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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)
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Fig.1:
x-ray views of cervical vertebrae
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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.
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Fig.
2: mri assessment of cervical vertebrae
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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.
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Fig.
3
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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.
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Fig.4
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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.
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