What is the diagnosis and treatment for a patient with neck pain and findings of multilevel spondylosis, anterolisthesis at C3-4 and C4-5, and posterior facet joint degenerative fusions at C2-3 and C4-5?

Cervical Spondylosis with Anterolisthesis and Facet Joint Degenerative Fusions: Diagnosis and Management

The patient's imaging findings indicate cervical degenerative spondylosis with anterolisthesis and facet joint fusions, which should be treated initially with conservative management including physical therapy, pain medications, and possibly cervical epidural steroid injections before considering surgical options in cases of persistent neurological symptoms or progressive myelopathy.

Understanding the Diagnosis

The radiographic findings reveal several degenerative changes in the cervical spine:

1. Multilevel spondylosis: This refers to degenerative changes affecting multiple levels of the cervical spine, including disc degeneration, osteophyte formation, and facet joint arthropathy 1.

2. Anterolisthesis at C3-4 and C4-5: Forward slippage of one vertebral body over another, similar to spondylolisthesis in the lumbar spine but occurring in the cervical region 2.

3. Posterior facet joint degenerative fusions at C2-3 and C4-5, possibly on the left at C1-2: These represent advanced degenerative changes where the facet joints have developed spontaneous fusion due to long-standing arthritis 1.

Clinical Correlation

It's important to note that radiographic findings often correlate poorly with clinical symptoms:

• Spondylotic changes on imaging are common in patients over 30 years of age and may not directly correlate with neck pain 1
• Physical examination findings may have limited correlation with MRI evidence of nerve root compression 1
• The C4-C5 level (one of the levels with anterolisthesis in this patient) is most frequently involved in cervical degenerative spondylolisthesis (43% of cases) 2

Management Algorithm

Step 1: Assess for Red Flags

Look for signs that would require urgent intervention:

• Myelopathic signs (wide-based gait, increased deep tendon reflexes, urinary difficulties)
• Progressive neurological deficits
• Intractable pain despite therapy
• Signs of spinal cord compression

Step 2: Conservative Management (First-line treatment)

If no red flags are present:

• Physical therapy focusing on:

  • Cervical spine stabilization exercises
  • Postural training
  • Range of motion exercises
  • Strengthening of neck muscles

• Medications:

  • NSAIDs for pain and inflammation
  • Muscle relaxants for associated muscle spasm 3
  • Short-term course of oral steroids if significant inflammation

• Activity modification:

  • Ergonomic adjustments
  • Proper neck positioning during sleep
  • Avoiding activities that exacerbate symptoms

• Cervical orthosis (collar) for short-term use during acute flare-ups

Step 3: Interventional Procedures

If conservative measures fail after 6-8 weeks:

• Epidural steroid injections for radicular symptoms
• Facet joint injections for facet-mediated pain
• Medial branch blocks followed by radiofrequency ablation if positive response 3

Step 4: Surgical Management

Consider surgery if:

• Persistent neurological symptoms despite conservative treatment
• Progressive myelopathy
• Significant functional limitation

Surgical options include:

• Anterior cervical decompression and fusion (ACDF) - particularly effective for cervical spondylolisthesis with neurological symptoms 2
• Posterior decompression with or without fusion

Important Considerations and Pitfalls

1. Avoid overreliance on imaging findings: Degenerative changes are common in asymptomatic individuals over 30 years of age 1.

2. Watch for myelopathy: Patients with cervical spondylolisthesis may develop myelopathy that can be overlooked if symptoms are attributed solely to radiculopathy or mechanical neck pain 4.

3. Consider adjacent segment disease: The presence of facet fusions may accelerate degeneration at adjacent mobile segments.

4. Distinguish between mechanical neck pain and radiculopathy: Treatment approaches differ based on whether symptoms are primarily axial (neck pain) or radicular (arm pain, numbness, weakness).

5. Recognize that facet effusions on MRI (if present) may indicate segmental instability that could require stabilization if symptoms persist 4.

6. Evaluate for dynamic instability: Flexion-extension radiographs may reveal additional information about segmental stability that isn't apparent on static imaging.

The presence of multilevel disease with both anterolisthesis and facet fusions suggests a more complex degenerative process that may require more comprehensive management, but most patients can still achieve good outcomes with appropriate conservative care.