however. Another study examined patients at autopsy.2 This can be a frustrating problem for physicians and patients because often the patient has no associated neurologic signs.6% of patients presenting with nontraumatic myelopathic symptoms had cervical spondylotic myelopathy. and History. half the men and one third of the women had significant disease. When neurologic deficits are present. In males. the prevalence ranged from 5% in the fourth decade to 96% in women older than 70 years.12 The narrowing of the spinal canal and abnormal motion seen with cervical spondylotic myelopathy may result in increased strain and shear forces. but the radiographic changes are more severe in men than in women. but this is not true in all studied populations. Race Cervical spondylosis may affect males earlier than females.Stretch-associated injury has recently been implicated as a pathophysiologic factor in cervical spondylotic myelopathy. the prevalence was 13% in the third decade. is the most common syndrome seen in clinical practice.14 A 1992 study noted that spondylotic changes are most common in persons older than 40 years. In females. imaging findings are not usually helpful because the incidence of radiologic . Sex Irvine et al defined the prevalence of cervical spondylotic myelopathy using radiographic evidence. Eventually.13 Mortality/Morbidity See Background. In one report. diagnostic imaging can often help define the cause. Pathophysiology. or cervicalgia. Clinical History The various clinical syndromes seen with cervical spondylosis manifest quite differently. At age 60 years. • Intermittent neck and shoulder pain. 23. Frequency International Cervical spondylotic myelopathy is the most common cause of nontraumatic spastic paraparesis and quadriparesis. increasing to nearly 100% by age 70 years.

In addition. Usually. paresthesias or weakness. the pain may be atypical and manifest as chest pain (pseudoangina) or breast pain. headaches can be the dominant symptom in a patient with degenerative cervical disease.2 Cervical spondylotic myelopathy is the most common cause of nontraumatic paraparesis and tetraparesis. with radiation into the shoulders or occiput. and abnormal sensations. even in asymptomatic patients. stiffness. although it is frequently present in both areas. o Weakness or clumsiness of the hands may be seen in conjunction with weakness in the legs. and/or hand pain.16 Perhaps more thoroughly understood than the above-discussed syndromes is radiculopathy associated with cervical spondylosis. 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. These patients often exhibit signs of spasticity. the upper limb. respectively. and proprioceptive loss in the legs.2 o One third of patients with cervicalgia due to cervical spondylosis present with headache." for which the patient describes difficulty writing.2 Those patients with a lower myelopathy typically present with a syndrome of weakness. A significant amount of these patients also present with arm.17 Cervical radiculopathy is not usually associated with myelopathy. shoulder. The most commonly involved nerve roots are the sixth and seventh nerve roots. or a combination of these symptoms. Patients also may present with stabbing pain in the preaxial or postaxial border of the arms. The vast majority of these patients present without a history of trauma or other recalled precipitated cause. and/or interscapular region.16 Another poorly understood clinical syndrome seen with cervical spondylosis is chronic suboccipital headache. a loss of manual dexterity.16 o The neck pain experienced with cervical spondylosis is often accompanied by stiffness. Patients usually present with pain. that may be chronic or episodic with long periods of remission. This syndrome is possibly related to compression of the sinovertebral nerves and the medial branches of the dorsal rami in the cervical region. The headaches are usually suboccipital and may radiate to the base of the neck and the vertex of the skull. The pain is usually in the cervical region. the pain is more frequent in the upper limbs than in the neck. no contributions to these joints occur from the dorsal rami of C1-C3. patients often present with neck stiffness. nonspecific and diffuse weakness. The process usually develops insidiously.10 Patients with a high compressive myelopathy (C3-C5) can present with a syndrome of "numb. and greater than two thirds present with unilateral or bilateral shoulder pain. o A large part of the problem is that the source of pain in this situation is poorly understood. Motor loss in the hands with relative sparing of . Regardless.• • • abnormalities is quite high in persons in this age group. the greater occipital nerve cannot usually be compressed by bony structures. clumsy hands. forearm. which are caused by C5-C6 or C6-C7 spondylosis. At times. o In the early stages.

18 Another syndrome that may be seen in relation to cervical spondylosis is central cord syndrome. and other causes of neck pain and stiffness (eg. Muscle testing is important because muscle findings have more specificity than sensory or reflex findings. intrinsic shoulder pathology) must be considered and excluded. Patients usually present with a history of a blow to the forehead. Perform a detailed sensory and reflex examination in every patient who presents with a history suggestive of cervical spondylosis. . If weakness is detected in either 1 myotomal distribution or 2-3 peripheral nerves. If the history is compatible with cervical radiculopathy. Winging of the scapula also may be present because it can occur with C6 or C7 radiculopathy. 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. Symptoms are commonly asymmetric in the legs. o Loss of sphincter control and urinary incontinence are rare. report urinary urgency. Conservative therapy with anti-inflammatory medications and other modalities has been advocated for mild-to-moderate cases of dysphagia. infraspinatus.10 o Cervical spondylotic myelopathy significantly affects patients' quality of life. peripheral nerve injury can likely be excluded as the cause. varying degrees of sensory disturbances below the lesion.20. and myelopathic findings such as spasticity and urinary retention. deltoid.23. Patients often experience more pain proximally in their limbs. 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.24 Dysphagia may occur when large anterior osteophytes cause mechanical compression of the esophagus or periesophageal inflammation causes motion over the osteophytes. triceps. while surgery has been reserved for more severe cases. dysphagia or airway dysfunction has been reported secondary to cervical spondylosis. The syndrome consists of greater upper extremity weakness than lower extremity weakness. however.22 Physical • • • • Examination findings include neck pain. myofascial pain. and/or hesitancy. Palpate all muscles because this may allow earlier detection of wasting than visualization can provide. radicular signs. carefully search for signs of muscle atrophy in the supraspinatus.21. Patients with neck pain from spondylosis often present with neck stiffness. some patients. distally. however. while. Note that radicular findings often do not adhere strictly to textbook dermatomal charts. This is a nonspecific sign. and myelopathic signs.2.22.• • the legs.19 Rarely. paresthesias dominate. and first dorsal interosseus muscles. is a relatively rare syndrome. frequency. resulting in acute cord compression.

including hyperactive deep tendon reflexes. Next. the patient's distal middle finger is flicked downward. if positive. It also may be found (usually bilaterally and incomplete) in persons without cervical spondylotic myelopathy. it can also be present in generalized hyperreflexic states and in neurosis. By having the patient make a fist and release it 20 times in 10 seconds.• • • • • Look for physical evidence of other causes of radiculopathy-type symptoms (eg. o The Hoffman sign is a reflex contraction of the thumb and index finger after nipping the middle finger. Other useful tests are the axial manual traction test and the shoulder abduction test. The neck compression test (Spurling test or sign). the Babinski sign. 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). This maneuver works by narrowing the ipsilateral neural foramina during flexion and rotation. and rotate to the side of the pain while sitting. Wasting of the intrinsic hand musculature is also a typical finding. o This is elicited by tapping the pectoralis tendon in the deltopectoral groove. A positive result suggests compression in the upper cervical spine (C2-C4). impairment or clumsiness may be observed that may suggest cervical spondylotic myelopathy. this sign is only valuable if it is associated with other upper motor neuron–related findings. Another occasionally useful test is the pectoralis muscle reflex. In cervical spondylotic myelopathy. use careful compression by slight axial loading. o This test is best performed by having the patient actively extend his or her neck. where upper extremity symptoms typically begin. o Thus. is useful when assessing a patient for cervical radiculopathy. the most typical examination findings are suggestive of upper motor dysfunction. Tinel sign). then the jaw jerk may distinguish an upper cervical cord compression from lesions that are above the foramen magnum. . o If the patient exhibits diffuse hyperreflexia. which causes adduction and internal rotation of the shoulder if hyperactivity is present. with the examiner's thumb. o While this maneuver has a low sensitivity for cervical radiculopathy. ankle and/or patellar clonus. and the Hoffman sign. Although this sign is usually present with corticospinal tract dysfunction. o A thorough examination of patients' hands should be performed. 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. it has a specificity of nearly 100%. tenderness lateral to the neck in the supraclavicular fossa. weakness is most commonly seen in the triceps and/or hand intrinsic muscles. In patients with cervical spondylotic myelopathy. laterally flex. while the initial extension causes posterior disk bulging. spasticity (especially of the lower extremities). unlike the Babinski sign.

o Loss of vibratory sense or proprioception in the extremities can occur. Other causes of the Lhermitte sign include multiple sclerosis. most commonly in the iliopsoas. Perform a complete motor examination. 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. The role of occupational trauma is controversial. tumors. o Diabetes mellitus or other metabolic causes of peripheral neuropathy can confound the sensory examination. a genetic cause is possible. gymnastics) may contribute. Wasting of the intrinsic hand musculature is a classic finding in persons with cervical spondylotic myelopathy. If the ulnar digits drift into abduction and flexion within 30-60 seconds. Sensory abnormalities in cervical spondylotic myelopathy have a variable pattern upon examination. the patient holds his or her fingers extended and adducted. o This sign is not specific for cervical spondylotic myelopathy and classically is attributed to posterior column dysfunction. particularly in the feet. o 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. and other compressive pathology. To assess this. Familial cases have been reported. especially in terms of worker's compensation claims and other related medicolegal clauses. o Causes In addition to age and possibly sex. . Spinothalamic sensory loss may be asymmetric. Conditions that contribute to segmental instability and excessive segmental motion (eg. Patients with cervical spondylotic myelopathy typically exhibit a stiff or spastic gait. o o o o Repeated occupational trauma (eg. carrying axial loads. A classic finding with examination of the lower extremities is proximal motor weakness. especially later in the course of their disease. several risk factors have been proposed for cervical spondylosis.• • • • The finger escape sign may also be present. Another helpful sign is the Lhermitte sign. Examine gait during any neurologic examination whenever possible. Down syndrome) may be risk factors for spondylotic disease. distal weakness is a less common finding. cervical spondylotic myelopathy may be present. Smoking also may be a risk factor. cerebral palsy. congenitally fused spine. professional dancing. followed by the quadriceps femoris. Cervical spondylotic myelopathy may be responsible for functional declines in patients with athetoid cerebral palsy.

lateral epicondylitis Brainstem syndromes Calcareous tendonitis Cervical disk syndromes Cervical lymphadenitis Cervical rib Congenital spinal lesion Diskitis Double crush syndrome Epidural abscess Extrinsic neoplasia (usually metastatic) Fibrositis syndromes Frozen shoulder syndromes Gallbladder disease Glenohumeral arthritis Gout (infrequently) Heart disease Hyperabduction syndrome Intervertebral osteoarthritis Idiopathic brachial plexopathy (neuralgic amyotrophy) Intrinsic neoplasia Lung disease Meningitis .Rotator cuff tears.Differential Diagnoses Amyotrophic Lateral Sclerosis Ankylosing Spondylitis Arteriovenous Malformations Brainstem Gliomas Cluster Headache Diabetic Neuropathy Median Neuropathy Meningioma Metastatic Disease to the Brain Metastatic Disease to the Spine and Related Structures Migraine Headache Migraine Headache: Neuro-Ophthalmic Perspective Migraine Variants Multiple Sclerosis Muscle Contraction Tension Headache Polyarteritis Nodosa Radial Mononeuropathy Reflex Sympathetic Dystrophy Subarachnoid Hemorrhage Syringomyelia Thoracic Outlet Syndrome Torticollis Other Problems to Be Considered Acromioclavicular pathology Acute posterior cervical strain Adhesive capsulitis Aortic disease Arachnoiditis Arteriovenous malformation Back pain Bicipital tendonitis .

