CERVICAL SPONDYLOSIS AND ITS MANAGEMENT

Spondylosis is a term meaning to degenerative Osteo Arthritis of the

joints between the center of the spinal vertebrae and or neural foramina
resulting pain parasthecia etc. If it is occurs on cervical vertebrae it is called Cervical spondylosis.So this is a diseases of elderly (more than 40 years) where there is degeneration of the apophysial joints and inter-vertebral disc joints with osteophyte formation and associated with or without neurological signs.

PATHOLOGY:

With the progressing of age in the spine disc gradually breakdown and degeneration occurs. As the age advances disc begins to loses its water content,elasticity begins to weakens and age related wear and tear affecting the cervical vertebrae,cause settling and collapse of the disc space and loss of the disc space height.

As the facet joint experiences increased pressure they also begins to degenerate and develops arthritis. Resulting in bone rubbing. for this mechanism body develops some preventing measures as a result growing new bones in facet joins to help support, further result as spur. It may narrow space between the vertebrae (stenosis). Due to age and some other factors brings down the calcification leading to extra bone formation known as osteophytes.
Due to trauma, pressure etc some factors like intra vertebral disc herniation may also result to cause this disease.

INTRA VERTEBRAL DISC HERNIATION:

The disc are made up of two concentric layers,the inner gel likeannulus pulposes and outer annulus fibroses. As a result of advancing age and other precipitating causes the nucleus loses fluid volume and resulting the entire disc structure become more susceptible to trauma compression (dehydration of the disc). The disc is then highly vulnerable to tears and wears. as a results inner annulus pulposes protrudes thereby fibrosis layer produce bulges in the disc (herniated disc) cause compression to the spinal cord and nerve root.when space narrows compression of nerve root emerging from spinal nerve may result radiculopathy (sensory and motor disturbances), direct pressure on the spinal cord may result myelopathy, weakness,  gait disturbances, loss of bowel and bladder control. may experience phenomena of numbness or burning sensation on hand and legs.

 CAUSES and  AGGRAVATING FACTORS:

• Trauma
• Incorrect posture while sleeping and working.
• Excess intake of sour and spicy food- cause to early degeneration.
• Genetically
• Smoking- tends to increase the disease and other symptoms.
• Occupational- reduced physical activity, sedentary habit, stress,
• Repetitive strain injury (RSI)- caused due to lifestyle without ergonomic care (while working in front of  computer), travelling, etc.
• Age. 
• Cold food, direct exposure of wind, heavy meal at night time, heavy exercise, use of improper pillow, lack of sleep at night and sleeping during day time, etc may aggravate the condition.  

SYMPTOMS:

• Pain and stiffness of neck and shoulder.
• Radiating shoulder pain to arms and upper part of chest.
• Tingling and pricking pain in arms and hand.
• Difficulty in writing , holding objects etc.
• Abnormal reflexes and irritability and lack of co-ordination, movements aggravates pain.
• Nausea (vomiting sensation), blurred vision, loss of memory, sleeping, giddiness on jerky neck movements.
• General tiredness and anxiety.
• Fibromyalgia.
• Feel or hear grinding or popping in neck.

Symptoms aggravated in sometimes, worsened by looking up or down for a long time or with activities like long driving, reading etc. Subsides with rest or lying down. these may worsened in early morning while waking up from bed.

What is FIBROMYALGIA:

It is an associated symptom, but a different condition. pain in muscles following spasm associated with morning stiffness, disturbed sleep, a feeling of swelling, some points are tender and when palpated produce pain.But it is not associated with muscle weakness. The pain is severe and it is localized to certain points in skeletal muscles, particularly the large muscles of neck and shoulder girdle, arms and thigh. Tender nodules can be felt in the muscle tissue, which serve as a trigger points. Many of the patients are tense sedentary women.

INVESTIGATIONS AND DIAGNOSIS: 

Through inspection and investigation is needed to diagnose this case. A detailed inspection and palpation is needed to locate any swelling and tenderness. Tenderness is a positive sign for cervical spondylosis .
it is needed to know that the exact location of pain, onset (gradual), occurrence, character and severity, aggravating and relieving conditions, etc.
History should be asked.

• Inspect and palpate the spine for deformity and for cervical rib.
• Peripheral pulses in detail.
• Movement of cervical spine and shoulder joint.
• CNS examination-motor, sensory and reflex change.
• Respiratory symptoms for pancoast tumor , TB.
• Spurlings test- rotate the patients head and placing downward pressure on it. a positive sign is neck or shoulder pain on he ipsilateral side. Radicular symptoms on extension and lateral rotation of neck due to narrowing of inter vertebral foramina.
• Lhermitte sign- feeling of electrical shock with neck flexion.

