Guide to Degenerative Diseases of the Cervical Spine

Introduction
The cervical spine consists of the top 7 vertebrae of the spine. Doctors often refer to these vertebrae as C1-C7, with the "C" indicating cervical, and the numbers 1-7 indicating the level of the vertebrae. C1 is closest to the skull, while C7 is closest to the thoracic (chest/rib cage) region of the spine.

The cervical spine is particularly susceptible to degenerative problems because of:

• its large range of motion
• its somewhat complex anatomy.

For example, cervical motion segments (i.e., a disc with a vertebra above and below) consist of five "joints" (the intervertebral disc, the two facet joints, and the two uncovertebral joints).

Symptoms
There are several symptoms that may indicate the presence of a degenerative condition in the cervical spine. Symptoms include neck pain, pain around the back of the shoulder blades, arm complaints (pain, numbness, or weakness), and rarely, difficulty with hand dexterity or walking.

The degenerative process may begin in any of the joints in the cervical spine, and over time it may also cause secondary changes in the other joints. For example, an intervertebral disc may be primarily affected. As the disc narrows, the normal movement of that segment is altered, and the adjacent joints (also called ‘osteoarthritis’ or ‘degenerative joint disease’) are subjected to abnormal forces and pressures, leading to degenerative arthritis (i.e., inflammation of a joint).

Neck pain as a result of spondylosis (i.e., a degenerative change) is relatively common. The pain may radiate, or spread, into the shoulder blade or down the arm. Patients may have an arm complaint (such as pain or weakness) as the result of nerve root compression from a bone spur.

The image above is a general illustration of the
spine and is not an exact replica of the cervical spine.

Dysphagia (i.e., difficulty in swallowing) can result from large anterior osteophytes (i.e. bony growths at the front of the spine), although this is rare.

Diagnosing the Problem
When a patient with a degenerative disorder of the cervical spine is examined by a doctor, one or more symptoms are likely to be apparent. The doctor will ask the patient many questions to gain a detailed history of the condition. A thorough evaluation of the patient will be conducted, including several types of tests, so as to accurately identify the problem.

A neurologic examination will be done to rule out a neurologic deficit. A shoulder examination will also probably be done to ensure that the symptoms are indeed originating from the neck.

Various diagnostic tools may be used, including:

X-rays
X-rays are useful for identifying such problems as:

• narrowing of the intervertebral disc space
• anterior osteophytes (i.e., bony spurs)
• spondylosis (i.e., arthritis) of the facet joints
• osteophytes from the uncovertebral joints (see figures below)

Fig.1: x-ray views of cervical vertebrae

Computed Tomography
Computed tomography (CT) can highlight the bony changes associated with degenerative spondylosis (arthritis). Osteophytes can be observed and evaluated as well. However, CT does not provide for optimal evaluation of discs (although it may sometimes show disc herniations).

Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a powerful tool in the assessment of patients with cervical spondylosis. Images from MRIs can help doctors to identify disc herniations, osteophytes, and joint arthrosis. MRI is best suited for soft disc herniations, but often times more information is needed.

Fig. 2: mri assessment of cervical vertebrae

Myelogram/CT
This is the "gold standard." It is often utilized in complex cases involving multi-level disease, or suboptimal MRI images. It is very useful in delineating bone spurs from safe disc herniations.

Fig. 3

Discography
As in the lumbar and thoracic spine, cervical discography (see figure) remains controversial. Although the discogram may add to the clinician's knowledge, it should not be used by itself to predicate treatment.

Fig.4

Facet Blocks
Facet blocks in the cervical spine are subject to the same criticisms as facet blocks used elsewhere. There is little scientific documentation to validate their use. Repeating the test and comparing results at different levels probably gives much more useful information than carrying out facet blocks at one or more levels at one point in time. The do aid physicians in determining the "pain generator."

Treatment Options
After the doctor has conducted the necessary tests to identify the problem in the cervical spine, a treatment plan will then be developed. Various treatment options are available, and can be subdivided into two categories:

• Non-surgical treatment
  
• Surgical treatment

Non-surgical Treatment
Non-surgical treatment of cervical degenerative disease provides good to excellent results in over 75% of patients. A multi-disciplinary approach includes:

• Immobilization can be achieved using a collar or braces; it's most beneficial during acute exacerbations of pain by reducing motion at the symptomatic levels.
  
  
• Physical therapy and manipulation (chiropractic) can be useful in decreasing muscle spasms that can contribute to symptoms; this is where heat, electrical stimulation, and exercise have their maximum benefit.
  
  
• Medications include painkillers, nonsteroidal anti-inflammatories, and muscle relaxants. In many cases, non-surgical treatment can provide good long-term results.

Surgical Treatment
A surgeon is likely to consider a surgical treatment of a cervical degenerative problem if one or more of the following criteria are met:

• Non-surgical treatments have been tried and failed.
• The disorder is causing spinal cord dysfunction.
• The disorder is causing prolonged arm pain or weakness.

The surgical procedure proposed for these patients is removing the bone spur and possible fusion of two or more cervical vertebrae. In most instances, the preferred approach is an anterior (i.e., from the front) interbody fusion. Using the anterior approach, a surgeon can perform a complete discectomy (i.e., removal of the disc between two vertebrae), and then seek to restore the normal disc space height and normal lordosis (i.e., the concave curve in the cervical spine) by implanting a carefully sculpted graft. A titanium plate may be utilized to improve the rate of fusion and avoid a neck brace.

A posterior approach (from the back of the spine) is often considered when a cervical disc has herniated laterally (i.e., sideways).

Conclusion
Cervical spine degenerative disorders can be diagnosed more accurately and treated more effectively today than even five or ten years ago. Under the guidance and treatment of an expert medical team, most patients can now hope to see a very significant improvement in their condition.