Although a narrow spinal canal with a sagittal diameter of 10-13 mm (as visualized on a plain radiograph) has been associated with a higher incidence of neurologic deficit and cervical spondylotic myelopathy. the imaging study of choice is MRI. MRI . Metabolic and infectious conditions may coexist with cervical spondylosis. thus.Musculoligamentous injuries to the neck and shoulder Neoplasms Neoplasms of the shoulder Nerve injuries Occipital neuralgia Osteomyelitis Osteoarthritis of apophyseal joints Paget disease Pancoast tumor Pancreatic disease Peptic ulcer disease Pharyngeal infections Posttraumatic facet fracture with narrowing of the foramen Postural disorders Psychogenic disorders Rheumatic fever (infrequently) Rheumatoid arthritis Rib-clavicle compression Rotator cuff tears and tendonitis Scalene muscle Septic arthritis Spinal cord tumors Sternocleidomastoid tendinitis Subacromial bursitis Synovial cysts Tabes dorsalis Thoracic disk Thoracic outlet syndrome Tropical spastic paraparesis Workup Laboratory Studies Cyanocobalamin (vitamin B-12) levels and a serum rapid plasma reagin may help distinguish metabolic and infectious causes of myelopathy from cervical spondylotic myelopathy. this measurement has become less important with the widespread availability of MRI. Imaging Studies • • Although plain films of the cervical spine are the least costly and most widely available imaging modality. and. an abnormal laboratory profile does not exclude cervical spondylotic myelopathy.

MRI was demonstrated to be 90% sensitive for the diagnosis of cervical stenosis. moderate. o MRI allows multiplanar imaging. Overall. Some researchers have concluded that CT myelography provides additional data only when myelography results are positive—negative . CT scanning is often used to complement MRI and to provide additional bony detail to characterize a lesion responsible for neural encroachment. excellent imaging of the neural elements. In one report. o In one study.27 It is particularly useful in patients under going reoperation. while CT myelography and CT scanning were 100% sensitive. 57% of patients who were older than 64 years had disk bulging and 26% of patients in this age group had evidence of cord compression on MRIs. o Some authors. uncovertebral joint hypertrophy.• • • • • • allows direct visualization of neural structures and allows a more accurate estimation of the cord space. and thus it has become the standard diagnostic study for spondylotic disease. apophyseal joint osteoarthritis. or severe spondylotic changes. however. Myelography is also useful for demonstrating nerve root lesions. CT scanning better defines the neural foramina. and vertebral canal diameter. Superior to MRI in its definition of bony anatomy. o The nearly universal presence of spondylotic radiographic changes in elderly patients (and the similar appearance of a cervical spine film in a symptomatic patient and an asymptomatic patient) allows the classification of an individual patient as having mild.26 Plain films of the cervical spine are an inexpensive way of assessing spondylotic disease in symptomatic patients. MRI is a noninvasive and radiation-free procedure that provides excellent imaging of the spinal cord and subarachnoid space and is a sensitive method for determining involvement of these by extradural pathology.25 o Some spondylotic changes (eg. and with myelography in 67% of cases. Myelography demonstrates nerve root take off very well. or the pathology may be unrelated to the symptoms. small lateral osteophytes. agreement with CT myelography in 84% of cases. report that CT myelography has a lower rate of false-positive results compared with conventional myelography. o It may detect pathology in the asymptomatic patient. CT scanning is another important imaging modality. o It has been demonstrated to be an accurate imaging modality in several studies. osteophytosis. agreement with MRI findings was found in 74% of cases. midbody calcific densities) may be overlooked by MRI. o Cervical spine films can demonstrate disk-space narrowing. and increased accuracy in diagnosing intrinsic cord disease. the advantages of MRI significantly outweigh its deficiencies. loss of cervical lordosis. o When surgical results were used as the criterion standard. Plain radiography can help assess the contribution of spinal alignment and degenerative spondylolisthesis to canal stenosis.

Many of these findings are similar to a pathological model of vascular occlusion.28 Recently. When using modern imaging techniques such as MRI. o It also provides an anatomic distribution of abnormalities. Wallerian degeneration of posterior columns cephalad to the site of compression and of corticospinal tracts caudal to site of compression is frequent. identify cervical spondylotic myelopathy. Extensive infarction of gray and white matter is associated with anteroposterior . when they occur. and hyalinized intermedullary blood vessels is frequently reported. are generally seen in the ventral inner portion of the dorsal column or in the lateral columns bordering the gray matter. thus facilitating the differential of cervical radiculopathy from other similar causes of radicular symptoms. Other Tests • • Electrodiagnostic studies are useful in many patients. Frequently. occasionally. EMG can exclude specific syndromes of peripheral neuropathy rather than confirm cervical spondylotic myelopathy. Histologic Findings Histologic findings associated with cervical spondylotic myelopathy are greatest at the site of maximal compression. o Electromyography (EMG) can help diagnose cervical radiculopathy and. Widespread proliferation of small. EMG can help clarify whether a lesion observed on imaging is the cause of nerve root pathology. o In a patient with cervical spondylotic myelopathy. Somatosensory evoked potentials and cortical motor evoked potentials also may help evaluate spinal cord dysfunction. although it varies in degree. in some cases altering the surgeon's approach on the basis of dynamic findings. involvement of white matter is minimal. dynamic CT myelography has been reported as useful in the surgical planning for patients with cervical spondylotic myelopathy. with the anterior columns being only slightly damaged. especially in timing intervention for the asymptomatic or minimally symptomatic patient with early cervical spondylotic myelopathy. o EMG is useful in the study of radiculopathy because it demonstrates a close correlation with neuroimaging and operative findings. Changes in the gray matter range from consistent motor-neuron loss and ischemic changes in surviving neurons to necrosis and cavitation.o o myelography findings followed by CT scanning in the case of suspected spondylosis is unlikely to show any clinically useful findings. thickened. Nongliotic necrosis is frequently described. White matter changes.29 Nevertheless. o EMG can help determine how long a lesion has been present. the exact role for dynamic imaging such as dynamic CT myelography and dynamic MRI remains to be determined.

CLOSE [X] SPECIALTY SITES Allergy & Clinical Immunology Anesthesiology Cardiology Critical Care Dermatology Diabetes & Endocrinology Emergency Medicine Family Medicine Gastroenterology General Surgery Hematology-Oncology HIV/AIDS Infectious Diseases Internal Medicine Lab Medicine Nephrology Neurology Ob/Gyn & Women's Health Oncology Ophthalmology Orthopaedics Pathology & Lab Medicine Pediatrics Plastic Surgery & Aesthetic Medicine Psychiatry & Mental Health Public Health & Prevention Pulmonary Medicine Radiology Rheumatology Surgery Transplantation Urology Women's Health OTHER SITES Business of Medicine Medscape Today Med Students Nurses Pharmacists Top of Form Medscape MEDLINE þÿ MedscapeCME All eMedicine Drug Reference Bottom of Form Log In | Register eMedicine Medicine Surgery Pediatrics . the critical degree of anteroposterior compression necessary to induce histopathologic changes in the spinal cord has been suggested to be 30%.7 Based on a cadaveric study.compression ratios of less than 20%..11..30 Medscape eMedicine MedscapeCME Physician Connect Find a Physician.

2009 Print This Email This Overview Differential Diagnoses & Workup Treatment & Medication Follow-up Multimedia References Keywords . Diagnosis and Management: Treatment & Medication Author: Sandeep S Rana.Allergy and ImmunologyNeurology Cardiology Obstetrics/Gynecology Clinical Procedures Oncology Critical Care Pathology Dermatology Perioperative Care Emergency Medicine Physical Medicine and Rehabilitation Endocrinology Psychiatry Gastroenterology Pulmonology Genomic Medicine Radiology Hematology Rheumatology Infectious Diseases Sports Medicine Nephrology Clinical Procedures General Surgery Neurosurgery Ophthalmology Orthopedic Surgery Otolaryngology and Facial Plastic Surgery Plastic Surgery Thoracic Surgery Transplantation Trauma Urology Vascular Surgery Cardiac Disease & Critical Care Medicine Developmental & Behavioral General Medicine Genetics & Metabolic Disease Surgery eMedicine Specialties > Neurology > Headache and Pain Cervical Spondylosis. MD. Drexel University College of Medicine Contributor Information and Disclosures Updated: Aug 14. Clinical Associate Professor of Neurology.

One study noted that 79% of patients with neck pain and/or referred pain syndromes and cervical spondylosis improved or became asymptomatic by the 15-year follow-up point. Despite widespread use. The long-term prognosis in cervical spondylotic myelopathy is less clear. opioids are reasonable alternatives. nonoperative treatment for neck pain and/or suboccipital pain syndromes caused by spondylosis and cervical radiculopathy. No carefully controlled trials have compared these modalities. but recent studies have raised concerns of the association of this class of drugs with higher cardiovascular events.32 However. sedation. They have not been demonstrated to change long-term outcomes. . Cervical radiculopathy usually resolves without intervention. Neck immobilization (with a soft collar. Eventually. and those who have failed nonopioid agents. hypertension.31 Medical treatments for cervical spondylosis include neck immobilization. Patients who experience more chronic pain symptoms may benefit from tricyclic antidepressants (TCAs). these therapies are often initiated based on a clinician's preference or specialty. Pharmacologic treatment includes several options. particularly the geriatric population. pharmacologic treatments. As symptoms improve. or a molded cervical pillow for support) is a common. rigid orthoses. constipation. but they may reduce muscle tone and cause neck stiffness from disuse. lifestyle modifications. and bleeding. therefore. opioids should be avoided if there is history of substance abuse or mood disorder. while most have long periods of stability of symptoms with intermittent exacerbations. NSAIDs are the mainstay of pharmacologic treatment. liver abnormalities. the collar can be worn only during strenuous activity. whose who are poor surgical candidates. exercises). soft collars are largely believed to work by placebo effect because they do not appreciably limit motion of the cervical spine. urinary retention. traction. Common side effects include dry mouth. They are effective in reducing the biologic effects of inflammation and pain. it can be discontinued. particularly at higher doses. and cardiac conduction blocks. renal toxicity. For patients who are at risk for NSAID toxicity. However. Muscle relaxants such as carisoprodol and cyclobenzaprine may also be beneficial in patients with a spasm in the neck muscles (which can be related to spondylotic changes). Their use should be monitored for adverse effects such as gastropathy. The collar should be worn as long as possible during the day. Opioids could be considered in patients who have moderate-to-severe pain due to significant structural spondylosis. Selective inhibitors of cyclooxygenase-2 (COX-2) such as celecoxib can lower the risk of gastrointestinal toxicity. patient comfort is key.Treatment Medical Care A brief discussion of the natural history of symptomatic cervical spondylosis is necessary before discussing therapeutic intervention. a soft collar maintains relative flexion. Minerva jacket. and physical modalities (eg. More rigid collars and devices may better limit motion of the cervical spine. manipulation. Comparing the efficacy of these treatments against no treatment is difficult. Some patients experience a progressive decline. Philadelphia collar. If worn properly. Implement a daily cervical exercise program to limit loss of muscle tone.

and the presence of objective signs of nerve root compromise. In some patients with severe radiculopathy. high-velocity. neck schools. spondylolisthesis. The most feared complication of cervical manipulation. vertebrobasilar artery dissection. myelopathy. dislocations. Studies have reported conflicting results. Initially. ergonomics and/or workplace modifications) may alleviate symptoms. It is contraindicated in patients who have myelopathy. in addition to cervical joint distraction. Lifestyle modifications (eg.33 Manipulation. A retrospective study found that cervical traction provided symptomatic relief in 81% of the patients with mild-to-moderately severe cervical spondylosis syndromes. and few well-controlled studies specifically concerning the treatment of cervical spondylosis symptoms have been published. instruction in body mechanics. . Neck school is a form of small group therapy that provides techniques to patients who are willing to actively work toward recovery. It remains a popular treatment for back pain. Some patients with progressive cervical spondylotic myelopathy also may benefit. Techniques vary and include low-velocity. and selecting the proper chair. Cervical mechanical traction. malignancy. and nonthrusting maneuvers. Epidural steroid injections may help patients with radicular symptoms. a weight of 10 lb is recommended. It can be used at home 2-3 times daily for 15 minutes at a time. avoiding prolonged extension of the neck. low-amplitude manipulation (eg. Studies regarding its efficacy are conflicting. with intermittent traction probably being more effective than static traction. a positive Lhermitte sign. was described as early as 4000 years ago. eventually increasing to 20 lb as tolerated. It may be of limited clinical value. infections. various rheumatologic and connective-tissue disorders. These include avoiding forward bending and rotation of the neck. Physical modalities are among the oldest treatments used for spine-related disorders. Contraindications to cervical manipulation include vertebral fractures. a high-dose oral steroid taper may rapidly reduce pain and shorten the course of symptoms. reduce compression and irritation of discs. No placebo controlled trials have studied gabapentin in cervical spondylosis. avoiding prolonged sitting or standing. and improve circulation within the epidural space. commonly used for cervical radiculopathy. relaxation techniques. postural awareness. Workplace modifications and ergonomics serve to reduce strenuous neck positions during work and leisure. Instruction in body mechanics focuses on low-load concepts. may loosen adhesions within the dural sleeves. thrusting or impulse manipulation). it is often being used off label for chronic pain associated with cervical spondylosis. Patients who present within 8 hours of an acute central cord injury (which can be caused partly by ventral osteophytes) may benefit from high doses of methylprednisolone.Steroid use is controversial. most commonly practiced by chiropractors and osteopathic physicians. or rheumatoid arthritis with atlantoaxial subluxation. high-amplitude manipulation. is rare and almost impossible to predict despite multiple proposed risk factors. but based on its efficacy in controlling neuropathic pain.

Patients who do not undergo fusion often report a shorter postoperative hospital stay and an earlier return to daily activities. decompresses and enlarges the neural foramen and spinal canal by the distraction of the disk space. The advantage of this procedure is the lack of bone graft–related complications and decreased manipulation and dissection of the cervical tissues. anterior cervical diskectomy (ACD) yields good-toexcellent results in almost 90% of patients when no other level of spondylosis is present. and minimizes surgical manipulation of the contents of the spinal canal. It does not promote stabilization of the motion segment to promote resorption of osteophytes. causes existing osteophytes to eventually regress as a result of spinal stability promoted by fusion. When adjacent levels of spondylosis were demonstrated. trigger-point injection. back strengthening exercises.34 Success of fusion is higher with autografts due to the presence of endogenous morphogenetic proteins that are present in the harvested bones and help with osteoinduction. Instability of the . Several approaches to the cervical spine have been proposed. only 60% of patients had goodto-excellent results. which was first described by Robinson and Smith in 1955. and aerobic exercises. Controlled trials regarding the efficacy of these routines are lacking. use of allografts. neck and shoulder stretching and flexibility exercises. Surgical Care Surgical care for cervical spondylosis involves anatomic correction of the degenerative pathologic entities that compress a nerve root or the spinal cord. most surgeons choose ACD with fusion for patients with cervical radiculopathy when taking an anterior surgical approach. The anterior approach allows excellent access to midline disease and visualization of pathology without manipulation of neural elements. Surgery has not been proven to help neck pain and/or suboccipital pain. ACD without fusion has been used based on the nonexistent correlation between successful fusion and clinical outcome and the significant incidence of pseudoarthrosis following ACD and fusion (10-20%). or the posterolateral approach. acupuncture. This procedure does not accomplish disk-space distraction and does not mechanically open the neural foramina. Research is being performed on the use of recombinant human morphogenetic proteins to improve success of fusion with allografts. Other commonly used modalities for pain include heat.35 When performed with fusion. or ventral cervical plating have become more popular as they eliminate morbidity of harvesting the graft.Exercises designed for cervical pain include isometric neck strengthening routines. progressive neurologic deficits. The approach selected is determined based on the type and location of pathology and the surgeon's preference. which could be in form of bone graft obtained from cadavers. and documented compression of nerve roots or of the spinal cord that leads to progressive symptoms. and low-power cold laser. cold. Cervical radiculopathy traditionally has been approached either via the anterior approach. thereby minimizing complications More recently. during which a "keyhole" foraminotomy is performed. ACD without fusion almost inevitably is followed by disk-space collapse. Robinson and Smith proposed that the anterior approach coupled with fusion using an iliac crest bone graft (autograft) arrests progressive spondylotic spurring. massage. Most of the passive modalities used for degenerative disease of the cervical spine are performed by physical therapists and are most efficacious in combination. As a result. Indications for surgery include intractable pain. transcutaneous electrical nerve stimulation.

cervical spine is rarely reported following ACD with or without fusion. cervical immobilization with a collar or brace is the most commonly used therapy for cervical spondylotic myelopathy. however. final outcomes clearly exceed expectant outcomes. The posterolateral approach to cervical radiculopathy has similar results to the anterior approach when used for the proper indications. In the United States. With current early intervention strategies tailored to the pathophysiology of myelopathy. Surgical intervention for cervical spondylotic myelopathy is controversial. Because of the possible progressive character of cervical spondylotic myelopathy. It is best used for nerve root decompression. some advocate a more aggressive approach to the disease to strive for improved outcomes. and inferiorly so that it lies free and without tension. The older literature reviewed by Rowland has been criticized because of uncertainty as to whether nonspondylotic causes of myelopathy were excluded prior to surgery. noted that a period of initial deterioration occurs. surgery is usually recommended in patients with moderate-to-severe disability or frank myelopathy. maintenance of the interspinous and most of the interlaminar ligaments is important for preserving stability in patients undergoing foraminotomy. In this approach. Nurick. superiorly. The impact of facetectomies on the stability of the cervical spine has been questioned. during which disability does not worsen for those with mild cervical spondylotic myelopathy. Studies demonstrate conflicting results regarding efficacy of this treatment. advocates surgery for those older than 60 years and for those with progressive decline in neurologic function. The natural history of cervical spondylotic myelopathy is highly variable. The conclusion was that large multicenter trials are needed to determine the benefit of surgery and to establish criteria for the operation/approach of operation. thus. when the pathologic entity is a lateral spondylotic spur or soft disk. followed by a clinical plateau that lasts for several years. The older literature notes the natural course of cervical spondylotic myelopathy to be that of progressive disability and deterioration in neurologic function.36 Risks of surgery are another concern. while increasing the exposure of the nerve root. The underlying lateral aspect of the ligamentum flavum is then removed to visualize the nerve root. a keyhole foraminotomy is made by removing the medial third of the facet joint and the most lateral aspects of the lamina at the involved level and side. Also noted was that diagnostic errors still occur. thus. namely with amyotrophic lateral sclerosis and multiple sclerosis. The nerve root is unroofed posteriorly. In all likelihood. He noted that older patients deteriorate more frequently and. Rowland noted in his proposed trial guidelines that patients with rapid progression of myelopathy may be allowed access to surgery without a trial of conservative therapy. In 1992. Bilateral facetectomies of 70% reduced the ability of the spine to withstand stresses. Researchers have reported that symptomatic patients may deteriorate neurologically during bracing. a thorough review of the literature pertaining to surgery for cervical spondylotic myelopathy concluded that the chances for improvement after surgery for cervical spondylotic myelopathy were approximately 50%. Bilateral 50% facetectomies have been demonstrated to expose the nerve by 3-5 mm without a notable effect on stability. but the incidence of postoperative neck pain is higher without fusion.37 . This approach is associated with greater initial postoperative discomfort but avoids the possibility of graft dislodgment and damage to neck structures.

a combined anteroposterior approach may be recommended. instrumentation). Laminectomy also is unable to address ventral osteophytic overgrowth via a posterior approach. The anterior approach involves an extensive resection. Neurologic deterioration.42 In the case of kyphosis. Nevertheless. neck instability can be prevented. This is because of both the direct decompression of the cord achieved by surgical removal of compressive elements (eg. The sagittal alignment of the cervical spine is important in choosing an approach for decompressing the cervical cord in cervical spondylotic myelopathy. This argument. for cervical laminectomy. laminectomy has increasingly been recognized as not appropriate for all patients. if necessary. a 3-year prospective randomized trial found no significant difference between patients who were treated surgically and those who were treated conservatively. and even vertebral bodies. In cases of combined anterior compression and posterior bulging of the ligamentum flavum causing narrowing of the vertebral canal. general insufficiency of the anterior column is caused by degenerative changes in diskoligamentous structures. surgical intervention is likely to be beneficial over further medical treatment. therefore. may be a relative contraindication for posterior decompression. Once moderate signs and symptoms develop. . even with minor trauma. Because of kyphosis. cervical plates (ie.41 Traditionally. a posterior approach has been the treatment of choice. to decompress the cord. has been used as an argument supporting surgery. has been attributed to the development of spinal instability and kyphotic deformities.40 Accurately prognosticating the course of disability for any given individual with cervical spondylotic myelopathy is difficult. in addition to improved surgical outcomes in those with decreased duration of symptoms. one can directly remove osteophytes. During the previous 20 years. leading to neutralization or inversion of the physiologic cervical lordosis. The primary goal of surgery for cervical spondylotic myelopathy is decompression of the spinal cord. ligamentum flavum. a recent Cochrane review found the natural course of cervical spondylotic myelopathy to be highly variable for patients with mild-to-moderate symptoms. Through an anterior cervical approach. for mild-to-moderate cervical spondylotic myelopathy. Fixed local or global kyphosis. Preoperative lordotic alignment of the cervical spine is necessary in order to maintain maximal benefit from posterior decompression. however. the cord shifts forward and is compressed by anterior osteophytes. With interposition of bone grafts and. disk material. in some instances. The posterior approach (often advocated by Japanese surgeons) is also accepted as a standard decompression procedure in patients who have more than 3 segments of stenotic changes.38 Similarly. in whom the review noted the disease to often remain static and symptoms to occasionally improve.Another factor that must be taken into consideration is that patients with cervical spondylotic myelopathy may be at risk for significant spinal cord injury. which has been reported after laminectomy. bone) and the indirect decompression achieved ventrally by posterior drift of the spinal cord.39 Excellent results have been demonstrated for patients undergoing surgical intervention. One prospective trial of 503 patients undergoing conservative management for cervical spondylotic myelopathy versus surgery reported that patients treated surgically had better outcomes than those treated medically and that medical treatment did not significantly alter neurologic outcomes.

44 Nevertheless. with acceptable risk of morbidity and reasonable expectation for clinical improvement. Haltran. which results in prostaglandin synthesis.43 Additionally. Advil. some authorities advocate laminectomy. myelopathy or both. dorsal laminoforaminotomy can be performed with minimally invasive techniques using microendoscope and tubular retractor system.53 Medication The goal of pharmacotherapy is to reduce pain and inflammation. Myelopathy due to osteophytes confined to 1-2 levels is treated using ACD and fusion with removal of the osteophytes. Although the effects of NSAIDs in the treatment of pain tend to be patient specific. Excellent laminoplasty results have been reported for the treatment of multilevel cervical spondylotic myelopathy.45 Minimally invasive surgical techniques are being developed for management of cervical spondylosis causing foraminal or central canal stenosis manifesting as radiculopathy. Dosing Interactions Contraindications Precautions Adult 200-800 mg PO q6-8h while symptoms persist. This approach is more frequently used in the United States because ventral compression is more common. the number of geriatric patients seeking surgical treatment for cervical spondylotic myelopathy is steadily increasing.46. Recent series have reported clinical improvement rates ranging from 80-94%. these cases are performed with electromyographic and somatosensory evoked potential monitoring. In these cases. In severe cases.49.45 Laminectomy combined with lateral mass fusion may yield excellent results without progression to spinal instability or kyphosis.48 The anterior approach is advocated for cervical spondylotic myelopathy when identifiable anterior compression or kyphotic deformity is present. Other options include naproxen and diclofenac. extensive decompression is performed using multilevel vertebrectomies (corpectomy) and reconstruction with bone graft and instrumentation.50 Neither the anterior nor posterior approach has been demonstrated superior to the other.2 g/d Pediatric Not established Dosing . which leads to better outcomes with less pain. Ibuprofen (Motrin. provided the appropriate procedure is performed for the proper clinical indication.52 Of note.51. Typically. Nonsteroidal anti-inflammatory drugs Used most commonly for the relief of mild to moderate pain. One study demonstrated that corrective surgical techniques could be performed in patients older than 70 years.Laminoplasty (a modern approach) and its variants preserve the lamina to avoid excessive scar formation and to reduce the incidence of postlaminectomy kyphosis. ibuprofen is usually the DOC for initial therapy. not to exceed 3.2. Nuprin) Inhibits inflammatory reactions and pain by decreasing activity of COX.2.47. The goal of these techniques is to minimize injury to surrounding tissue. long-term results with laminoplasty have been reported with fewer late complications then laminectomy.

which results in decreased prostaglandin synthesis. Naprelan. inhibits inflammatory reactions and pain. nasal polyps. instruct patient to watch for signs and symptoms of bleeding. may decrease effect of loop diuretics when administered concurrently. do not administer to patients in whom aspirin. not to exceed 1. caution in patients with anticoagulation abnormalities or who are receiving anticoagulant therapy Naproxen (Aleve. monitor patient for bleeding and obtain a PT before administering an NSAID concomitantly with these types of medications. urticaria. rhinitis. may increase serum lithium levels and risk of methotrexate toxicity Dosing Interactions Contraindications Precautions Documented hypersensitivity. iodides. use only if benefits outweigh risk to fetus Precautions Caution in patients with congestive heart failure.Interactions Contraindications Precautions Probenecid may increase concentrations and possibly toxicity.Fetal risk shown in humans. angioedema. and other symptoms of allergic or anaphylactoid reactions Dosing Interactions Contraindications Precautions Pregnancy B . PT may increase when an NSAID is administered concurrently with anticoagulants. may increase to 1. Naprosyn) Relieves mild to moderate pain. Anaprox.25 g/d Pediatric Not established Dosing Interactions Contraindications Precautions . or other NSAIDs have induced symptoms of asthma. hypertension. Dosing Interactions Contraindications Precautions Adult 250-500 mg PO bid. bronchospasm. probably by decreasing activity of COX. and decreased renal and hepatic function.5 g/d for limited periods.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D . because of potential cross-sensitivity to other NSAIDs.

inhibits inflammatory reactions and pain. and renal papillary necrosis may occur. effects of loop diuretics may decrease when administered concurrently with naproxen. doses greater than this generally do not increase effectiveness Pediatric Not established Dosing Interactions Contraindications Precautions . conversely. probably by decreasing activity of COX. interstitial nephritis. increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion. discontinuation of therapy may be necessary if persistent leukopenia. granulocytopenia.Fetal risk shown in humans. and anti-inflammatory activity. hyperkalemia. use only if benefits outweigh risk to fetus Precautions Acute renal insufficiency.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D . which results in prostaglandin synthesis. antipyretic. PT may increase when naproxen is administered concurrently with anticoagulants.Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs. caution in patients with anticoagulation defects or who are receiving anticoagulant therapy Diclofenac (Voltaren) Has analgesic. monitor PT closely and instruct patients to watch for signs and symptoms of bleeding. WBC counts rarely decrease and usually return to normal in ongoing therapy. hyponatremia. if well-tolerated. or thrombocytopenia occurs. Dosing Interactions Contraindications Precautions Adult 25 mg PO bid/tid. increase daily dose by 25 or 50 mg at weekly intervals until satisfactory response obtained or until total daily dose of 150-200 mg is reached. concurrent administration with phenytoin may increase pharmacologic and toxic effects of phenytoin Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B .

and other NSAIDs. hyponatremia. caution in patients with bleeding tendencies or on anticoagulants. Prednisone (Sterapred) Decreases inflammation by suppressing migration of PMN leukocytes and reversing increased capillary permeability. interstitial nephritis. instruct patients to watch for signs and symptoms of bleeding. coadministration with anticoagulants may prolong PT. do not administer to patients with hypersensitivity to aspirin. patients with preexisting renal disease or compromised renal perfusion are at greatest risk of acute renal failure. because of potential cross-sensitivity to other NSAIDs. low WBC counts occur rarely.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals D . monitor PT and patients closely. hyperkalemia. or other NSAIDs Dosing Interactions Contraindications Precautions Pregnancy B . taper over 2 wk as symptoms resolve. phenylacetic acid. and swelling Pediatric Not established Dosing . iodides. nephrotoxicity) Dosing Interactions Contraindications Precautions Documented hypersensitivity. NSAIDs may increase serum lithium levels and risks of methotrexate toxicity (eg.Fetal risk shown in humans. stomatitis. Dosing Interactions Contraindications Precautions Adult 5-60 mg/d PO or divided bid/qid. effect of loop diuretics may be decreased when administered concurrently. they are transient and usually return to normal while with ongoing therapy. injection into an inflamed joint may provide temporary relief from pain. use only if benefits outweigh risk to fetus Precautions Potential exists for cross-hypersensitivity to aspirin. granulocytopenia. stiffness.Probenecid may increase concentrations and possibly toxicity of NSAIDs. consider effects on platelet function and gastric mucosa. or thrombocytopenia warrants further evaluation and may require discontinuation Corticosteroids Used for potent anti-inflammatory activity and relieve inflammation associated with cervical radiculopathy. persistent leukopenia. and renal papillary necrosis may occur. if low WBC counts occur. acute renal insufficiency. bone marrow suppression.

