Spondylosis

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Spondylosis
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Thoracic spondylosis
Specialty Neurosurgery
Orthopedics

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints (facet syndrome). If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

Contents

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 disturbances, such as severe pain in the neck, shoulder, arm, back, or leg, accompanied by muscle weakness). Less commonly, direct pressure on the spinal cord (typically in the cervical spine) may result in myelopathy, characterized by global weakness, gait dysfunction, loss of balance, and loss of bowel or bladder control. The patient may experience 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. Lower back spondylosis is labeled lumbar spondylosis. The term is from Ancient Greek σπόνδυλος spóndylos, "a vertebra", in plural "vertebrae – the backbone".

Signs and symptoms

Cervical spondylosis

In cervical spondylosis, a patient may be presented with dull neck pain with neck stiffness in the initial stages of the disease. As the disease progresses, symptoms related to radiculopathy (due to compression of exiting spinal nerve by narrowed intervertebral foramen) or myelopathy (due to compression on the spinal cord) can occur. [1] Reduced range of motion of the neck is the most frequent objective finding on physical examination. [2]

In cervical radiculopathy, there would be numbness, tingling, or burning pain at the skin area supplied by the spinal nerve, shooting pain along the course of the spinal nerve, or weakness or absent tendon reflex of the muscle supplied by the nerve. [1] This symptom can be provoked by neck extension. Therefore, Spurling's test, which take advantage of this phenomenon, is performed by extending and laterally flexing the patient's head and placing downward pressure on it to narrow the intervertebral foramen. [1] Neck or shoulder pain on the ipsilateral side (i.e., the side to which the head is flexed) indicates a positive result for this test. A positive test result is not necessarily a positive result for spondylosis and as such additional testing is required. [3]

In cervical myelopathy, almost always involves both the upper and lower limbs. A person may experience difficult gait or limb stiffness in the early stages of the disease. [1] Iliopsoas muscle is the first group of muscles that is affected. Lower limb weaknesses without any upper limb involvement should raise the suspicion of thoracic cord compression. [1] Finger escape sign is performed to detect the weakness of the fingers. A person's forearm is pronated and the fingers are extended. If the person has myelopathy, there will be slow abduction and flexion of the fingers on the ulnar side. The degree of loss of sensation may be different on both upper limbs. [1] Lhermitte sign is performed by asking a person to gently extend the neck. Those with cervical myelopathy will produce a feeling of electrical shock down the spine or arms. [1] [4] Muscle spasticity, hyperreflexia or even clonus are characteristic of myelopathy. Other abnormal reflexes such as Hoffmann's reflex, upward response of plantar reflex (Babinski response), and Wartenberg's sign (abnormal abduction of little finger) can also be elicited. [1]

Lumbar spondylosis

Since the spinal cord ends at L1 or L2 vertebral levels, the job of nerve transmission is continued by spinal nerves for the remaining part of the vertebral canal. Degenerative process of spondylosis such as disc bulging, osteophyte formation, and hypertrophy of the superior articular process all contributes to the narrowing of the spinal canal and intervertebral foramen, leading to compression of these spinal nerves that results in radiculopathy-related symptoms. [5]

Narrowing of the lumbar spinal canal causes a clinical condition known as neurogenic claudication, characterised by symptoms such as lower back pain, leg pain, leg numbness, and leg weakness that worsens with standing and walking and improves with sitting and lying down. [5]

Complications

A rare but severe complication of this disease is vertebrobasilar insufficiency. [6] This is a result of the vertebral artery becoming occluded as it passes up in the transverse foramen. The spinal joints become stiff in cervical spondylosis. Thus the chondrocytes which maintain the disc become deprived of nutrition and die. Secondary osteophytes may cause stenosis for spinal nerves, manifesting as radiculopathy.

Causes

Congenital cervical spine stenosis commonly occurs due to short pedicles (that form the vertebral arch). When the spinal canal diameter divided by vertebral body diameter is less than 0.82, or the anteroposterior diameter of the spinal canal is less than 1.3cm or the distance between the pedicles is less than 2.3cm during imaging, cervical spine stenosis is diagnosed symptoms correlate well with the spinal canal narrowings. [7] This is because some patients may not have any symptoms at all even when there is severe cervical spine spondylosis. [1]

Spondylosis is caused from years of constant abnormal pressure, caused by joint subluxation, stress induced by sports, acute and/or repetitive trauma, or poor posture, being placed on the vertebrae and the discs between them. The abnormal stress causes the body to form new bone in order to compensate for the new weight distribution. This abnormal weight bearing from bone displacement will cause spondylosis to occur. Poor postures and loss of the normal spinal curves can lead to spondylosis as well. Spondylosis can affect a person at any age; however, older people are more susceptible. [8]

Degeneration of the intervertebral disc, facet joints, and its capsules, and ligamentum flavum all can also cause spinal canal narrowing. [7]

Diagnosis

CT scan of a man presenting with radiculopathy of the left cervical spinal nerve 7. It shows spondylosis with osteophytes between the vertebral bodies C6 and C7 on the left side, causing foraminal stenosis at this level (lower arrow, also showing axial plane), explaining the symptoms. There is also spondylosis of the facet joint between C2 and C3, with some foraminal stenosis at this level (upper arrow), which appears to be asymptomatic. CT of spondylosis causing radiculopathy.png
CT scan of a man presenting with radiculopathy of the left cervical spinal nerve 7. It shows spondylosis with osteophytes between the vertebral bodies C6 and C7 on the left side, causing foraminal stenosis at this level (lower arrow, also showing axial plane), explaining the symptoms. There is also spondylosis of the facet joint between C2 and C3, with some foraminal stenosis at this level (upper arrow), which appears to be asymptomatic.

Those with neck pain only without any positive neurological findings usually do not require an x-ray of the cervical spine. For those with chronic neck pain, a cervical spine x-ray may be indicated. There are various ways of doing cervical spine X-rays such as anteroposterior (AP) view, lateral view, Swimmer's view, and oblique view. Cervical X-rays may show osteophytes, decreased intervertebral disc height, narrowing of the spinal canal, and abnormal alignment (kyphosis of the cervical spine). Flexion and extension view of the cervical spine is helpful to look for spondylolisthesis (slippage of one vertebra over another). [1]

MRI and CT scans are helpful for diagnosis but generally are not definitive and must be considered together with physical examinations and history. [2] CT scan is helpful to see small bony elements of the spine such as facet joint and to determine whether there is osteoporosis of the spine. However, interverterbral foramen and ligaments are not well visualised on the CT. Therefore, contrast is injected into the spinal canal via lumbar puncture and then imaged using CT scan (known as CT myelography). CT myelography is useful when the person is contraindicated to MRI scan due to presence of pacemaker or infusion pump in the body. [1]

MRI is the investigation of choice to investigate radiculopathy and myelopathy. MRI can show intervertebral foramen, spinal canal, ligaments, degree of disc degeneration or herniation, alignment of the spine, and changes on the spinal cord accurately. [1]

Treatment

Many of the treatments for cervical spondylosis have not been subjected to rigorous, controlled trials. [9] 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 cervical spondylosis with myelopathy (CSM) remain somewhat controversial, but "most clinicians recommend operative therapy over conservative therapy for moderate-to-severe myelopathy". [10]

Physical therapy may be effective for restoring range of motion, flexibility and core strengthening. Decompressive therapies (i.e., manual mobilization, mechanical traction) may also help alleviate pain. However, physical therapy and osteopathy cannot "cure" the degeneration, and some people view that strong compliance with postural modification is necessary to realize maximum benefit from decompression, adjustments and flexibility rehabilitation.

Surgery

Current surgical procedures used to treat spondylosis aim to alleviate the signs and symptoms of the disease by decreasing pressure in the spinal canal (decompression surgery) and/or by controlling spine movement (fusion surgery) but the evidence is limited in support of some aspects of these procedures. [11]

In cervical myelopathy, if the spine still retains its neutral or lordotic alignment, with one or two involved spinal segments, anterior approaches such as anterior cervical discectomy (removal of the intervertebral disc) and fusion (joining two or more vertebrae together), anterior cervical corpectomy (removal of vertebral body) and fusion, and cervical arthroplasty (joint surgery) can be used to relieve the spinal cord from compression. The anterior approach is also preferred when the source of compression arises from the anterior part of the cervical canal. If the cervical spine is in a fixed kyphotic position and with one to two involved spinal segments, posterior approaches such as laminoplasty (removal of lamina with a bone graft or metal plate as replacement) or laminectomy (removal of lamina without any replacement) with or without fusion can be used for decompression. The posterior approach is also used when the source of compression arises from the posterior part of the spinal canal. The posterior approach also avoids some technical challenges associated with the anterior approach, such as obesity, short neck, barrel chest, or previous anterior neck surgery. If three or more spinal segments are involved, both anterior and posterior approaches are used. [7]

Decompression surgery: The vertebral column can be operated on from both an anterior and posterior approach. The approach varies depending on the site and cause of root compression. Commonly, osteophytes and portions of intervertebral disc are removed. [12]

Fusion surgery: Performed when there is evidence of spinal instability or mal-alignment. Use of instrumentation (such as pedicle screws) in fusion surgeries varies across studies. [11]

See also

Related Research Articles

<span class="mw-page-title-main">Spinal nerve</span> Nerve that carries signals between the spinal cord and the body

A spinal nerve is a mixed nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each side of the vertebral column. These are grouped into the corresponding cervical, thoracic, lumbar, sacral and coccygeal regions of the spine. There are eight pairs of cervical nerves, twelve pairs of thoracic nerves, five pairs of lumbar nerves, five pairs of sacral nerves, and one pair of coccygeal nerves. The spinal nerves are part of the peripheral nervous system.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Medical condition of the spine

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

Myelopathy describes any neurologic deficit related to the spinal cord. The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM), also called degenerative cervical myelopathy, results from narrowing of the spinal canal ultimately causing compression of the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.

<span class="mw-page-title-main">Cervical vertebrae</span> Vertebrae of the neck

In tetrapods, cervical vertebrae are the vertebrae of the neck, immediately below the skull. Truncal vertebrae lie caudal of cervical vertebrae. In sauropsid species, the cervical vertebrae bear cervical ribs. In lizards and saurischian dinosaurs, the cervical ribs are large; in birds, they are small and completely fused to the vertebrae. The vertebral transverse processes of mammals are homologous to the cervical ribs of other amniotes. Most mammals have seven cervical vertebrae, with the only three known exceptions being the manatee with six, the two-toed sloth with five or six, and the three-toed sloth with nine.

<span class="mw-page-title-main">Degenerative disc disease</span> Medical condition

Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with or without symptoms, but is typically identified once symptoms arise. The root cause is thought to be loss of soluble proteins within the fluid contained in the disc with resultant reduction of the oncotic pressure, which in turn causes loss of fluid volume. Normal downward forces cause the affected disc to lose height, and the distance between vertebrae is reduced. The anulus fibrosus, the tough outer layers of a disc, also weakens. This loss of height causes laxity of the longitudinal ligaments, which may allow anterior, posterior, or lateral shifting of the vertebral bodies, causing facet joint malalignment and arthritis; scoliosis; cervical hyperlordosis; thoracic hyperkyphosis; lumbar hyperlordosis; narrowing of the space available for the spinal tract within the vertebra ; or narrowing of the space through which a spinal nerve exits with resultant inflammation and impingement of a spinal nerve, causing a radiculopathy.

<span class="mw-page-title-main">Retrolisthesis</span> Posterior displacement (but not dislocation) of a vertebra relative to the one below it

A retrolisthesis is a posterior displacement of one vertebral body with respect to the subjacent vertebra to a degree less than a luxation (dislocation). Retrolistheses are most easily diagnosed on lateral x-ray views of the spine. Views where care has been taken to expose for a true lateral view without any rotation offer the best diagnostic quality.

Radicular pain, or radiculitis, is pain "radiated" along the dermatome of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. A common form of radiculitis is sciatica – radicular pain that radiates along the sciatic nerve from the lower spine to the lower back, gluteal muscles, back of the upper thigh, calf, and foot as often secondary to nerve root irritation from a spinal disc herniation or from osteophytes in the lumbar region of the spine. Radiculitis indicates inflammation of the spinal nerve root, which may lead to pain in that nerve's distribution without weakness – as opposed to radiculopathy. When the radiating pain is associated with numbness or weakness, the diagnosis is radiculopathy if the lesion is at the nerve root, or myelopathy if at the spinal cord itself.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together. Additional hardware is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

Wobbler disease is a catchall term referring to several possible malformations of the cervical vertebrae that cause an unsteady (wobbly) gait and weakness in dogs and horses. A number of different conditions of the cervical (neck) spinal column cause similar clinical signs. These conditions may include malformation of the vertebrae, intervertebral disc protrusion, and disease of the interspinal ligaments, ligamenta flava, and articular facets of the vertebrae. Wobbler disease is also known as cervical vertebral instability (CVI), cervical spondylomyelopathy (CSM), and cervical vertebral malformation (CVM). In dogs, the disease is most common in large breeds, especially Great Danes and Doberman Pinschers. In horses, it is not linked to a particular breed, though it is most often seen in tall, race-bred horses of Thoroughbred or Standardbred ancestry. It is most likely inherited to at least some extent in dogs and horses.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Anterior cervical discectomy and fusion</span> Surgical procedure

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy, followed by inter-vertebral fusion to stabilize the corresponding vertebrae. This procedure is used when other non-surgical treatments have failed.

<span class="mw-page-title-main">Neurogenic claudication</span> Medical condition

Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Neurogenic means that the problem originates within the nervous system. Claudication, from the Latin word for to limp, refers to painful cramping or weakness in the legs. NC should therefore be distinguished from vascular claudication, which stems from a circulatory problem rather than a neural one.

<span class="mw-page-title-main">Laminotomy</span> Surgical procedure

A laminotomy is an orthopaedic neurosurgical procedure that removes part of the lamina of a vertebral arch in order to relieve pressure in the vertebral canal. A laminotomy is less invasive than conventional vertebral column surgery techniques, such as laminectomy because it leaves more ligaments and muscles attached to the spinous process intact and it requires removing less bone from the vertebra. As a result, laminotomies typically have a faster recovery time and result in fewer postoperative complications. Nevertheless, possible risks can occur during or after the procedure like infection, hematomas, and dural tears. Laminotomies are commonly performed as treatment for lumbar spinal stenosis and herniated disks. MRI and CT scans are often used pre- and post surgery to determine if the procedure was successful.

<span class="mw-page-title-main">Laminoplasty</span>

Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or weakness in arm movement. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord. The spinous process may be removed to allow the lamina bone flap to be swung open. The bone flap is then propped open using small wedges or pieces of bone such that the enlarged spinal canal will remain in place.

<span class="mw-page-title-main">Spinal decompression</span> Relief of pressure on the spinal cord or compressed nerve roots

Spinal decompression is the relief of pressure on the spinal cord or on one or more compressed nerve roots passing through or exiting the spinal column. Decompression of the spinal neural elements is a key component in treating spinal radiculopathy, myelopathy and claudication.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

The ventral slot technique is a procedure that allows the surgeon to reach and decompress the spinal cord and associated nerve roots from a ventral route in veterinary medicine. There are also alternative ways to open the spinal canal from dorsal by performing a hemilaminectomy, but this often gives only limited access. Even when the main pathological changes evolve from the midline, it is necessary to choose a ventral approach.

<span class="mw-page-title-main">Vertebra</span> Bone in the vertebral column

Each vertebra is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal segment and the particular species.

Cervical spondylotic myelopathy (CSM) is a disorder characterised by the age-related deterioration of the cervical spinal cord. Also called spondylotic radiculomyelopathy (SRM), it is a neurological disorder related to the spinal cord and nerve roots. The severity of CSM is most commonly associated with factors including age, location and extent of spinal cord compression.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 Takagi I, Eliyas JK, Stadlan N (October 2011). "Cervical spondylosis: an update on pathophysiology, clinical manifestation, and management strategies". Disease-a-Month. 57 (10): 583–591. doi:10.1016/j.disamonth.2011.08.024. PMID   22036114.
  2. 1 2 McCormack BM, Weinstein PR (1996). "Cervical spondylosis. An update". The Western Journal of Medicine. 165 (1–2): 43–51. PMC   1307540 . PMID   8855684.
  3. ↑ Caridi JM, Pumberger M, Hughes AP (October 2011). "Cervical radiculopathy: a review". HSS Journal. 7 (3): 265–272. doi:10.1007/s11420-011-9218-z. PMC   3192889 . PMID   23024624.
  4. ↑ Lhermitte JJ (4 March 1920). "Les Formes douloureuses de la Commotion de la Moelle épiniére" [Painful Forms of Spinal Cord Concussion]. Revue neurologique (in French). Société Française de Neurologie. 36 (3): 257–262 – via Internet Archive.
  5. 1 2 Middleton K, Fish DE (June 2009). "Lumbar spondylosis: clinical presentation and treatment approaches". Current Reviews in Musculoskeletal Medicine. 2 (2): 94–104. doi:10.1007/s12178-009-9051-x. PMC   2697338 . PMID   19468872.
  6. ↑ Denis DJ, Shedid D, Shehadeh M, Weil AG, Lanthier S (May 2014). "Cervical spondylosis: a rare and curable cause of vertebrobasilar insufficiency". European Spine Journal. 23 (Suppl 2): 206–213. doi:10.1007/s00586-013-2983-2. eISSN   1432-0932. OCLC   27638222. PMID   24000075. S2CID   1552821.
  7. 1 2 3 Bakhsheshian J, Mehta VA, Liu JC (September 2017). "Current Diagnosis and Management of Cervical Spondylotic Myelopathy". Global Spine Journal. 7 (6): 572–586. doi:10.1177/2192568217699208. PMC   5582708 . PMID   28894688.
  8. ↑ Newman & Santiago, 2013[ full citation needed ]
  9. ↑ Binder AI (March 2007). "Cervical spondylosis and neck pain". BMJ. 334 (7592): 527–531. doi:10.1136/bmj.39127.608299.80. JSTOR   20506602. PMC   1819511 . PMID   17347239.
  10. ↑ Baron ME [ full citation needed ]
  11. 1 2 Gibson JN, Waddell G (October 2005). Gibson JN (ed.). "Surgery for degenerative lumbar spondylosis". The Cochrane Database of Systematic Reviews. 2005 (4): CD001352. doi:10.1002/14651858.CD001352.pub3. PMC   7028012 . PMID   16235281.
  12. ↑ Malcolm GP (September 2002). "Surgical disorders of the cervical spine: presentation and management of common disorders". Journal of Neurology, Neurosurgery, and Psychiatry. 73 (Suppl 1): i34–i41. doi: 10.1136/jnnp.73.suppl_1.i34 . eISSN   1468-330X. PMC   1765596 . PMID   12185260. Cervical discs or osteophytes indenting the cord anteriorly will therefore be removed by anterior cervical discectomy, whereas a narrow cervical canal secondary to hypertrophied posterior ligaments or a congenitally narrow canal will be treated by a posterior decompression.

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