What is cervical spondylosis in the context of a patient with a history of neck pain and cervicogenic dizziness?

What is Cervical Spondylosis

Cervical spondylosis is an age-related degenerative condition affecting the cervical spine that involves progressive deterioration of the intervertebral discs, vertebral bodies, facet joints, and ligamentous structures, which is part of the normal aging process and affects most people if they live long enough. 1, 2

Pathophysiology and Anatomic Changes

Cervical spondylosis represents a generalized disease process affecting all levels of the cervical spine through a sequence of degenerative changes 2:

• Intervertebral disc degeneration is the primary initiating event, with disc space narrowing and loss of disc height 3, 2
• Osteophyte formation develops on vertebral bodies and uncovertebral joints, which can encroach on the spinal canal and neural foramina 1, 3
• Facet joint hypertrophy and laminal arch thickening contribute to canal narrowing 2
• Ligamentous changes including hypertrophy and potential ossification (such as OPLL) further compromise canal diameter 4, 2
• Segmental instability may develop as the degenerative cascade progresses 2

The biomechanical basis involves the disc and facets serving as connecting structures between vertebrae for force transmission and facilitating cervical spine mobility, which deteriorate over time 3.

Epidemiology and Natural History

The prevalence and clinical significance of cervical spondylosis must be understood in context 4, 5:

• Spondylotic changes are extremely common in patients over 30 years of age and correlate poorly with the presence of neck pain 4, 5
• In a 10-year longitudinal MRI study, cervical disc degeneration progressed in 85% of patients, yet symptoms developed in only 34% 4, 5
• Most patients with radiographic evidence of spondylosis remain asymptomatic throughout their lives 4
• The condition is part of the normal aging process, making senescent and pathologic processes morphologically indistinguishable 2

Clinical Manifestations in Your Patient Context

In a patient presenting with neck pain and cervicogenic dizziness, several important considerations arise 5, 6:

• Intermittent neck pain is the most common symptom, typically occurring in middle-aged and elderly patients 6
• Cervicogenic dizziness combined with neck pain represents a potential red flag requiring exclusion of more serious pathology including vertebrobasilar insufficiency, cervical myelopathy, or radiculopathy 5
• Vertigo suggests either mechanical compression causing vertebrobasilar insufficiency, cervical myelopathy, or atypical symptoms from dural/cord stimulation 5

Two Distinct Clinical Syndromes

When cervical spondylosis becomes symptomatic, it typically manifests as one of two syndromes 1, 2:

Cervical Spondylotic Radiculopathy

• Occurs when osteophytes or disc material compress cervical nerve roots in the neural foramina 4, 1
• Presents with dermatomal arm pain, sensory changes, motor weakness, and reflex changes 4
• 75% to 90% of patients achieve symptomatic relief with nonoperative conservative therapy 4, 7

Cervical Spondylotic Myelopathy (CSM)

• CSM is the most common cause of myelopathy in adults and represents the most serious and disabling manifestation of cervical spondylosis 1, 6
• Occurs when degenerative changes compromise the spinal canal diameter and compress the spinal cord 1, 3
• Clinical manifestations arise when morphologic changes are superimposed on a developmentally narrow spinal canal 2
• Presents with signs and symptoms of cervical spinal cord dysfunction including gait disturbance, upper motor neuron signs, and hand clumsiness 1
• Compression produces direct neurological damage or ischemic changes leading to spinal cord disturbances 3

Critical Diagnostic Considerations

For your patient with neck pain and cervicogenic dizziness 5:

• A detailed neurologic examination must be performed to look for motor weakness, sensory deficits, gait abnormalities, and upper motor neuron signs that would indicate myelopathy 5
• MRI of the cervical spine is the preferred initial diagnostic study when neurologic symptoms are present, as it is more sensitive than CT in identifying degenerative cervical disorders 4, 5, 6
• Vascular imaging (CTA or MRA) should be considered if vertigo is positional and suggests vertebrobasilar insufficiency 5
• The presence of degenerative changes on imaging must be interpreted with extreme caution given the high prevalence in asymptomatic individuals 4

Management Principles

Conservative management is appropriate only after serious pathology is excluded 5, 6:

• Activity modification, NSAIDs, physical therapy, and neck immobilization are first-line treatments 5, 6, 7
• 30% to 50% of patients have residual or recurrent symptoms up to 1 year, requiring ongoing monitoring 5, 6
• Surgical decompression should be considered for progressive or moderate to severe neurologic deficits, particularly in myelopathy 1, 6, 7

Key Clinical Pitfall

The most critical pitfall is assuming that radiographic evidence of cervical spondylosis explains a patient's symptoms without excluding more serious pathology. Given that 85% of patients show progressive degenerative changes on MRI but only 34% develop symptoms 4, 5, the presence of spondylosis on imaging does not establish causation. In your patient with cervicogenic dizziness, vertebrobasilar insufficiency, myelopathy, and radiculopathy must be systematically excluded before attributing symptoms to "simple" spondylosis 5.