viral. mental illness. peptic ulcer. Dosing Interactions Contraindications Precautions Adult 2-60 mg/d PO in 1-4 divided doses. may increase digitalis toxicity secondary to hypokalemia. phenobarbital. and rifampin may increase metabolism of glucocorticoids (consider increasing prednisone dose). myopathy. estrogens may increase levels. osteoporosis. psychosis. Depopred) Decreases inflammation by suppressing migration of PMN leukocytes and reversing increased capillary permeability. or tubercular skin lesions Dosing Interactions Contraindications Precautions Pregnancy B . adrenal crisis may occur if glucocorticoids are withdrawn abruptly. hypokalemia. nonspecific ulcerative colitis. monitor patients for hypokalemia when administering concurrently with diuretics Dosing Interactions Contraindications Precautions Documented hypersensitivity.Interactions Contraindications Precautions Clearance may decrease when used concurrently with estrogens. euphoria. phenytoin. hyperglycemia. edema. and myasthenia gravis. phenytoin. growth suppression.Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Caution in patients with hyperthyroidism. diabetes. osteonecrosis. Solu-Medrol. phenobarbital. osteoporosis. and infections are possible complications Methylprednisolone (Adlone. peptic ulcer disease. cirrhosis. hypothyroidism. followed by gradual reduction to lowest level that maintains clinical response Pediatric Not established Dosing Interactions Contraindications Precautions Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia. cirrhosis. when used concurrently with digoxin. Depo-Medrol. diabetes. and rifampin may decrease . fungal. Medrol.

barbiturates.levels (adjust dose). hypokalemia. quinidine) may increase levels. fungal. and infections are possible complications Tricyclic antidepressants A complex group of drugs that has central and peripheral anticholinergic effects and sedative effects. phenobarbital may decrease effects. blocks uptake and prevents hypotensive effects of guanethidine. may interact with thyroid medications. other drugs that inhibit this enzyme system (eg. growth suppression. may use if benefits outweigh risk to fetus Precautions Hyperglycemia. myopathy. edema.Fetal risk revealed in studies in animals but not established or not studied in humans. Dosing Interactions Contraindications Precautions Adult 30-100 mg/d PO hs Pediatric Not established Dosing Interactions Contraindications Precautions Because drug metabolized by P-450 2D6 system. osteonecrosis. osteoporosis. euphoria. or tubercular skin infections Dosing Interactions Contraindications Precautions Pregnancy C . cimetidine. They block the active reuptake of norepinephrine and serotonin. psychosis. and disulfiram Dosing Interactions Contraindications Precautions . monitor patients for hypokalemia when administering medication concurrently with diuretics Dosing Interactions Contraindications Precautions Documented hypersensitivity. viral. useful as an analgesic for certain chronic and neuropathic pain. CNS depressants. Amitriptyline (Elavil) Increases synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake at presynaptic neuronal membrane. peptic ulcer disease. alcohol.

MAOIs in past 14 d Dosing Interactions Contraindications Precautions Pregnancy D . may increase PT in patients stabilized with warfarin Dosing Interactions Contraindications Precautions Documented hypersensitivity. Dosing Interactions Contraindications Precautions Adult 25 mg PO tid/qid. it increases their synaptic concentration. use only if benefits outweigh risk to fetus Precautions Caution in patients with cardiac conduction disturbances and those with a history of hyperthyroidism or renal or hepatic impairment.Fetal risk shown in humans. additional pharmacodynamic effects (eg. by inhibiting reuptake of serotonin and/or norepinephrine at the presynaptic neuronal membrane.Documented hypersensitivity. MAOIs in past 14 d Dosing Interactions Contraindications Precautions Pregnancy D . down-regulation of beta-adrenergic receptors and serotonin receptors) appear to be involved. avoid in older patients Nortriptyline (Aventyl hydrochloride. not to exceed 150 mg/d Pediatric Not established Dosing Interactions Contraindications Precautions Cimetidine may increase levels when used concurrently. use only if benefits outweigh risk to fetus Precautions .Fetal risk shown in humans. because of pronounced effects in cardiovascular system. desensitization of adenyl cyclase. patients diagnosed with narrow-angle glaucoma. Pamelor) Effective in treatment of chronic pain.

may use if benefits outweigh risk to fetus D . COX-1 isoenzyme is not inhibited. cardiac conduction disturbances. seek lowest dose for each patient. incidence of costly and potentially fatal GI bleeding is clearly less with COX-2 inhibitors than with traditional NSAIDs. Dosing Interactions Contraindications Precautions Adult 200 mg/d PO. NSAIDs may mask usual signs of infection. caution in severe heart failure and hyponatremia because may deteriorate circulatory hemodynamics. coadministration with rifampin may decrease celecoxib plasma concentrations Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy C . Ongoing analysis of cost avoidance of GI bleeding will further define populations that most benefit from COX-2 inhibitors. use only if benefits outweigh risk to fetus Precautions May cause fluid retention and peripheral edema.Caution in patients with renal or hepatic impairment.Fetal risk shown in humans. Celecoxib (Celebrex) Inhibits primarily COX-2. alternatively. caution in compromised cardiac function. which is considered an inducible isoenzyme induced during pain and inflammatory stimuli. thus GI toxicity may be decreased. at therapeutic concentrations. inhibition of COX-1 may contribute to NSAID GI toxicity. 100 mg PO bid Pediatric Not established Dosing Interactions Contraindications Precautions Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism.Fetal risk revealed in studies in animals but not established or not studied in humans. or a history of hyperthyroidism Cyclooxygenase 2 inhibitors Although increased cost can be a negative factor. caution in presence of existing controlled . and conditions predisposing to fluid retention. hypertension.

clindamycin. structurally related to TCAs and thus carries some of same liabilities. not to exceed 60 mg/d Pediatric .Fetal risk revealed in studies in animals but not established or not studied in humans. Dosing Interactions Contraindications Precautions Adult 350 mg PO tid/qid Pediatric Not established Dosing Interactions Contraindications Precautions Increases toxicity of alcohol.infections. influencing both alpha and gamma motor neurons. may use if benefits outweigh risk to fetus Precautions Caution in renal or hepatic impairment Cyclobenzaprine (Flexeril) Skeletal muscle relaxant that acts centrally and reduces motor activity of tonic somatic origins. CNS depressants. Carisoprodol (Soma) Short-acting medication that may have depressant effects at spinal cord level. evaluate symptoms and signs suggesting liver dysfunction or in abnormal LFT results Muscle relaxants Reduce associated cervical muscle spasm. Dosing Interactions Contraindications Precautions Adult 20-40 mg/d PO divided bid/qid. acute intermittent porphyria Dosing Interactions Contraindications Precautions Pregnancy C . and phenothiazines Dosing Interactions Contraindications Precautions Documented hypersensitivity. MAOIs.

Dosing Interactions Contraindications Precautions Adult 1-2 tab or cap PO q4-6h prn pain Pediatric Not established Dosing Interactions Contraindications Precautions Coadministration with phenothiazines may decrease analgesic effects. and barbiturates may be enhanced Dosing Interactions Contraindications Precautions Documented hypersensitivity. toxicity increases with CNS depressants or TCAs Dosing Interactions Contraindications Precautions Documented hypersensitivity. high-altitude cerebral edema. MAOIs within last 14 d Dosing Interactions Contraindications Precautions Pregnancy C . effects of alcohol. may have additive effect when used concurrently with anticholinergics. Hydrocodone and acetaminophen (Vicodin.Fetal risk revealed in studies in animals but not established or not studied in humans. Margesic. or elevated ICP . may use if benefits outweigh risk to fetus Precautions Caution in angle-closure glaucoma and urinary hesitance Opiates For use in short-term management of acute pain.Not established Dosing Interactions Contraindications Precautions Coadministration with MAOIs and TCAs may increase toxicity. Lortab. CNS depressants. Lorcet-HD) Drug combination indicated for moderately severe to severe pain. Norcet.

It is particularly controversial because some authorities claim that diskography is a useful tool. . only one patient was noted to experience a typical hyperextension injury as a result of a rearend car collision. Ribs. while others remain skeptical because of a high rate of false-positive results. visit eMedicine's Back. Roxicet. Roxilox. especially when legal and/or compensatory matters were involved. In addition. and Head Center.54 Repetitive trauma has been implicated (eg. which may cause hypersensitivity.Dosing Interactions Contraindications Precautions Pregnancy C . In one series of 648 patients with ruptured cervical disks. Verbiest warned clinicians to be wary of patients who present after minor trauma with symptoms attributable to cervical spondylosis. Neck. caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms. Tylox) Drug combination indicated for relief of moderately severe to severe pain. In 1973. see eMedicine's patient education articles Vertebral Compression Fracture and Neck Strain. Miscellaneous Medicolegal Pitfalls • • • • The role of cervical spondylosis in postautomobile accident cervical whiplash syndrome has been a controversial medicolegal area. neck pain and suboccipital pain attributable to cervical spondylosis). caution in severe renal or hepatic dysfunction Oxycodone and acetaminophen (Percocet.Fetal risk revealed in studies in animals but not established or not studied in humans. may use if benefits outweigh risk to fetus Precautions Tab contains metabisulfite. but the cause-and-effect relationship for auto accidents or other infrequently occurring trauma has not been demonstrated. Dosing Interactions Contraindications Precautions Follow-up Patient Education For excellent patient education resources. in those carrying baskets on their heads). Special Concerns Cervical diskography is a controversial tool used to assess patients with nonradicular or nonmyelopathic symptoms (eg.

Relief of pressure: Lying down is perhaps the simplest way to relieving the neck of its heavy load. most advocates recommend it as a test of final resort once MRI or myelography results are demonstrated to be within normal limits. traction or exercises). pressure on the neck causes pain and pain causes muscle spasms. In most neck conditions. decompression from front or by laminectomy may be required and thereafter it may be advisable to fuse the affected segments of the spinal column by a bone-grafting operation. Many of them require daily applications. Begin by lying on the floor or g on a firm mattress with rolled-up towels under your neck and low back. though they may persist for several months and the structural changes are clearly permanent. Some authors also use relief of the symptoms (elicited by local injection of anesthetic) as corroborative evidence of diskogenic pain. Your legs may be straight or bent. In the exceptional cases in which the spinal cord is constricted. treatment can be decided. Treatment is thus aimed at assisting natural resolution of temporarily inflamed or edematous soft tissues. it also reduces neck mobility. In mild cases physiotherapy may be recommended (radiant heal. The morphology of the disk after contrast injection is important to some authorities. short wave diathermy. Not only is spinal molding a relaxing way to start and end your body. Bed rest gives the muscles a chance to recover. so they must be done by the patient at home. The best way to break the cycle and stop the pain is to relieve both pressure and spasms. the test can localize the pathologic disk responsible for a patient's symptoms. while others discount it as a meaningless entity. In theory.• • • The technique involves the injection of a small amount of contrast into the disk space. Cervical collar helps the neck muscles support the head. There are various approaches to achieve each of these goals. The collar should fit snugly around the neck and be long enough to . massage. it also reshapes your spine into its natural curves. In the more severe cases judicious use of a close-fitting cervical collar for supporting the neck (it should be worn for 1-3 months depending on progress) and rest to the neck is advisable. The duration of bed rest should be advised by the physiotherapist. One study reported that 70% of patients who underwent surgical intervention based on diskography studies experienced excellent or good results There is a strong tendency for the symptoms of cervical spondylosis to subside spontaneously. Physiotherapy Once the neck problem is diagnosed. Lie in this position for 15-20 minutes. A positive study result occurs when a patient's symptoms are reproduced by the injection. Regardless. setting up a cycle. The therapist may prescribe wearing of a cervical collar for the acute phase of neck problems and the duration of wearing it.

