Cervical Spondylosis

Age related degeneration of the cervical spine: disc dehydration and height loss, osteophyte formation (uncovertebral and facet), facet joint arthritis, ligamentum flavum thickening, and ossification of ligaments. It is the commonest cause of neck pain and cervical myelopathy in older adults.

• Radiographic changes are present in about 60% of people over 40 and above 85% over 60, and are often asymptomatic, so imaging must be matched to symptoms.
• Syndromes:
  • Axial neck pain (neck stiffness and pain).
  • Cervical radiculopathy (nerve root compression, most often C7 then C6, annual incidence about 83 per 100,000).
  • Cervical spondylotic myelopathy (spinal cord compression, the commonest cause of spinal cord dysfunction in adults over 55).
  • Cervicogenic headache and dizziness.
• Risk factors: age, occupational loading, smoking, previous neck injury, congenital narrow canal (anteroposterior diameter below 13 mm), and a family history.
• Most neck pain and radiculopathy improve within 6 to 12 weeks. Myelopathy tends to progress in steps.

• Axial: neck pain and stiffness, worse with movement and static posture, occipital headaches, trapezius and interscapular pain, and reduced rotation and extension, with local tenderness and paraspinal spasm.
• Radiculopathy: unilateral arm pain with dermatomal paraesthesia, weakness and reduced reflexes. C5 (shoulder pain, deltoid weakness), C6 (thumb and index finger, biceps and wrist extensors, biceps reflex), C7 (middle finger, triceps and wrist flexors, triceps reflex), C8 (ring and little fingers, finger flexors and intrinsic muscles). A positive Spurling test (neck extension, lateral flexion and axial compression reproducing arm pain), relief on shoulder abduction (shoulder abduction relief sign), and a positive upper limb tension test.
• Myelopathy: hand clumsiness (difficulty with buttons and writing), numb hands, gait imbalance and leg stiffness, falls, urinary urgency, Hoffmann sign, hyperreflexia, clonus, positive Babinski sign, inverted supinator reflex, wasting of intrinsic hand muscles, and Lhermitte phenomenon (electric shock on neck flexion).
• Differential diagnosis: cervical disc herniation, cervical facet syndrome, rotator cuff disease, carpal tunnel syndrome and ulnar neuropathy, brachial plexopathy and neuralgic amyotrophy, thoracic outlet syndrome, motor neurone disease, multiple sclerosis, B12 deficiency, syringomyelia, spinal tumour or metastasis, infection (discitis, epidural abscess), vertebral fracture, inflammatory spondyloarthritis, and cardiac pain.
• Red flags: progressive weakness, gait disturbance and sphincter dysfunction (myelopathy), fever, unexplained weight loss, history of cancer, trauma, night pain, bilateral arm symptoms, immunosuppression, and intravenous drug use.
• Complications: myelopathy and tetraparesis, chronic radicular pain, loss of function, fall risk and, after minor trauma in a narrow canal, central cord syndrome.

• Clinical, with a full neurological examination (power, sensation, reflexes, Hoffmann sign, gait and tandem walk) and examination of the shoulders and wrists.
• X-ray (anteroposterior, lateral, flexion extension, and oblique views) shows disc space narrowing, osteophytes, foraminal narrowing, instability and alignment. Not required for uncomplicated axial pain.
• MRI of the cervical spine is the investigation of choice for radiculopathy lasting beyond 6 weeks, any myelopathy, progressive deficit, or red flags, and shows cord compression and signal change. CT shows bony stenosis and ossification of the posterior longitudinal ligament. Nerve conduction studies and electromyography to differentiate radiculopathy from peripheral neuropathy.
• Blood tests (full blood count, CRP, ESR, B12, glucose, thyroid function, calcium) when systemic, inflammatory or metabolic causes are possible.

• Axial neck pain and mild radiculopathy (the majority):
  • Reassurance, staying active, ergonomic review, and avoiding prolonged static postures. A soft collar for a few days at most, because longer use causes weakness and stiffness.
  • Paracetamol 1 g orally 6 hourly. Naproxen 500 mg orally 12 hourly (or ibuprofen 400 mg 8 hourly, or diclofenac 50 mg 8 hourly) with food for 1 to 2 weeks, with gastroprotection where needed. Topical diclofenac 1% gel 2 to 4 g 3 to 4 times daily.
  • Muscle relaxants for acute spasm, for 5 to 7 days: tizanidine 2 mg orally 8 hourly increasing to a maximum of 36 mg daily, or cyclobenzaprine 5 to 10 mg at night or 8 hourly, with sedation as the main side effect.
  • Neuropathic arm pain: gabapentin 300 mg at night increasing over 1 to 2 weeks to 300 mg 8 hourly (maximum 3600 mg daily), pregabalin 75 mg 12 hourly increasing to 150 mg 12 hourly (maximum 300 mg 12 hourly), amitriptyline 10 mg at night increasing to 25 to 50 mg, or duloxetine 30 mg daily increasing to 60 mg daily. Adjust for renal function.
  • A short oral prednisolone course for severe radicular pain (30 to 40 mg daily for 5 to 7 days, evidence limited).
  • Physiotherapy: deep neck flexor and scapular strengthening, posture and mobilisation, cervical traction (limited evidence), and a home exercise programme.
  • Heat, and a cervical pillow.
• Cervical epidural or selective nerve root steroid injection for radicular pain persisting after 6 weeks (triamcinolone 40 mg or dexamethasone 10 mg, under imaging guidance by specialists), with relief lasting weeks to months and rare serious neurological complications.
• Surgery:
  • Progressive or moderate to severe myelopathy: decompression and stabilisation without delay (anterior cervical discectomy and fusion, corpectomy, laminoplasty, or laminectomy with fusion), which stops progression and may improve function. Mild myelopathy may be observed with close review every 3 to 6 months.
  • Radiculopathy with progressive or severe motor deficit, or disabling pain persisting beyond 6 to 12 weeks despite treatment: anterior discectomy and fusion, disc arthroplasty, or posterior foraminotomy.
• Avoid chiropractic high velocity manipulation of the neck in myelopathy or vertebrobasilar risk.
• Special groups:
  • Elderly: higher risk of myelopathy, falls and drug side effects, so reduce doses of gabapentin, pregabalin, tizanidine and amitriptyline, and avoid cyclobenzaprine.
  • Diabetes: monitor glucose with steroids, and treat diabetic neuropathy separately.
  • Pregnancy: physiotherapy, paracetamol and posture. Avoid NSAIDs after 20 weeks and gabapentinoids unless essential.
  • Renal impairment: reduce gabapentin and pregabalin doses, and avoid NSAIDs.
  • Anticoagulation: epidural injection requires holding the drug under specialist guidance.
• Follow up: review at 2 to 4 weeks and at 3 months. Refer urgently to spinal surgery for any myelopathy, progressive weakness, bladder or bowel dysfunction, or cord signal change. Refer routinely for radiculopathy beyond 6 to 12 weeks.