What is spondylosis of the cervical spine?

Cervical Spondylosis of the Spine: Definition and Clinical Implications

Cervical spondylosis is a degenerative condition of the cervical spine characterized by age-related changes including disc degeneration, osteophyte formation, facet joint hypertrophy, and ligamentous alterations that can lead to varying degrees of neurological symptoms depending on severity. 1, 2

Pathophysiology

• Cervical spondylosis results from progressive degenerative changes in the intervertebral discs, leading to loss of disc height and subsequent formation of osteophytes on vertebral bodies 1, 2
• These degenerative changes affect multiple components of the cervical spine, including:
  • Intervertebral discs (degeneration and herniation)
  • Vertebral bodies (osteophyte formation)
  • Facet joints (hypertrophy)
  • Ligaments (thickening and ossification)
  • Uncovertebral joints (hypertrophy) 3, 2
• The natural history of cervical spondylosis is strongly associated with the aging process, with prevalence and severity increasing with age 3, 4
• In a study of 1,581 patients between 18 and 97 years of age, 53.9% demonstrated disc degenerative changes, with prevalence and severity increasing with age 3

Clinical Presentations

Cervical spondylosis can manifest as three distinct but potentially overlapping clinical syndromes:

1. Axial Neck Pain

• Most common presentation, characterized by neck pain without neurological symptoms 3, 4
• Neck pain has an estimated 1-year mean prevalence of 25% 3
• Approximately 30-50% of patients develop chronic neck pain symptoms lasting more than a year 3
• Pain may be mechanical in nature, worsening with movement and improving with rest 5

2. Cervical Radiculopathy

• Characterized by upper limb pain or sensorimotor deficit due to cervical nerve root impingement 3, 4
• Annual incidence of approximately 83 per 100,000 persons 3
• Presents as neck and/or upper limb pain with varying degrees of sensory or motor deficits 3
• Caused by nerve root compression from:
  • Herniated disc ("soft disc")
  • Spondylarthrosis such as facet or uncovertebral joints ("hard disc")
  • Combination of both 3, 6
• Typically self-limiting, with 75-90% of patients achieving symptomatic relief with conservative therapy 3

3. Cervical Spondylotic Myelopathy (CSM)

• Most serious manifestation, resulting from spinal cord compression 5, 4
• Symptoms include:
  • Generalized weakness or stiffness in legs
  • Gait disturbances
  • Fine motor coordination problems
  • Bowel/bladder dysfunction in advanced cases 7, 5
• Natural history is variable, with approximately 70% of patients with mild CSM maintaining stable clinical status over 3 years with nonoperative treatment 7

Diagnostic Evaluation

Imaging Approaches

• Radiographs: Often the first imaging modality for assessment of chronic neck pain 3

  • Useful for diagnosing spondylosis, degenerative disc disease, and malalignment
  • However, the association between radiographic findings and clinical symptoms remains unclear 3

• MRI: Most sensitive test for detecting soft tissue abnormalities 3

  • Not considered first-line imaging for uncomplicated neck pain due to high rate of abnormal findings in asymptomatic individuals 3
  • Should be interpreted in combination with clinical findings due to frequent false-positive and false-negative findings 3

• CT: Offers superior depiction of cortical bone compared to radiographs 3

  • Particularly useful for evaluating potential nerve-impinging osseous structures such as osteophytes, uncovertebral joints, and facet joints 3
  • Less sensitive than MRI for evaluation of nerve root compression 3
  • Superior for assessing ossification of the posterior longitudinal ligament (OPLL) 3

Management Approaches

Conservative Management

• Appropriate for mild symptoms and axial neck pain 5
• Includes:
  • Activity modification
  • Neck immobilization (cervical collar)
  • Isometric exercises
  • Anti-inflammatory medications 7, 5

Surgical Intervention

• For cervical spondylotic myelopathy:

  • Mild CSM (mJOA scale scores >12) can be treated with either surgical decompression or nonoperative therapy in the short term (3 years) 3
  • More severe CSM (mJOA scale score ≤12) should be considered for surgical decompression 3
  • Benefits of surgery for severe CSM are maintained for at least 5 years and up to 15 years postoperatively 3

• For cervical radiculopathy:

  • Surgical intervention is typically considered when pain persists despite conservative treatment or when there is progressive neurological deficit 5
  • Anterior cervical discectomy and fusion (ACDF) shows good to excellent outcomes in approximately 90% of patients with radiculopathy 7

Prognosis

• Younger patients and those with milder disability generally have better prognosis 7
• For cervical radiculopathy, 75-90% of patients achieve symptomatic relief with conservative therapy 3
• For cervical myelopathy, surgical results show good initial improvement in about 70% of patients, though functional outcome may decline with long-term follow-up 5

Important Clinical Considerations

• Degenerative changes on imaging are common in asymptomatic individuals over age 30 and correlate poorly with the presence of neck pain 3
• Physical examination tests for cervical radiculopathy have limited evidence for accuracy when compared to imaging or surgical findings 3
• "Red flags" that may indicate need for more urgent evaluation include trauma, malignancy, prior neck surgery, spinal cord injury, systemic diseases, suspected infection, intractable pain despite therapy, or neurological deficits 3