Cervical Spondylosis: A Comprehensive Clinical Review

Introduction

Cervical spondylosis is a degenerative disorder of the cervical spine encompassing intervertebral disc degeneration, osteophyte formation, ligamentous hypertrophy, and facet joint arthropathy. It commonly manifests in individuals over 50 and can lead to radiculopathy, myelopathy, vertebrobasilar insufficiency, and sympathetic dysfunction. Early recognition and a multidisciplinary approach are critical to prevent irreversible neurological damage and optimize functional outcomes.

Epidemiology and Risk Factors

• Prevalence: Radiographic evidence of cervical spondylosis is present in >85% of individuals older than 60. Symptomatic disease occurs in approximately 10–20% of this population.
• Age and Sex: Incidence increases with age; men and women are affected equally, although men may present earlier with radicular symptoms.
• Genetic Predisposition: Family history of degenerative spine disease contributes to earlier onset and severity.
• Mechanical Stressors: Occupational exposure to repetitive neck flexion/extension (e.g., desk work, manual labour) and a history of trauma accelerate degenerative changes.
• Lifestyle Factors: Smoking and poor posture negatively impact disc nutrition and accelerate degeneration.

Pathophysiology

Degeneration begins with dehydration and fissuring of the nucleus pulposus, reducing disc height and loading adjacent facets and uncovertebral joints. Osteophyte formation and ligamentum flavum hypertrophy narrow the spinal canal and neuroforamina. Compression or irritation of nerve roots and the spinal cord triggers pain, sensory disturbances, reflex changes, and in severe cases, myelopathy.

Clinical Presentation

1. Axial Neck Pain

• Localized, dull ache exacerbated by sustained posture or movement.
• May radiate to trapezius or between the scapulae.

2. Cervical Radiculopathy

• Unilateral radiating pain along a dermatomal distribution, commonly C6–C7.
• Paresthesia, numbness, and motor weakness in affected myotomes (e.g., wrist extension, grip strength).
• Spurling’s test reproduction of radicular pain.

3. Cervical Myelopathy

• Gait instability, hand clumsiness, and balance disturbances.
• Hyperreflexia, positive Hoffmann and Babinski signs, and Lhermitte’s phenomenon.
• Urinary urgency in advanced cases.

4. Vertebrobasilar Insufficiency and Sympathetic Symptoms

• Dizziness, vertigo, visual disturbances, and tinnitus due to vertebral artery compression.
• Autonomic signs including headaches, palpitations, and diaphoresis.

Diagnostic Evaluation

1. History and Physical Examination: Detailed neurologic assessment, including motor strength, sensory testing, deep tendon reflexes, and gait analysis.
2. Imaging:
3. X-ray: Static and dynamic (flexion/extension) views to assess alignment, disc height, and osteophytes.
4. MRI: Gold standard for soft tissue evaluation, disc herniation, ligamentous hypertrophy, and spinal cord signal changes.
5. CT Myelography: Consider when MRI is contraindicated or to delineate bony anatomy prior to surgery.
6. Electrodiagnostic Studies:
7. EMG and NCS: Confirm radiculopathy and exclude peripheral neuropathies.

Differential Diagnosis

• Rotator cuff pathology
• Brachial plexopathy
• Thoracic outlet syndrome
• Multiple sclerosis and other central nervous system disorders

Management

Conservative Treatment (First-line)

• Physical Therapy: Cervical traction, mobilization, posture correction, core strengthening, and home exercise programs.
• Pharmacotherapy:
• NSAIDs for analgesia and anti-inflammatory effect.
• Short-term muscle relaxants for spasm relief.
• Neuropathic agents (e.g., gabapentin, duloxetine) for radicular pain.
• Cervical Collar: Soft collar for short-term relief (≤2 weeks) to limit painful motion; avoid long-term immobilization.
• Interventional Techniques:
• Epidural Steroid Injections: For refractory radicular symptoms; fluoroscopic guidance to target affected level.
• Facet Joint Injections and Medial Branch Nerve Blocks: Diagnostic and therapeutic in facet-mediated pain.

Surgical Intervention (Indications)

• Progressive myelopathy or significant gait impairment.
• Intractable radicular pain unresponsive to 6–12 weeks of conservative care.
• Radiographic evidence of spinal cord compression with neurologic deficits.

Common Procedures:
– Anterior Cervical Discectomy and Fusion (ACDF): Decompression and stabilization with interbody graft and plate.
– Cervical Disc Arthroplasty: Motion-preserving alternative in select patients.
– Posterior Laminectomy and Fusion: For multilevel myelopathy or when anterior approach is contraindicated.

Rehabilitation and Follow-Up

• Initiate postoperative physical therapy focusing on cervical range of motion, scapular stabilization, and ergonomic training.
• Serial imaging at 3, 6, and 12 months to assess fusion status or prosthesis integrity.
• Ongoing evaluation for adjacent segment degeneration in fusion cases.

Prevention and Patient Education

• Ergonomics: Advise proper workstation setup, monitor height, and regular micro-breaks to minimize static neck posture.
• Exercise: Daily neck and upper back strengthening, stretching, and cardiovascular fitness.
• Lifestyle Modification: Smoking cessation, weight management, and adequate sleep support disc nutrition.
• Symptom Monitoring: Educate patients to report new neurologic signs promptly (e.g., hand weakness, gait changes).

Conclusion

Cervical spondylosis is a prevalent degenerative condition with a spectrum of clinical manifestations. Successful management hinges on accurate diagnosis, a tailored conservative approach, timely surgical referral for progressive neurologic compromise, and patient engagement in prevention strategies. An interdisciplinary care model, including neurology, orthopedics, physical therapy, and pain management, optimizes outcomes and maintains quality of life in affected individuals.