Cervical Spondylosis is a
non-specific term describing the morphological manifestations of
progressive degeneration of the spine.
SPONDYLO is a Greek word
meaning vertebra. Spondylosis generally mean changes in the vertebral
joint characterized by increasing degeneration of the intervertebral disc
with subsequent changes in the bones and soft tissues.
From the IV to V decade, it
is clear that IVD undergoes progressive desiccation, becomes more
compressible and less elastic and secondary changes ensue. Although the
majority of individuals over 40 years of age demonstrate significant
radiological evidence, but only a small percentage develop symptoms. The
changes result in neural compression resulting in radiculopathy or
compression of the spinal cord resulting in myelopathy. Both the neural
and spinal cord compression will result in radiculomyelopathy.
Males predominate for
myelopathy. There is no such proclivity for disc disease.
The primary event is a
progressive decrease in the degree of hydration resulting in loss of disc
height, disc fibrosis and annular weakening. The extra mobility between
adjacent vertebral areas probably results in osteophyte formation. Though
osteophyte formation may be the body’s attempt to stabilize the joints,
their growth can result in narrowing of the spinal canal and cord
There are several
predisposing factors, which may cause acceleration of these changes.
Occupations requiring repetitive motion of the cervical spine.
Previous injury with fracture or disc prolapse
Segmentation defects like hemivertebra or fused vertebrae.
The various factors that play
a role in spondylitic myelopathy are
Congenital narrowing of the cervical spinal canal can be a major cause of
It may be localized or generalized .
Myelopathy is often seen when canal
sagittal diameter is 12 mm or less.
Acquired narrowing may be due to
can also cause
root sleeve fibrosis due to irritation.
(b) ossified posterior longitudinal
a well recognized
cause in Japan;
may be related to
Diffuse Idiopathic Skeletal Hyperostosis (DISH). Fluorosis may play a part
bone is fragile and the dura may be adherent to this fragile bone and at
(c) Facet joint hypertrophy
may result in
foraminal stenosis and compression of the root and radicular artery
(d) hypertrophied ligamentum flavum
the cord during extension.
Dural adhesions to the posterior longitudinal ligament and the root
sleeves make the cord
4) Vascular compromise by
compression of the anterior spinal and radicular arteries and veins may
for ischaemia of the cord and not improve with surgery.
Neural compression syndromes
They can be acute, sub-acute,
or chronic and occasionally acute exacerbation of chronic symptoms can
Radiculopathy refers to
symptoms and signs of nerve root compression such as shooting pain down
the arm, “pins
and needles” to frank sensory
and motor deficits and absence of reflex corresponding to the nerve root
involved. There is
also frequently referred pain
and tenderness along the medial border of the scapula and in about 60% of
is occipital headache due to
The commonest roots affected
are C5 and C6.
Myelopathy has been
classified in various ways and depends on the involvement of the lateral
or medial cord or vascular
involvement. The signs
may be a mixture of upper motor neuron signs in the lower limbs and lower
motor neuron signs in
the upper limbs and may
simulate MND or syringomyelia.
Occasionally the presentation
may be that of Brown-Sequard syndrome.
Bladder involvement is
Combination of radicular and
cord symptoms are found in radiculomyelopathy.
Various autonomic symptoms
can be produced, such as vertigo, flushing, tinnitus and visual
These may be mediated
by the sympathetic contribution to
the sinveretebral nerves from the stellate ganglion.
insufficiency due to spondylitic compression of the vertebral artery is
uncommon, though popularly diagnosed.
The mainstay of imaging
is plain X-Rays and MRI.
Plain X-Rays reveal
narrowed disc space, and anterior and posterior marginal lipping of
the vertebral bodies. Loss of cervical lordosis is an early finding.
Spinal cord narrowing correlates with myelopathy.
studies (EMG and nerve conduction studies) can be
used when the diagnosis is in doubt. Carpal tunnel syndrome,
thoracic inlet syndrome, amyotrophic lateral sclerosis may be
accurately diagnosed by neurophysiological studies.
