Cervical Spondylosis, Stenosis, and Rheumatoid Arthritis Matthew McDonnell, MD, and Phillip Lucas, MD CERVI ca L SPONYLOSIS /STENOSIS The uncovertebral joints hypertrophy, Clinical Presentations Cervical spondylosis is common and which may lead to foraminal stenosis. The Axial Neck Pain progresses with increasing age. It is the posterior zygoapophyseal joints can also Neck pain is an extremely common result of degenerative changes in the cer- become arthritic, causing foraminal nar- but nonspecific presenting symptom. vical spine, including disc degeneration, rowing. The ligamentum flavum thickens It is often associated with stiffness and facet arthropathy, osteophyte formation, and sometimes buckles as a result of the headaches. The pain or soreness is usu- ligamentous thickening and loss of cervi- loss of disk height. These degenerative ally in the paramedian neck muscles cal lordosis. Spinal stenosis, or narrowing changes can result in cervical stenosis with posteriorly, with radiation toward the of the spinal canal, may occur as a result spinal cord compression. Concomitant occiput or into the shoulder, arm and of progression of spondylotic changes. straightening of cervical lordosis (or even periscapular regions. The referred pain Spinal cord or nerve root function may kyphosis), disk herniations or protru- does not follow a dermatomal distribu- be affected, resulting in symptoms of sions often may accentuate the problem tion. Deep palpation of some of these myelopathy or radiculopathy. because the spinal cord will be stretched areas results in reproducible patterns of over the posterior aspect of the disks and referred pain. Determining the source Natural History and Epidemiology vertebral bodies. of neck pain can be a diagnostic chal- Spinal cord compression resulting Cervical spondylosis will typically lenge. New pain patterns may develop from spondylotic changes is usually a slow result in stiffening of the spinal motion as a result of postural adaptations and and progressive process. Many patients segments. It is not uncommon for the compensatory overuse of normal tissues have evidence of significant compression motion segments one or two levels above further confusing the clinical picture. on imaging studies but are asymptomatic. the stiff segments to become hypermobile. Shoulder pathology sometimes presents Most cases of myelopathy develop in a The resulting instability may lead to dy- with pain referred to the neck. A careful stepwise fashion described by episodes of namic cord compression.1,4,5 history should be obtained to rule out exacerbation of symptoms and worsen- Radiculopathy is due to biochemical inflammatory arthritis or an infectious ing function followed by long periods of and biomechanical changes that occur or neoplastic process.2,4,8 static function. Fewer patients have steady with age as a result of the degenerative progressive deterioration. With vascular cascade and lead to insufficiency, acute onset may occur with disc herniation or fo- devastating, irreversible ischemic changes raminal narrowing. occurring within the cord.1,2 The intervertebral disc Approximately 25% of individu- gradually loses height, als younger than forty years of age, posterior portions of 50% of individuals over forty years of the disc bulge into the age, and 85% of individuals over sixty spinal canal and the years of age have some degree of disc neuroforamina, the degeneration.1-3 ligamentum flavum and facet joint capsule Pathophysiology infold, and osteophytes The pathoanatomy of cervical spon- form. All of this leads to dylosis results from the sequelae of the ag- decreases in canal and ing process in the spine, specifically, disk foraminal size. Sublux- degeneration with hypertrophic osseous ation and hypermobil- and ligamentous changes. Disk desic- ity between vertebral cation is accompanied by biochemical bodies may occur. The changes, with a relative increase in the pain that occurs as a ratio of keratan sulfate to chondroitin result of nerve root sulfate. The loss of elasticity and total compression is thought disk substance results in a decrease in disk to be mediated by an height with annular bulging. This altered inflammatory response biomechanical environment stimulates as well as nerve root Figure 1: Lateral cervical spine xrays of a patient with 6,7 formation of chondro-osseous spurs at edema and fibrosis. degenerative cervical spondylosis showing disk space narrowing, the annular insertion near the end-plates. end-plate sclerosis and osteophytes. 105 VOLUME 95 NO. 4 APRIL 2012 �������� ���������������������������������������������������������������� ���������������������������������������� � Cervical Radiculopathy be obtained in essentially all patients with Treatment Cervical radiculopathy refers to neck pain or neurologic symptoms. Typi- Axial Neck Pain symptoms in a specific dermatomal dis- cal radiographic manifestations of cervical Nonoperative treatment is the stan- tribution in the upper extremity. Severe spondylosis include disk-space narrowing, dard for discogenic and axial neck pain. neck and arm pain is typical, partially al- end-plate sclerosis, and osteophytic changes Nonsteroidal anti-inflammatory agents, leviated by holding the arm over the head at the end-plates, uncovertebral joints, and narcotic analgesics, corticosteroids, or tilting the head to the contralateral side. facet joints. (Figure 1) The AP view allows muscle relaxants, and antidepressants Patients may report sensory or motor loss identification of cervical ribs and scoliotic are commonly used to relieve neck pain corresponding to the involved nerve root. deformity. The lateral view demonstrates and radiculopathy. A short period of rest On physical exam, symptoms are aggra- the degree of disk narrowing, the size and the use of a soft collar with the neck vated by extension and lateral rotation of of end-plate osteophytes, the size of the in mild flexion may sometimes alleviate the head (Spurling Maneuver). Sensory spinal canal, and overall sagittal alignment acute pain and spasm. Physical therapy, deficits, motor deficits, and diminished which may influence the choice of surgi- including isometric exercises, active range- reflex activity may be elucidated on exam. cal procedure. Flexion-extension views are of-motion exercises, aerobic conditioning, Care should be taken to differentiate critical to diagnose instability, which may and resistive exercises, has been found to cervical radiculopathy from compressive not be evident on a neutral lateral view. be helpful for patients with chronic neck lesions of nerves of the upper extrem- Oblique views can be used for visualizing pain.12 In one study, nonoperative man- ity (i.e. carpal tunnel syndrome, cubital foraminal narrowing, which is typically due agement resulted in complete resolution tunnel syndrome) and electrodiagnostic to uncovertebral joint spurs. studies can often be useful. Additionally, Magnetic resonance imaging (MRI), patients with metabolic disorders, such while not indicated for every patient with as diabetes, who have neuropathy may neck pain, is the next step in the evalua- be more susceptible to radiculopathy and tion of the patient with a presumed diag- compressive neuropathy.2,8 nosis of spondylosis with myelopathy or radiculopathy. Persistent neck or arm pain Cervical Myelopathy of several months duration, neurologic The patient with cervical spondylotic findings, or a worsening symptomatic myelopathy may present with subtle find- picture warrants MRI. If evidence of my- ings that have been present for years or elopathy is present on exam, MR imaging with quadriparesis that developed over the is indicated to assess for disk herniation, course of a few hours. If the cord compres- hypertrophy, buckling of the ligamentum sion and myelopathy are either moderate flavum and the degree of cord compres- or severe, patients complain of gait and sion. One of the strengths of MR imaging balance abnormalities involving the lower is the ability to visualize the spinal cord, its extremities. They also have numbness or size, shape, quality (pathologic changes) paresthesias in their upper extremities. and degree of compression.10,11 Fine motor control is usually affected as Although MR imaging provides well, and they will note changes in their optimal visualization of soft tissues, CT- handwriting or ability to manipulate but- myelography offers better definition of tons or zippers. Arm weakness is common. bone spurs or and ossified posterior lon- Leg weakness can occur, and patients gitudinal ligament (OPLL). The exact de- may notice problems moving their body gree of cord deformation in the transverse weight, such as is necessary when rising out plane is more sharply visualized with CT- of a chair or going up stairs. The proximal myelography as well. This modality is also motor groups of the legs are more involved useful when MRI is contraindicated. than the distal groups. Changes in bowel Lastly, electrodiagnostic studies are or bladder function can occur in extremely sometimes used. For patients with cervical severe cases of myelopathy. On physical radiculopathy, electromyographic–nerve examination, the findings that establish conduction studies may be useful in con- the diagnosis are brisk reflexes, clonus, or sidering the differential diagnosis of carpal pathological reflexes confirming an upper- tunnel syndrome, ulnar cubital tunnel motor-neuron lesion.1,9 syndrome, or thoracic outlet syndrome. Electrodiagnostic modalities may also Diagnosis help elucidate the