Repeat this exercise 10 times. place your fingers together and point your elbows outward. place your hands on your knees and push down. Start by placing your fingers together and pointing your elbows outward. Repeat on your other side. Men can minimize irritation from the collar by shaving frequently. Repeat this exercise 10 times. Extension and flexion is especially helpful when you feel your neck and back stiffen. tilting your body to one side as far as you can. rotating your head and neck to the same side Cervical Spondylosis Buy the Book Print This Topic Email This Topic Pronunciations . This exercise increases the flexibility of your entire spine. To begin. Then bend your head and neck in the same direction. Slowly and gently twist at your waist. While sitting. Slowly arch your back and bend your back backward.support the chin. Then slowly slump forward. Side bends increase your side-to-side flexibility. Bend at the waist.

arthritis

cervical spondylosis

computed tomography

methocarbamol

myelitis

myelopathy

. Repeat toward the other sid

Cervical Spondylosis (Neck Osteoarthritis)

What is it? Cervical spondylosis is a condition of the neck which results in pain and stiffness. It is an age related condition in which the discs and vertebrae degenerate or suffer from ‘wear and tear’. In a normal vertebral segment the bones are adequately separated by a full size disc, the ligaments are nicely aligned and the cartilage covering the bone ends is defect free. The effects of degeneration result in a narrowed joint space, thinned discs, worn cartilage and tightened ligaments. When the joints become closer together the pressure on the ends of the bones becomes greater leading to further wear. The body responds by increasing the surface area of the joint ends by laying down new bone along the edges of the joints. These projections of new bone are called osteophytes and they are often responsible for nerve root compression which can lead to cervical radiculopathy (trapped nerves).

Causes Degeneration generally increases with age, is more common in men than women and changes can start by the age of 30. It is thought that approximately 95% of men and women over the age of 70 will show signs of cervical spondylosis. Certain posture types can increase the likelihood of developing wear and tear symptoms earlier. As with many conditions, education, postural awareness and preventative treatment can reduce the symptoms.

Treatment

Following a thorough examination and assessment of the presenting problem, advice and treatment may include the following:

• • • • • •

Advice regarding activity modification and reducing aggravating factors Electrotherapy i.e. Interferential / TENS to control pain Soft tissue mobilisation to restore normal tissue feel and function Joint mobilisations to the neck, upper back, shoulder and elbow if appropriate to improve neck range of movement Acupuncture to reduce pain, normalise tissue tone and improve blood flow Individually tailored exercise programme to stretch, strengthen and mobilise appropriate areas including postural re-education

e. Repeat this exercise 10 ti

Spondylosis

From Wikipedia, the free encyclopedia

Jump to: navigation, search This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (December 2007) Not to be confused with spondylitis, spondylolysis, or spondylolisthesis.

Spondylosis
Classification and external resources ICD-10 ICD-9 OMIM DiseasesDB MedlinePlus eMedicine MeSH M47. 721 184300 12323 000436 neuro/564 [1]

Spondylosis is degenerative arthritis of the joints between the centra of the spinal vertebrae. In this condition the interfacetal joints are not involved. If severe, it may cause pressure on nerve roots with subsequent pain or paresthesia in the limbs. When the space between two adjacent vertebrae narrows, compression of a nerve root emerging from the spinal cord may result in radiculopathy (sensory and motor system disturbances, such as severe pain in the neck, shoulder, arm, back, and/or leg, accompanied by muscle weakness). Less commonly, direct pressure on the spinal cord (typically in the cervical spine) may result in global weakness, gait dysfunction, loss of balance, and loss of bowel and/or bladder control. The patient may experience a phenomenon of shocks (paresthesia) in hands and legs because of nerve compression and lack of blood flow. If

vertebrae of the neck are involved it is labelled cervical spondylosis. side. and lifestyle modifications.E. Many of the treatment modalities for cervical spondylosis have not been subjected to rigorous. Surgery is occasionally performed." (Baron. To prevent further dislocation. Surgery is advocated for cervical radiculopathy in patients who have intractable pain. manual mobilization. Alternative therapies such as osteopathic manipulative medicine (OMM). However. Portions of a disc may be removed. flexibility. and some people view that strong compliance with postural modification is necessary to realize maximum benefit from decompression and flexibility rehabilitation. but "most clinicians recommend operative therapy over conservative therapy for moderateto-severe myelopathy. [edit] Surgery There are many different surgical procedures to correct spinal deformity. physical modalities. Lower back spondylosis is labeled lumbar spondylosis. . controlled trials. chiropractic and acupuncture may be utilized to control pain and maintain musculoskeletal function in some people. or rear.) Physical therapy may be effective for restoring range of motion. physical therapy cannot "cure" the degeneration.e. Surgical indications for cervical spondylosis with myelopathy (CSM) remain somewhat controversial. Contents [hide] • • • • • 1 Treatment 2 Surgery 3 See also 4 References 5 External links [edit] Treatment "Treatment is usually conservative in nature. and core strengthening. massage. M. Understanding anatomy is the key to conservative management of spondylosis. trigger-point therapy. or weakness that fails to improve with conservative therapy. progressive symptoms. fusion of two vertebrae may be done by taking pieces of bone from the patient's hip and inserting them between the two vertebrae which are fused together and secured by screws. the most commonly used treatments are nonsteroidal anti-inflammatory drugs (NSAIDs). Decompressive therapies (i. The vertebrae can be approached by the surgeon from the front. mechanical traction) may also help alleviate pain.

com mes. Chiropractic & Osteopathy Volume 17 Viewing options: • Abstract • Full text • PDF (442KB) Associated material: • Readers' comments • PubMed record Related literature: • Articles citing this article on PubMed Central • Other articles by authors on Google Scholar on PubMed • Related articles/pages on Google on Google Scholar on PubMed Tools: • Download citation(s) • Download XML • Email to a friend • Order reprints • Post a comment • Sign up for article alerts Post to: • • • • • Citeulike Connotea Del. http://www. (1985). M.us Facebook Twitter . Clayton L.[edit] See also • • Spinal disc herniation Laminectomy [edit] References • • Thomas. ISBN 0-8036-8309-X.A. F.emedicine.icio. Baron. Taber's Cyclopedic Medical Dictionary. Pennsylvania. Davis Company. Philadelphia.E. (2007) Cervical Spondylosis: Diagnosis and Management.

College of Chiropractic. However. 89. 600 Pawtucket Ave. provided the original work is properly cited. New York Chiropractic College. USA 3 Department of Research. A number of studies and reviews of the risks and benefits of decompression surgery in patients with cervical . PC. which permits unrestricted use. USA 4 Shoreline Spine & Pain Associates. Box G-A. Christopher M Coulis4. USA 5 Clinical Sciences.0). RI 02912. Guilford.com/content/17/1/8 Received: Accepted: 25 April 2009 24 August 2009 Published: 24 August 2009 © 2009 Murphy et al. New York 13148. CT 06604. 17:8doi:10.chiroandosteo. Bridgeport. so the designs did not allow firm conclusions to be drawn. Providence. Methods A literature search was conducted on the risk of spinal cord injury in individuals with asymptomatic cord encroachment and the risk and benefit of preventive decompression surgery.1186/1746-1340-17-8 The electronic version of this article is the complete one and can be found online at: http://www. Alpert Medical School of Brown University.Review Cervical spondylosis with spinal cord encroachment: should preventive surgery be recommended? Donald R Murphy1.org/licenses/by/2.5 and Jonathan K Gerrard6 1 Rhode Island Spine Center. USA author email corresponding author email Chiropractic & Osteopathy 2009. Seneca Falls. Pawtucket. none were prospective cohort studies or case-control studies. Results Three studies on the risk of spinal cord injury in this population met the inclusion criteria.3 . Preventive decompression surgery has been recommended for these individuals. The evidence behind claims of increased risk is investigated as well as the evidence regarding the risk of decompression surgery. Abstract Background It has been stated that individuals who have spondylotic encroachment on the cervical spinal cord without myelopathy are at increased risk of spinal cord injury if they experience minor trauma. licensee BioMed Central Ltd. V6Z 2Y1. University of Bridgeport. 2360 State Rte. distribution. #210-179 Davie Street Vancouver. CT 06437. and reproduction in any medium.2. All reported increased risk. USA 6 Aquarius Chiropractic. USA 2 Department of Community Health. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. The purpose of this paper is to provide the non-surgical spine specialist with information upon which to base advice to patients. RI 02860-6059.126 Park Avenue. 2415 Boston Post Rd.

and compressed. with the development of osteophytes. he did not provide evidence-based recommendations as to how to determine risk of quadriplegia or the level of risk that would warrant surgery in the absence of frank myelopathy. Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in older individuals and usually develops insidiously [7]. may warrant early decompression".3]. have had patients consult them for second opinion after being recommended this type of surgery. The authors. it has been reported to develop after trauma [8-15]. Thus. For example. However. Spondylosis. If it occurs in the central canal it can cause myelopathy. This has led some surgeons to recommend decompression surgery for the purpose of preventing this trauma-induced myelopathy in presumed susceptible individuals [18. Matsumoto. For example.myelopathy were found.6%. but no studies were found that addressed surgery in asymptomatic individuals thought to be at risk. However. with rates ranging from 0. This can lead to the development of clinical symptoms in some individuals if the osteophytes impinge on neural structures such as the nerve root or spinal cord. but the significant risks may outweigh the unknown benefit in asymptomatic individuals. It was reported in each of these cases that the surgeon making the recommendation did so based on the view that the spinal cord encroachment placed the patient at risk of spinal cord .4]. the spinal cord. if mildly symptomatic or at risk for quadriplegia with even mild trauma.17]. et al [1] assessed 497 asymptomatic subjects and found posterior disc protrusion with compression of the spinal cord in 7. all non-surgical spine specialists. They are generally asymptomatic [2. The complications of decompression surgery range from transient hoarseness to spinal cord injury. but cervical MRI had revealed cervical spondylosis which encroached on. While this figure was presented in the abstract of the paper. However. There is no evidence that prophylactic decompression surgery is helpful in this patient population. Epstein [18] stated "Patients under 65 years of age. Each of these patients was asymptomatic with regard to cervical myelopathy (though they had neck pain). Decompression surgery appears to be helpful in patients with cervical myelopathy. no details were provided as to how this compression was measured. the figure was similar to that of Teresi. Conclusion There is insufficient evidence that individuals with spondylotic spinal cord encroachment are at increased risk of spinal cord injury from minor trauma. occurs as part of the degenerative process. Cord compression without myelopathy has also been found on CT myelography [6]. Recommendations to individual patients must consider possible unique circumstances. encroachment in either of these regions can also be asymptomatic with regard to myelopathy [1. If this encroachment occurs in the lateral recess or lateral canal it can lead to radiculopathy.19]. However. Background Degenerative changes in the cervical spine are part of the normal aging process and are nearly ubiquitous in older people [1]. Some authors have suggested that individuals who have asymptomatic spondylotic encroachment on the cervical spinal cord are at increased risk of acute myelopathy if they experience minor trauma such as a fall or motor vehicle collision [16. Prospective cohort or case-control studies are needed to assess this risk.3% to 60%. broad recommendations for decompression surgery in suspected at-risk individuals cannot be made. et al [5] who found cord compression on MRI in 7 of 100 asymptomatic subjects.

23] were excluded because they assessed younger individuals in whom degenerative spondylotic change would not be expected. Table 1. One study was excluded because it looked at rate of recovery and not incidence or risk [27]. All 25 patients with no bony injury were evaluated with . One study that excluded subjects with cervical spondylosis was also excluded from the present study [24]. Searches of the authors' own libraries were also conducted. Also excluded were studies reporting risk of spinal cord injury resulting from major trauma and studies involving individuals who had narrowing of the central canal from sources other than degenerative changes. Finally.injury if he or she were to experience even relatively minor trauma. Case reports and small case series were excluded. The purpose of this review is to investigate whether the scientific literature can be used to inform the surgical and non-surgical spine specialist regarding how to advise patients who have spondylotic encroachment on the cervical spinal cord in the absence of frank myelopathy. 25 had no bony or ligamentous injury and another 17 had "subtle" signs of bony or ligamentous injury. The search terms used for the database searches can be found in table 1. et al [14] retrospectively reviewed the medical records of 88 patients over age 40 with spinal cord injury resulting from trauma and compared them with a group of 35 young adults (16–36 years) with spinal cord injury. only one of the 35 younger patients had developed spinal cord injury without severe bony or ligamentous injury. Search terms The search yielded 1881 citations. Relevant papers were retrieved and reviewed by two independent reviewers. Three studies were excluded because all of the subjects [25. citation searches of relevant articles and texts were conducted manually. Evidence-based medicine calls for the clinician to provide counseling and treatment that is based on the best available evidence. Embase and MANTIS. Regenbogen.15]. 2008: Medline. Of the 88 older patients.13. unless this was necessary to clarify information that was not readily apparent from the systematic review. Methods The following databases were searched up to May 31. Two studies met the inclusion criteria [14. In contrast. Cinahl. These patients expressed a desire for a non-surgical opinion as to whether such surgery is truly advisable. Studies that were deemed relevant were those that investigated the risk of spinal cord injury from minor trauma in patients with pre-existing spondylotic central canal encroachment and those that reported on outcomes and complications to cervical decompression surgery. In cases in which systematic reviews of the literature were found.26] or more than half [12] had major trauma (fracture and/or dislocation). a publication of the North American Spine Society [19]. Results Risk of Spinal Cord Injury from Minor Trauma Five studies [9-11. with or without fusion. This is apparently a frequent enough occurrence in the experience of other spine specialists to have warranted a "Curve/Countercurve" piece in a recent issue of Spine Line. the individual studies included in the reviews were not reviewed separately. combined with clinical experience and patient preference [20-22].

All studies that related to the risk of spinal cord injury in patients with asymptomatic encroachment located in the search were case reports. circumferential decompression with fusion. or vertebral artery. et al [15] reported on 27 patients with ossification of the posterior longitudinal ligament who sustained minor trauma ("such as tumbling. while it can be said that there may be an association between the presence of asymptomatic cord encroachment and spinal cord injury after trauma. recurrent laryngeal nerve. However. Eighteen of the 19 patients with a narrow central canal (<10 mm) developed neurologic deterioration. Benefits and Risks of Surgery in the Cervical Spine in Asymptomatic Spinal Cord Encroachment The search did not reveal any studies on the outcome of surgery in asymptomatic or presumed "at risk" subjects. he estimated the "worst case scenario" risk of myelopathy in this patient population to be 1:2100. whereas this occurred in only two of the eight patients with a wider canal (10 mm or greater). National Library of Medicine. nerve roots. decompression surgery is appropriate in this patient population. laminoplasty and corpectomy. The purpose of this study is to assess the evidence regarding this risk and attempt to compare what is known about this risk with what is known about the risk of surgery. Thirteen of these patients developed new myelopathy. CSF leakage. [19] argued that the risk of myelopathy in patients with asymptomatic encroachment on the cervical spine is not worth the risk of surgery. Riew. slipping or jumping from small steps") to the cervical spine. this would be twice the risk of myelopathy after trauma [19]. Katoh. in a pointcounterpoint piece. however. All patients imaged with myelography had signs of "moderate to severe" spondylosis. laminectomy with or without foraminotomy or fusion. The most common surgical procedures used in this patient population are discectomy. case series or retrospective crosssectional studies. Table 2. It is hoped that all spine clinicians can take an evidence-based approach to counseling patients with this condition. Each has its own indications and contraindications as well as complications. no firm conclusions can be drawn about causation. Surgical procedures for cervical spondylotic myelopathy Discussion The role of preventive surgery in patients with asymptomatic cervical spinal cord encroachment has been a point of controversy amongst surgeons. infection and pseudoarthrosis (Table 2). As has been pointed out in the present paper. Others [18] have argued that because of the potentially catastrophic nature of spinal cord injury after trauma. this point only strengthens his recommendation against surgery in this population. sympathetic ganglia. 7 experienced deterioration of pre-existing myelopathy and 7 experienced no neurologic sequelae.26].radiographs and 16 with pantopaque myelography. None were case-control or prospective cohort studies. the studies Riew cited on which he based the assumption of risk were of inadequate design to assess true risk [25. It did reveal a number of review papers [28-34] that included most of the studies found in the search. and the US Census. Potential complications to these surgical procedures include injury to the spinal cord. Combining data from the Paralyzed Veterans of America. These are provided in Table 2. He argued that even if the risk of serious complication from surgical decompression was 1:1000. Case-control or prospective cohort studies would be necessary to make this . Thus.

determination [35]. et al [37. Because the studies were of inadequate design to assess risk and used inadequate measurement methods. The only risk factors for the progression to CSM in this cohort were symptomatic radiculopathy at baseline. decreased cross sectional area of the spinal canal. Based on this review of the literature. Until such studies have been performed. preferably. In a more recent publication with a larger sample size (n = 199) and longer follow period (2–12 years. they found that 13 subjects (19. They did not include exposure to trauma in their analysis. without signs or symptoms of myelopathy.6%) developed symptomatic CSM. personal communication 26th June 2008). This determination would require population-based case-control or. With these designs. Factors in their model that were not found to increase risk of the development of CSM were age. but these did not reach statistical significance (p = 0. there is currently no substantial evidence upon which to base a recommendation for prophylactic decompression surgery in this patient population. the subjects had symptomatic myelopathy.112. decreased Pavlov ratio and hyperintense signal within the spinal cord on T2-weighted MRI image. the role surgery plays in preventing spinal cord injury in asymptomatic subjects thought to be at risk is not known. number of stenotic levels. median 44 months) [38] they found that 45 subjects (22. No outcome studies were found that included asymptomatic subjects thought to be at risk. Thus. is at increased risk of spinal cord injury after trauma. disc herniation or the combination of both). type of compression (spondylosis. respectively). it is not likely that the complication rate would be substantially different in asymptomatic individuals as compared to symptomatic individuals. the present authors did not feel that it was of benefit to undergo a formal critical appraisal of the studies. However. Also. prospective cohort studies. electromyographic (EMG) evidence of anterior horn lesion at baseline and abnormal somatosensory evoked potentials (SSEP) at baseline. In their initial study of 66 subjects with this condition who were followed for 2–8 years [37]. In all the surgical studies found in the search. . However.7%) developed symptomatic CSM. EMG evidence of anterior horn cell lesion and abnormal SSEP were found to be risk factors for the development of CSM during the follow up period.38] have studied risk factors for the development of CSM in individuals with asymptomatic spondylotic cord compression using a prospective cohort design. Baseline symptomatic radiculopathy. There was a tendency toward increased risk in males vs females and in those with abnormal motor evoked potentials. It is also not known whether the complication rate of decompression surgery in patients with asymptomatic cord encroachment would be the same as in those with myelopathy. it remains to be determined whether an individual with cervical spinal cord encroachment. bias can be minimized and statistical conclusions can be drawn regarding risk [35]. when re-analyzing the data they found relatively few exposures to trauma and that these had no impact on development of CSM (Bednarik J. Bednarik. Because of this. however. It also remains to be determined what the magnitude is of any increased risk. Recent evidence indicates poor correlation between radiographicallydetermined central canal size and that determined by MRI [36]. as the reported postsurgical complications generally relate to the surgery itself and not to the myelopathy (see Table 1).072 and p = 0. in the majority of cases the size of the central canal was measured with radiographs. it cannot be stated with certainty that individuals with the findings discussed here are at increased risk of trauma-induced myelopathy.

In some cases. . in order to lessen the likelihood of falling [41]. low signal change within the spinal cord on T1 weight images with high signal on the T2 weighted images (which has been found to correlate with poor surgical outcome) [39]. it would be reasonable for elderly patients with this finding to be provided prevention strategies. However. Competing interests The authors declare that they have no competing interests.Myelopathy: . . There may be individual variations in a particular case. Populationbased case-control or prospective cohort studies are needed to determine whether the magnitude of any risk in this patient population justifies surgical intervention. It has been said that individuals with this finding are at increased risk of severe myelopathy if they experience minor trauma. All authors read and approved the final manuscript. . Given the fact that post-traumatic myelopathy has been reported to be associated with falls in the elderly [40]. All authors reviewed and made editorial changes in the manuscript.myelopathy hand: . prophylactic decompression surgery has been recommended. CMC and JKG conducted the literature searches and were involved in data extraction. References Physical Exam for Cervical Spondylosis .characterized by weakness (upper > lower extremity). ossification of the posterior longitudinal ligament or persistent engagement in high-risk activities.pain is earlly symptom.evidence-based medicine calls for recommendations to be individually directed and to take into account scientific evidence combined with clinical experience and patient preference [20-22]. there is no good evidence that these individuals are at increased risk and. . Authors' contributions DRM conceived of the research idea. particularly those that could involve high-acceleration extension injury. Conclusion Asymptomatic cervical spondylotic spinal cord encroachment is fairly common. sensory changes. the evidence does not allow for firm and broad recommendations to be made regarding prophylactic surgery. given the potentially serious complications of surgery. Also it may be advisable for the nonsurgical spine specialist to counsel patients who have asymptomatic cord encroachment to avoid high-risk activities. which may influence one's recommendation.rarely urinary retention. such as severe canal encroachment. including exercises for improved balance.ataxic broad based suffling gait.Signs and Symptoms: (see C-spine Exam) . which may be ischemic in origin. supervised the literature search and data extraction process and was the principle writer of the manuscript.

myelopathy or pending myelopathy. Surgical Indications: ..full laminectomy is required. .osteophytosis occurs as result of breakdown in the out annular fibers of annulus fibrosis. clonus. .can be associated with myelopathy. . .later on osteophytes extend vertically from edges of vertebra.note: to maintain stability the posterior longitudinal ligament should be left intact. if possible.disk material stretching & displacing these fibers. . causing stress at ligamentous attachments leading to formation of osteophytes.mechanical stress.intractable pain. . and removal of the bony sclerotic bed of the vertebral body. . . posterior arthrodesis should be done. the test is likely to be negative with radiculopathy caused by Spondylosis (osteophyte compression).stability of bone graft is achieved by initial distraction of soft tissues as graft is inserted.lower nerve root at a given level is usually affected. such as excessive vertebral motion.the one exception to this may be the rheumatoid C-spine.gentle neck hyperextension with the head tilted toward the affected side will narrow the size of the neuroforamen and may exacerbate the symptoms or produce radiculopathy. shoulder. . . . distractive force is removed the graft will be held firmly between vertebral bodies.findings may overlap because of intraneural intersegmental connections of sensory nerve roots.severe deltoid or wrist extensor weakness. .osteophytes collects initially extend horizontally. . . whereas.can involve one or multiple roots.Pathoanatomy: .resection of > 25 % of facet can result in cervical instability. . or Babinski's sign may be present.posterior approach: .Surgical Treatment: .Radiculopathy: . paresthesias.fusion of one or more levels is performed by countersinking iliac crest bone graft between vertebral bodies. and numbness.Shoulder Abduction Relief Test: . Pathoanatomy of Cervical Spondylosis .laminaplasty: . characterized by central burning and stinging with or w/o (Lhermitte's phenomenon . sometimes bridging disk space.if destabilizing facet resection is needed in order to decompress cord. and arm pain.facet joints: . . . . and symptoms include neck.progressive neurological deficit. . .radiatineg lightening like sensations down back w/ neck flexion) may also be present w/ myelopathy.anterior approach: & fusion.removal of the spinous process & lamina on each side at multiple levels. .when the primary pathology is mostly anterior.funicular pain. or central cord syndrome.once.upper motor neuron findings such as hyper-reflexia.this sign is more likely to be present w/ soft disc herniation. . .Spurling's Manuever: . . . .significant relief of arm pain with shoulder abduction. may exacerbate symptoms.requires discectomy. . generally the anterior approach should be anterior.finger escape sign (small finger spontaneously abducts due to weak intrinsics) indicating cervical myelopathy. . . the pathology will be anterior and will be reflecting clinically as myelopathy. anterior cord syndrome. . removal of posterior osteophytes.may be indicated for multi-level disease. .in most cases of cervical spondylosis involving one or two levels.

loss of disk height leads to reduced neuroforaminal volume.Syringomyelia .lateral view & oblique view: . . .Herpes Zoster.joints give rise to bony spurs or ridges -osteophytes. .rarely osteophytes may also project anteriorly and impinge upon vertebral artery.Low pressure hydrocephalus . Differential Dx of C-Spine Pathology .allows evaluation of facet joints. and hypertrophic facets and infolded ligamentum flavum posteriorly.Cervical Disc Herniation . . .Pancoast Tumors . .Myelopathy: Diff Dx: .Stroke / TIA.exiting nerve root on each side travels between these joints.hyperflexion: . . between posterior edge of uncinate process & lateral edge of posterior longitudinal ligament.cord increases in diameter and it & roots are pinched between discs and adjacent spondylitic bars anteriorly.spondylotic changes in the foramina primarily from chondro-osseous spurs of the joints of Luschka may restrict motion and may lead to nerve root compression. . . . & can be compressed by osteophytes extending into intervertebral foramen from any or all three of sources mentioned.cervical cord becomes impinged when diameter of canal (normally about 17 mm) is reduced to less than 13 mm.is usually posterolateral.Myopathic Disorders .Subacute Combined Degeneration .Cerebral hemisphere lesion .Spinal Cord Tumor .Multiple Sclerosis .involves the disc.hyperextension: .spondylotic bars with a congenitally narrow canal. . .as can main fascet joints & edges of vertebral bodies adjacent to intervertebral disc.Apophyseal Joints: .Joints of Luschka: ..Reflex Sympathetic Dystrophy .this is symphysis type of articulation between vertebral bodies.central herniation. .Amyotrophic Lateral Sclerosis . . rendering root more susceptible to compression. .specifically. . two facet joints & two false uncovertebral joints (Lushka).joint space narrowing and eventual spurring and sclerosis.determine if osteophytes of apophyseal joints project medially into foramina canal. . .Brachial Neuritis (upper & lower motor neurons. . . osteophytes arising from the ventral portion of superior articular process may cause symptomatic foraminal narrowing.show early irregularity and blurring of the joint surfaces.myelopathy: . . resulting in acute radiculopathy.Thoracic Outlet Syndrome.cord narrows and the neural structures are tethered anteriorly across discs or spondylitic bars. sensation is Nl).radiculopathy: . resulting in arterial insufficiency.soft disc herniation: .

to evaluate motor neuron dysfunction.Subacromial Impingement.Neuropraxia . . . . distinguishing between partial and complete lesions.silent rest activity. Electromyography .increased insertional activity.The Expert Electromyographer .EMG Findings in Specific Conditions: .Normal Study: . .Anterior Horn Disease . .no biphasic and triphasic potentials.biphasic and triphasic potentials.interference: none .rest activity: fibrillations & positive sharp waves. . .silent rest activity. .Neurotmesis . but results are nonspecific. .interference: incomplete.Demyelinating Neuropathies . .Axonotmesis: .Peripheral Neuropathy .complete interference.no biphasic and triphasic potentials. . .no biphasic and triphasic potentials. . .normal insertional activity.increased insertional activity.EMG Table of Contents: . .Neuropathic Disorders . .interference: incomplete. .Nerve Injury: .Myopathic Disorders .large polyphasic contractions. .increased insertional activity.interference: none . .EMG studies are highly sensitive.normal insertional activity. .rest activity: fibrillations & positive sharp waves.no biphasic and triphasic potentials. . . .. .rest activity: fibrillations & positive sharp waves.Thoracic Outlet Syndrome.rest activity: fibrillations & positive sharp waves.increased insertional activity.Indications for EMG: .Axonal Neuropathies: .no biphasic and triphasic potentials.interference: none .outside links: . .normal insertional activity.silent rest activity.useful in localizing level of specific lesion.Nerve Menu . . .confirme & extension of clinical examination. differentiating primary muscle . .See: .

infrared lamps etc.F wave is often measured to supplement routine nerve conduction studies because the F wave permits evaluation of the proximal segments of peripheral nerves. Cervical Spondylosis : In case of intense pain in the neck due.Number of motor units under voluntary control.F wave: .Rest Activity: .useful for diff dx & in presence of coexisting disease. . plexuses and the proximal segments of peripheral nerves. . There is a lot of vibrations and jerks in the neck during travelling and it is advisable to stop travelling and stay away from office /institution /academy for a few days. . . to cervical spondylosis associated with painful or painless weakness in the arm stoppage of neck movement is immediately required. They provide deep penetrating heat.Duration and Amplitude of each Motor Unit Potential. Heat is the best agent to relax the muscles.F waves are valuable in evaluating disorders involving the nerve roots. hot water bags..radiculopathy due to dz of C-spine.Sensory latency: . i. they generate pain. .Specific Measurements: . When the tension in the muscle becomes too much.no other test has a higher diagnostic accuracy in patients w/ final diagnosis of carpal tunnel syndrome.e. .Technique: . .small needle is inserted into muscle to record electrical activity of several neighboring motor units. A cervical collar is advisable to restrict undue movements of the neck.determine of F wave latencies is particularly valuable in evaluating patients with demyelinating paolyradiculopathies. . Whenever there is pain in the joints.S wave: . . or proximal median neuropathy can pose clinical questions that electrodiagnostic testing can answer. .occurs when action potentials travel from the point of stimulation of peripheral nerve to the spinal cord and back to the muscle. . Many gadgets and home remedies can be used. the muscles encircling that joint become tight and reduce the mobility of the joint as a protective mechanism.Nerve Entrapment: . The more preferable heat treatments are short wave diathermy (WD) and ultrasound heat. & evaluating malingerers. electrical heating pads.or nerve pathology.Motor Conduction Latency: . .another factor that may lead to normal EMG in presence of compressive radiculopathy is overlapping motor innervation of single muscle. diffuse peripheral neuropathy.

there is little reason to insist on the use of traction any further. com/ortho/ap_of_spine Sciatica : . Traction can be intermittent or steady traction kept up for some time.Traction (cervical) is quite effective when a slipped disc presses a nerve root. Traction increases the intervertebral disc space and therefore the pressure of disc on the nerve root is released.wheelessonline. If traction fails to reduce pain in 24 to 48 hours. http://www.

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