MRI is the preferred
modality. Apart from clearly delineating the soft tissue and disc
compression it may show signal intensity changes in the cord itself
and helps to assess the degree of cord damage.
Medical Management mainly
targets pain relief. Radiculopathy improves in majority without the
need for surgery. Commonly used drugs are the NSAIDs and muscle
relaxants. The antidepressants may be useful if functional overlay is
MRI-C-5/C-6 Disc prolapse
MRI-Posterior osteo phytes
( Axial )
Physiotherapy has an
important role adjuvant to medical or surgical treatment. The main
objectives are to decrease the duration of disability, to reduce the use
of drugs and to prevent chronicity and recurrence. Active modalities such
as exercises for the neck, shoulder and the limbs are preferred.
Passive modalities such as
heat, cold, ultrasound, cervical collar, traction, interferential therapy,
etc should be used only temporarily as an adjunct.
Manipulation should be
intraoperative video clippings
It is indicated when
There is progressive cord dysfunction,
In acute cord compression,
Persistent pain not responding to conservative measures and
interfering with normal life.
Two surgical approaches,
anterior and posterior, are available.
With better imaging and use
of surgical microscope, anterior approach are now used in majority of
cases because it is simple and allows early postoperative mobilization and
shorter hospitalization. In addition, the primary pathology such as disc,
and osteophytes are dealt with directly.
A left sided approach avoids
injury to the recurrent laryngeal nerve injury.
On occasions, such as OPLL it
may require drilling of the vertebral body (corpectomy) for adequate
decompression. Visualization of the posterior longitudinal ligament and a
possible tear, and exploration of the same for extruded disc fragments is
an important step .The presence of such extruded disc fragments may be
suggested by a careful study of the MRI pictures.
When multiple levels (more
than two) are involved many advocate fusion in addition to discectomy.
Various techniques are available.
When root pain is the
predominant symptom a fusion to prevent narrowing of the intervertebral
foramen is recommended.
A tricorticate graft obtained
from the posterior iliac crest so that its cancellous part lie against the
subchondral bone above and below the space, while its cortical part forms
the support between the vertebrae (Smith Robinson Technique) is
Attempts to take a graft from
the anterior iliac crest may injure the lateral cutaneous nerve of the
The drilling the adjacent
vertebral surfaces, after removing the cartilaginous plates, helps in
technique, using a bone dowel is also popular.
technique involves making a keystone square
in the adjacent vertebral bodies for the graft.
Bailey and Badgley
technique involves making a
rectangular trough in the adjacent bodies for the graft.
Cadaveric bone grafts and
methyl methacrylate are used by some for obvious reasons, but autografts
have been found superior .
Some advocate suturing the
prevertebral fascia over the graft to prevent graft migration.
Some advocate anterior
instrumentation in addition to bone grafting, especially in cases where
trauma is a factor. Anterior self locking plate fixation is common.
Titanium cage filled with cancellous bone fixation is specially useful
(with or without plates) in multilevel corpectomy.
Post operatively, a hard
cervical collar is advised for six weeks.
Posterior approach may be
indicated in canal stenosis, either congenital or degenerative with
hard disc protrusions or hypertrophy of the ligamentum flavum or multi
C3 to C7 posterior
laminectomy is recommended despite the level of involvement and gives
adequate decompression. Additional foraminotomy (removal of the
posterior wall of the intervertebral foramen) is helpful in
Occasionally a soft
lateral disc protrusion can be removed through hemi or a partial
laminectomy or through an interpedicular approach.
The complications of an
extensive laminectomy are, late development of spinal deformity and
peridural fibrosis. These can possibly be avoided by expansive
laminoplasty. It is performed by completely incising the laminae on
one side and partially on the opposite side. Elevation with tilting
of the lamina upwards on the incised side allows enlargement of the
surgical approach used, improvement can be expected if symptoms have
been present for less than two years. Results of treatment are also
influenced by the degree of cord compression, changes in signal
intensity of the cord on MRI and number of levels involved.
OPLL-Post corpectomy with titanium cage fixation AP & LAT
Listhesis PRE & POST OP
In myelopathy, the
motor functions improve faster and better as compared to sensory