Cervical Spondylosis: Diagnosis Rate this Article

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Last Updated: April 8, 2005 Colleague
Synonyms and related keywords: cervical degenerative joint disease,
cervical degenerative disk disease, cervical osteoarthritis, cervical
spondylotic myelopathy, CSM, disk degeneration, degenerative cervical
disease, osteophytic bars, cervical radiculopathy, neck pain, shoulder
pain, cervicalgia, chronic suboccipital headache, paresthesias,
pseudoangina, breast pain, nontraumatic paraparesis, nontraumatic
tetraparesis, numbness, clumsy hands, loss of manual dexterity,
difficulty with writing, central cord syndrome, Tinel sign, Spurling sign,
Babinski sign, Hoffman sign, pectoralis muscle reflex, spastic gait,
Lhermitte sign
  AUTHOR INFORMATION Section 1 of 11   

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures
Bibliography

Author: Eli M Baron, MD, Staff Physician, Department of Neurosurgery,

Temple University School of Medicine
Coauthor(s): William F Young, MD, Director of Neuro-Spine Program,
Assistant Professor, Departments of Neurosurgery and Physiology, Temple
University
Eli M Baron, MD, is a member of the following medical societies: Alpha
Omega Alpha, American Medical Association, Pennsylvania Medical Society,
and Phi Beta Kappa
Editor(s): William J Nowack, MD, Associate Professor, Department of
Neurology, University of Kansas Medical Center; Francisco Talavera,
PharmD, PhD, Senior Pharmacy Editor, eMedicine; James H Halsey, MD,
Professor, Department of Neurology, University of Alabama Medical Center;
Selim R Benbadis, MD, Director of Comprehensive Epilepsy Program,
Associate Professor, Departments of Neurology and Neurosurgery, University
of South Florida, Tampa General Hospital; and Nicholas Lorenzo, MD, Chief
Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and
Consultants

Disclosure

  INTRODUCTION Section 2 of 11   

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures
Bibliography

Background: Cervical spondylosis is a common degenerative condition of

the cervical spine that most likely is caused by age-related changes in the
intervertebral disks. Clinically, several syndromes, both overlapping and
distinct, are seen: neck and shoulder pain, suboccipital pain and headache,
radicular symptoms, and cervical spondylotic myelopathy (CSM). As disk
degeneration occurs, mechanical stresses result in osteophytic bars, which
form along the ventral aspect of the spinal canal.

Frequently, associated degenerative changes in the facet joints, hypertrophy

of the ligamentum flavum, and ossification of the posterior longitudinal
ligament occur. All can contribute to impingement on pain-sensitive structures
(nerves and spinal cord), thus creating various clinical syndromes.
Spondylotic changes often are observed in the aging population. However,
only a small percentage of patients with radiographic evidence of cervical
spondylosis are symptomatic.

Treatment usually is conservative, with nonsteroidal anti-inflammatory drugs,

physical modalities, and lifestyle modifications most commonly used. Surgery
occasionally is performed. Many of the treatment modalities for cervical
spondylosis have not been subjected to rigorous, controlled trials. Surgery is
advocated for cervical radiculopathy in patients who have intractable pain,
progressive symptoms, or weakness that fails to improve with conservative
therapy. Surgical indications for CSM remain somewhat controversial.

Pathophysiology: Disk degeneration causes cervical spondylosis. As disks

age, they fragment, desiccate and collapse. Initially, this starts in the nucleus
pulposus, resulting in the central annular lamellae buckling inward while the
external concentric bands of the annulus fibrosis bulge outward. This results
in increased mechanical stress at the cartilaginous end plates at the vertebral
body lip.

Studies by McCormack and Weinstein and by Parke indicate that

subperiosteal bone formation occurs next, forming osteophytic bars that
extend along the ventral aspect of the spinal canal. In some patients, these
bars encroach on neural tissue. These most likely stabilize adjacent
vertebrae, which are hypermobile as a result of lost disk material.

Uncinate process hypertrophy also occurs, often encroaching upon the

ventrolateral portion of the intervertebral foramina. Nerve root irritation also
may occur as intervertebral disk proteoglycans degrade.

CSM occurs as a result of 3 important pathophysiologic factors: static-

mechanical, dynamic-mechanical, and spinal cord ischemia. A congenitally
narrowed spinal canal (10-13 mm) is an important predisposing factor to
CSM. As ventral osteophytosis occurs in a person with a congenitally
narrowed canal, the cord space becomes further reduced. Age-related
hypertrophy of the ligamentum flavum and thickening of bone may restrict the
cord space further and cause buckling of these elements into the cord.

Dynamic factors may be important in that normal flexion and extension of the
cord may aggravate spinal cord damage, initiated by static compression of the
cord. During flexion, the spinal cord lengthens, which stretches it over ventral
osteophytic bars. During extension, the ligamentum flavum may buckle into
the cord, pinching the cord between the ligaments and anterior osteophytes.

Spinal cord ischemia probably also is involved in CSM. Histopathologic

changes that are observed in CSM frequently involve gray matter with minimal
white matter involvement (a pattern consistent with ischemic insult). Ischemia
probably occurs at the level of impaired microcirculation.

Frequency:

 Internationally: CSM is the most common cause of nontraumatic

spastic paraparesis and quadriparesis. In the 1997 Moore and
Blumhardt series, 23.6% of patients presenting with nontraumatic
myelopathic symptoms had CSM.

Mortality/Morbidity: See Background, Pathophysiology, and History

sections.

Race: Cervical spondylosis may affect males earlier than females, but this is
not true in all studied populations.

Sex:

 Irvine et al defined the prevalence of CSM using radiographic

evidence. In males, prevalence was 13% in the third decade, rising to
nearly 100% by age 70 years. In females, the prevalence ranged from
5% in the fourth decade to 96% in those older than 70 years.

 Another study, in 1996, by Holt and Yates examined patients at

autopsy. At age 60 years, one half of the men and one third of the
women had a significant amount of disease.

 In 1992, Rahim and Stambough noted that spondylotic changes are

most common in those older than 40 years. Eventually, more than 70%
of men and women are affected, but the radiographic changes are
more severe in men than in women.

Age: See the "Sex" section.

  CLINICAL Section 3 of 11   

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures
Bibliography

History:

 Clinical syndromes associated with cervical spondylosis vary.

 Intermittent neck and shoulder pain (cervicalgia) is the most common
syndrome in clinical practice. This is a frustrating problem for
physicians and patients, as often no associated neurologic signs are
present.

o When neurologic deficits are present, diagnostic imaging often

can define the cause. When they are not present, imaging
usually is not helpful, as the incidence of radiologic
abnormalities is high in older patients, even in asymptomatic
patients. A main problem is that the source of pain in this
situation is poorly understood. This syndrome may be related to
compression of the sinuvertebral nerves and the medial
branches of the dorsal rami in the cervical region.

o Neck pain experienced with cervical spondylosis often is

accompanied by stiffness, with radiation into the shoulders or
occiput. It may be chronic or episodic, with long periods of
remission. One third of patients with cervicalgia from cervical
spondylosis present with headache, and over two-thirds present
with unilateral or bilateral shoulder pain. A significant amount of
these patients also present with arm, forearm, and/or hand pain.

 Another poorly understood associated clinical syndrome is chronic

suboccipital headache.

o Although the dermatomes corresponding to cervical nerve roots

1-3 (C1-C3) are located on the head, occipitoatlantal and
atlantoaxial degeneration seems unlikely to be the cause of pain
in these areas, because there are no contributions to these
joints from the dorsal rami of C1-C3.

o The greater occipital nerve usually cannot be compressed by

bony structures, yet headaches can be the dominant symptom
in a patient with degenerative cervical disease. Headaches
usually are suboccipital and may radiate to the base of the neck
and the vertex of the skull.