X-RAY:

AP and LATERAL view of neck x-ray is useful to find any spur, reduction in space,ostoephyte formation, and cervical rib formation.

 CT-

 Helps to view bone and spinal canal.

 

MRI:

Get better image of soft tissue, spinal cord compression if any, degree of compression etc.

MYELOGRAPHY- X-RAY STUDY:

Injecting due or contrast material into spinal canal for evaluating spinal canal and nerve root.

EMG ELECTROMYOGRAPHY:

Nerve conducting study and EMG for evaluating nerve damage and pinching.

BLOOD TEST: To rule out any other diseases,

DIFFERENTIAL DIAGNOSIS: 

Neck pain may be due to spinal causes, extra spinal causes, or due to myalgia, etc.

Spinal- mechanical (OA, herniation)
Inflammatory (RA, polymyalgia rheumatica)
Metabolic (osteoporosis)
Spinal (metastasis)
Neoplasmic.
Extraspinal-
Brachial plexus pain.
Injury, Peri arthritis, bursitis, pancoat tumour of lung, soft tissue rheumatic pain, trauma.
CTS- carpel tunnel syndrome
Coronary artery disease.

NEUROLOGICAL SYMPTOMS IN RADICULOPATHY:

SENSORY DISTRIBUTION                                                 PAIN DISTRIBUTION

• C5 over deltoids, +/- index and thumb                           Lateral arm and medial scapula.
• C6 thumb, index finger, radial hand, forearm                  Lateral forearm,thumb,index finger.
• C7 middle finger, dorsum of forearm                             Posterior forearm, dorsal forearm,lateral hand
• C8 little finger, medial hand, forearm                              4th 5th finger,medial forearm.

COMPLICATIONS:

• Chronic neck pain.
• Progressive loss of muscle function or feeling.
• Inability to retain feces and urine (fecal or urinary incontinence).
• If spinal cord is effected there will loss of balance and loss of bladder control and bowel control,muscle weakness,sensory loss, and gait disturbances.

TREATMENTS: (all these should be used as directed by the physician)

Hot fomentation is beneficial, hot and cold therapy and gentle massage is helpful. Violent massage with deep pressure is very harmful for the patient. Only gentle massage over the muscles of the neck and shoulder joint should be applied which directed outwards that is from the neck towards the shoulders.

Physical therapy:

Strengthening and stretching of weakened or strained muscles.
Traction and postural therapy.

Medication:

Acetaminophen- mild pain
NSAIDs with Acetaminophen
Ibuprofen and naproxen (pain, swelling)
muscle relaxant like cyclobenzoprene, or corisoprodol.
Soft collars- limit neck motion and give rest. only for short duration. long term duration will cause to muscle weakness.
Ice heat and other modalities, steroid based injections- will reduce pain.

CERVICAL EPIDURAL BLOCK- 

Steroid and anaesthetic medicines is injected into space next to covering of spinal cord. (for neck arm pain due to herniation).

cervical epidural injection

CERVICAL FACET JOINT BLOCK:

Steroid and anaesthetic medicines is injected into the capsule of the facet joint. the facet joints are located in the back of neck and provide stability and movement, can develop arthritic changes that may contribute to neck pain.

MEDIAL BRANCH BLOCK AND RADIO FREQUENCY ABLATION:

This procedure is used in some cases of chronic pain.can be used  for both diagnosis and treatment of a potentially painful joints. During diagnosis portion the nerve that supplies the facet joints is blocked with local anaesthetic and check if pain neck pain is completely gone.If so that point is pinpointed the source of neck pain.Next step is to block the pain permanently by damaging the nerve radio frequency, A procedure called radio frequency ablation.Although less invasive than surgery. Steroid based injection are prescribed only after a complete evaluation by the physician. 
Before considering these injunctions discuss with a good doctor about risk and benefits of these procedures for your specific conditions.

MEDIAL BRANCH BLOCK AND RADIO FREQUENCY ABLATION

SURGERY:

It is preserved only for the patients who have sever pain that has not been relieved by other treatment. Some patients with severe pain will unfortunately not be candidates of surgery. This is due to the widespread nature of there arthritis other medical problems or other causes for their pain such as fibromyalgia. People who have progressive neurological symptoms  such as weakness, numbness or falling are more likely to be helped by surgery.

EXERCISES:

Mild exercise is beneficial for first stages of diseases. Vigorous  diseases are not advisable to these patients.One should always start gradually mild exercises in beginning. And gradually increasing the types and time.There are many types of exercises which mainly concentrates on cervical region.Exercise flexion of neck, extension, rotation etc. 

EXERCISES AND CORRECT POSITIONS: