Cervical spondylosis

Cervical spondylosis is chronic cervical disc degeneration with herniation of disc material, calcification and osteophytic outgrowths.

After back pain, simple neck pain (pain varying over time and with activity) is the most frequent musculoskeletal cause of consultation in primary care worldwide. As with simple back pain, it is multifactorial in origin, reflecting poor posture, muscle strain and sporting and occupational activities as well as psychological factors. Cervical spondylosis undoubtedly contributes to this burden but may also cause:

• Radiculopathy due to compression, stretching or angulation of the cervical nerve roots.

• Myelopathy due to compression, compromised blood supply or recurring minor trauma to the cord.

Epidemiology¹

• Neck pain is one of the most common musculoskeletal complaints. About two thirds of the population will experience neck pain at some point in their lives.

• Women are affected slightly more than men².

• Problems begin earlier in males.

• Prevalence rises with age for men and women and is the highest in the age group between 50-59 years.

• The incidence of neck pain in general practice has been estimated to be between 18 and 23 per 1,000 registered patients per year.

• The percentage of people in whom neck pain becomes chronic is generally thought to be about 10%.

• X-ray findings suggest that the majority of men older than 50 years and women older than 60 years have evidence of degenerative changes in the cervical spine. The boundary between normal ageing and disease process is difficult to define³.

Presentation

Symptoms

• Cervical pain worsened by movement.

• Referred pain (occiput, between the shoulder blades, upper limbs).

• Retro-orbital or temporal pain (from C1 to C2).

• Cervical stiffness - reversible or irreversible.

• Vague numbness, tingling or weakness in the upper limbs.

• Poor balance.

Signs

• Limited range of movement (forward flexion, backward extension, lateral flexion and rotation to both sides).

• Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy).

• Poorly localised tenderness.

Radiculopathy⁴

Suspect this where there is unilateral neck, shoulder, or arm pain approximating to a dermatome. There may be accompanying changes in sensation or weakness in related muscles. NB: pain or paraesthesia radiating into the arm is a nonspecific sign for nerve root pain.

• There may be postural asymmetry with the patient flexing their head to decompress the nerve root.

• Neck movement may be restricted.

• Dural irritation can be demonstrated with the Spurling test (flexion of the neck laterally, rotation and pressure on the top of the patient's head) - typical radicular pain is reproduced if the test is positive.

• The most commonly affected nerve roots are between the C5 to C7 levels.

• Sensory symptoms (shooting pains, numbness, hyperaesthesia) are more common than weakness.

• Reflexes are usually diminished at the appropriate level (biceps - C5/C6, supinator - C5/C6, or triceps - C7).

See also the separate Neurological Examination of the Upper Limbs article.

'Red flag' features²⁴

Differential diagnosis

• Other nonspecific neck pain lesions - eg, acute neck strain, postural neck ache or whiplash.

• Malignancy - primary tumours, secondary deposits or myeloma.

• Infections - eg, osteomyelitis or tuberculosis.

• Mechanical lesions - disc prolapse.

• Fibromyalgia.

• Psychogenic neck pain.

• Inflammatory disease - eg, rheumatoid arthritis.

• Metabolic diseases - eg, Paget's disease of bone, osteoporosis.

Investigations

Most patients do not need further investigation and the diagnosis is made on clinical grounds alone.

• Plain X-ray of cervical spine showing formation of osteophytes, narrowing of disc spaces with encroachment of intervertebral foraminae. This is not diagnostic, as these findings are common in normal middle-aged patients.

• Patients with neurological abnormality will need magnetic resonance imaging (MRI) of the cervical spine at an early stage, particularly if they have progressive myelopathy, radiculopathy or intractable pain.

Management

There is little robust evidence to support many of the commonly used treatments. Most GPs will employ a 'wait and see' strategy, expecting a favourable natural course supported by medication, or referral to a physiotherapist¹.

General measures⁵

• For the first 3-4 weeks, provide reassurance that neck pain is common and is likely to resolve.

• The patient should be advised to keep active, maintain their normal activities and to avoid the use of a cervical collar.

• However, one study of patients with recent-onset cervical radiculopathy found that a semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy⁶.

• Strongly discourage prolonged absence from work.

• Advise against driving if the range of neck movement is restricted.

• Patients should be advised to use only one firm pillow at night.

• Identify and address psychosocial factors that increase the risk of chronicity and disability - eg, underlying concerns about the neck pain, unrealistic expectations of treatment, disabling sickness behaviour, mood disorders.

• Similarly, identify and address workplace-associated risks for developing neck pain. Offering postural advice on daily activities, work and hobbies may be helpful for some patients.

• Where symptoms are more prolonged (4-12 weeks), refer to physiotherapy for a multimodal treatment strategy (see under 'Mechanical', below) and consider referral to a psychologist or occupational health doctor.

• Where symptoms have become chronic (>12 weeks), continue examining psychosocial factors, consider referral to a pain clinic or, where there are nerve root symptoms, consider referral for assessment for surgical intervention.

Mechanical

• Manipulation⁷:

  • Although support can be found for use of thoracic manipulation versus control for neck pain, function and quality of life, results for cervical manipulation and mobilisation versus control are few and diverse.

  • Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up.

  • Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up.

  • There is a risk of very rare but serious adverse events for manipulation - eg, arterial dissection, myelopathy, vertebral disc extrusion and epidural haematoma⁸.

• Yoga, the Pilates method, and the Alexander Technique all improve neck posture but their value in treating neck pain is uncertain.

• Specific strengthening exercises of the neck, scapulothoracic region and shoulder are beneficial for chronic neck pain and chronic cervicogenic headache⁹.

• Evidence suggests that acupuncture has only a small benefit for patients with chronic neck pain¹⁰.

• There is no conclusive evidence about the effectiveness of traction compared with a range of other treatments in patients with chronic neck pain¹¹.

Pharmacological

• Muscle relaxants, analgesics and NSAIDs have limited evidence and unclear benefits¹².

• Low-dose tricyclic antidepressants, like amitriptyline 10-30 mg per night, are also used where the pain is not responsive to standard analgesics².

Surgical

Indications for surgery include:

• Progressive neurological deficits.

• Documented compression of the cervical nerve root, spinal cord, or both.

• Intractable pain.

However, the outcome of decompressive surgery is often disappointing, especially for myelopathy complicating cervical spondylosis. While progression of the neurological deficit may be slowed by surgery, lost function may not recover or symptoms may progress at a later date. Poor outcome after surgery may reflect irreversible damage to the cervical cord or compromise to the vascular supply to the cord².

A Cochrane review concluded that there is currently insufficient evidence to determine whether the risks of surgery are outweighed by benefits, such as more rapid relief of pain, and low-grade evidence that surgical patients do no better than those receiving conservative management in the longer term¹³.

Epidural injection in the cervical region is effective for treatment of chronic intractable pain of cervical origin but is more invasive than in the lumbar region¹⁴.

Prognosis

Cervical spondylosis progresses slowly. It is a chronic joint disability, especially when it is associated with neuronal compression. However, most with acute neck pain do well.

A Dutch study found that a year after primary care consultation for this problem¹⁵:

• Approximately three quarters are 'much improved'.

• However, just under half still had some ongoing symptoms.

• Over half who had been off work when first seen had gone back to work within a week.

• GP advice to 'wait and see' was associated with a higher rate of recovery than referral to either physiotherapy or a specialist.