 Radiculopathy is understood more thoroughly than the previously

outlined syndromes.

o The most commonly involved nerve roots are the sixth and
seventh cervical nerve roots, caused by C5-6 or C6-7
spondylosis, respectively. Patients usually present with pain,
paresthesias, weakness, or a combination of these symptoms.
Most present without a history of trauma or a precipitated cause.
The pain usually is in the cervical region, upper limb, shoulder,
and/or interscapular region.
 o Occasionally, the pain may be atypical and present as chest
pain (pseudoangina) or breast pain. Usually the pain is more
frequent in the upper limb than in the neck, although it frequently
is present in both areas. Cervical radiculopathy usually is not
associated with myelopathy.

 CSM is the most common cause of nontraumatic paraparesis and

tetraparesis. The process usually develops insidiously.

o In the early stages, patients often present with a stiff neck. They
also may present with stabbing pain in the preaxial or postaxial
border of the arms.

o Patients with a high compressive myelopathy (C3-C5) can

present with a syndrome of "numb, clumsy hands." The patient
describes a loss of manual dexterity; difficulty with writing;
nonspecific, diffuse weakness; and abnormal sensations.

o Patients with a lower cervical myelopathy typically present with a

syndrome of weakness, stiffness, and proprioceptive loss in the
legs. These patients often exhibit signs of spasticity. Weakness
or clumsiness of the hands may be observed in conjunction with
weakness in the legs. Motor loss in the hands with relative
sparing of the legs is a relatively rare syndrome.

o Symptoms commonly are asymmetric in the legs.

o Loss of sphincter control and urinary incontinence are rare, but

some patients complain of urgency, frequency, and urinary
hesitancy.

 An important cause of acute myelopathy that may be related to cervical

spondylosis is central cord syndrome.

o 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, resulting in acute cord
compression.

o Patients usually present with a history of a blow to the forehead.

o The syndrome consists of upper extremity weakness greater

than lower extremity weakness, varying degrees of sensory
disturbances below the lesion, and myelopathic findings (eg,
spasticity, urinary retention).

Physical:
 Examination findings include neck pain, radicular signs, and
myelopathic signs. Patients with neck pain from spondylosis often
present with neck stiffness. This is a nonspecific sign, and other
causes of neck pain and stiffness (eg, myofascial pain, intrinsic
shoulder pathology) must be considered and excluded.

 If the history is compatible with cervical radiculopathy, carefully search

for signs of muscle atrophy in the following muscles: supraspinatus,
infraspinatus, deltoid, triceps, and the first dorsal interosseus muscle.

 Winging of the scapula also may occur, since it may occur with C6 or
C7 radiculopathy. Palpate all muscles, since this may allow earlier
detection of wasting than visualization. Detecting weakness in either
one myotomal distribution or 2-3 peripheral nerves likely excludes
peripheral nerve injury as the cause. Muscle testing is important
because muscle findings have more specificity than sensory or reflex
findings.

 Perform a detailed sensory and reflex examination in every patient who

presents with a history that is suggestive of cervical spondylosis. Note
that radicular findings often do not adhere strictly to textbook
dermatomal charts. Patients often experience more pain proximally in
their limbs, while paresthesias dominate distally.

 Look for physical evidence of other causes of radiculopathy-type

symptoms (eg, tenderness lateral to the neck in the supraclavicular
fossa, Tinel sign).

 The neck compression test (Spurling test or sign), if positive, is useful

when assessing a patient for cervical radiculopathy.

o This test is best performed by having the patient actively extend

his or her neck, laterally flex, and rotate to the side of the pain
while sitting. Next, use careful compression by slight axial
loading. This maneuver works by narrowing the ipsilateral neural
foramina during flexion and rotation, while the initial extension
causes posterior disk bulging.

o While this maneuver has a low sensitivity for cervical

radiculopathy, it has a specificity of nearly 100%. Other useful
tests are the axial manual traction test and the shoulder
abduction test.

 In CSM, the most typical examination findings are suggestive of upper

motor dysfunction, including hyperactive deep tendon reflexes, ankle
and/or patellar clonus, spasticity (especially of the lower extremities),
Babinski sign, and Hoffman sign.
 o The Hoffman sign is a reflex contraction of the thumb and index
finger after nipping the middle finger. Although this sign usually
is present with corticospinal tract dysfunction, unlike the
Babinski sign, it also can be present in generalized hyperreflexic
states and in neurosis. It also may be found (usually bilaterally
and incomplete) in persons without CSM.

o Thus this sign is only valuable if it is associated with other upper

motor neuron–related findings. The Hoffman sign is best elicited
by positioning the patient's hand at rest, then stabilizing the
proximal phalanx between the examiner's index and middle
finger; with the examiner's thumb, the patient's distal middle
finger is flicked downward. The sensitivity of this examination
maneuver may be increased by examining the patient during
multiple full flexion or extension of the neck (dynamic Hoffman
sign).

 Another occasionally useful test is the pectoralis muscle reflex.

o This is elicited by tapping the pectoralis tendon in the

deltopectoral groove, which causes adduction and internal
rotation of the shoulder if hyperactivity is present. It suggests
compression in the upper cervical spine (C2-C4).

o If the patient exhibits diffuse hyperreflexia, then the jaw jerk may
distinguish an upper cervical cord compression from lesions that
are above the foramen magnum.

 Examine gait in any neurologic examination whenever possible.

Patients with CSM typically exhibit a stiff or spastic gait, especially later
in the course of their disease.

 Another helpful sign is Lhermitte sign.

o This consists of electric shocklike sensations that run down the

center of the patient's back and shoot into the limbs during
flexion of the neck.
o This sign is not specific for CSM and classically is attributed to
the posterior column's dysfunction. Other causes of Lhermitte
sign include multiple sclerosis, tumors, and other compressive
pathology.

 Sensory abnormalities in CSM have a variable pattern on examination.

o Loss of vibratory sense or proprioception in the extremities can

occur, particularly in the feet. Spinothalamic sensory loss may
be asymmetric.
 o Diabetes mellitus or other metabolic causes of peripheral
neuropathy can confound the sensory examination. Perform a
complete motor examination. Wasting of the intrinsic hand
musculature is a classic finding in CSM.

Causes:

 In addition to age and possibly gender, several risk factors have been
proposed for cervical spondylosis.

o Repeated occupational trauma (eg, carrying axial loads,

professional dancing, gymnastics) may contribute. The role of
occupational trauma is controversial, especially in terms of
worker's compensation claims and other related medicolegal
clauses.

o Familial cases have been reported; a genetic cause is possible.

o Smoking also may be a risk factor.

o Conditions that contribute to segmental instability and excessive

segmental motion (eg, congenitally fused spine, cerebral palsy,
Down syndrome) may be risk factors for spondylotic disease.

  DIFFERENTIALS Section 4 of 11   

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures
Bibliography

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
Temporomandibular Joint Syndrome
Thoracic Outlet Syndrome
Torticollis

Other Problems to be Considered:

Acromioclavicular pathology
Acute posterior cervical strain
Adhesive capsulitis
Aortic disease
Back Pain
Calcareous tendonitis
Cervical lymphadenitis
Cervical rib
Fibrositis syndromes
Frozen shoulder syndromes
Gallbladder disease
Glenohumeral arthritis
Gout (infrequently)
Heart disease
Hyperabduction syndrome
Intervertebral osteoarthritis
Lung disease
Meningitis
Musculoligamentous injuries to the neck and shoulder
Neoplasms
Neoplasms of the shoulder
Nerve injuries
Occipital neuralgia
Osteomyelitis
Osteoarthritis of apophyseal joints
Paget disease
Pancreatic disease
Peptic ulcer disease
Pharyngeal infections
Postural 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
Psychogenic disorders
Bicipital tendonitis: rotator cuff tears, lateral epicondylitis
Discitis
Double crush syndrome
Idiopathic brachial plexopathy (neuralgic amyotrophy)
Pancoast tumor
Posttraumatic facet fracture with narrowing of the foramen
Synovial cysts
Thoracic outlet syndrome
Arachnoiditis
Arteriovenous malformation
Congenital spinal lesion
Epidural abscess
Extrinsic neoplasia (usually metastatic)
Intrinsic neoplasia
Tabes dorsalis
Thoracic disk
Tropical spastic paraparesis
Brainstem syndromes
Cervical disk syndromes