Introduction

Cervical spondylosis is a term used to describe degeneration of the vertebral column in the cervical (neck) region. It is otherwise known as cervical osteoarthritis. It most commonly presents in clinical practice as neck pain.

Risk factors for developing cervical spondylosis include:
  • Ageing (degeneration typically begins in the second or third decade of life).
  • An occupation involving repetitive neck movement, or overhead work (e.g. painting/decorating).
  • Previous traumatic neck injury (which accelerates the natural ageing process).
  • Family history of the condition.
A minority of patients with cervical spondylosis present and/or develop associated radiculopathy and/or myelopathy.

Epidemiology

  • Incidence: 300.00 cases per 100,000 person-years
  • Peak incidence: 70+ years
  • Sex ratio: 1:1
Condition Relative
incidence
Cervical spondylosis1
Carpal tunnel syndrome0.67
Polymyalgia rheumatica0.28
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Patients will generally present in primary care with neck pain.

Characteristics of pain associated with cervical spondylosis:
  • Pain and/or stiffness in cervical region
  • Referred pain: retro-orbital, temporal, occipital, interscapular, upper limbs.

Examination findings:
  • Reduced range of movement of neck (in all directions)
  • Poorly localised tenderness
  • Signs of radiculopathy (most commonly affecting nerve roots C5 to C7)
    • Unilateral neck, shoulder or arm pain, paraesthesia, or hyperaesthesia
    • Diminished arm reflexes (triceps: C7, biceps: C5/C6, supinator: C5/C6).
  • A small number (<0.1% of patients with cervical spondylosis) of patients with associated acute myelopathy can develop quadriplegia.

It is worth noting that many patients with degenerative change in the cervical region are asymptomatic.

Investigations

Generally cervical spondylosis is diagnosed clinically.

Plain cervical X-Ray:
  • Can demonstrate changes associated with the condition
    • Osteophyte formation
    • Narrowed disc spaces
    • Narrowing of intervertebral foramina
  • These findings do not change clinical management unless associated with symptoms.

Magnetic resonance imaging (MRI):
  • Patients suspected of having cervical spondylosis with neurological involvement should undergo MRI.

Many patients with radiographic evidence of cervical spondylosis are asymptomatic.

Management

Lifestyle:
  • Maintain normal activities.
  • Avoid use of cervical collar.
  • Advise against driving- if range of movement of neck is severely restricted.
  • Advise use of one firm pillow at night.
  • Offer postural advice for daily activities, work, and for hobbies where relevant.

Pharmacological:
  • Offer oral analgesia when associated pain is severe- e.g. paracetamol, non-steroidal anti-inflammatory medication (such as ibuprofen), codeine.
  • Consider use of topical NSAID.
  • Some studies advocate the use of low-dose tricyclic antidepressants (amitriptyline) and/or anti-epileptic medication (pregabalin or gabapentin) in patients who fail to respond to conventional analgesia.
  • When pain is severe and ongoing for >12weeks (despite a multi-modal approach)- referral can be made to a specialist pain clinic.
  • For patients with severe chronic pain epidural injection into the cervical region can be considered.

Referral for physiotherapy:
  • When symptoms related to cervical spondylosis continue for >4weeks- referral to physiotherapist is advised.
  • Performing regular exercises on the advice of a physiotherapist can help to improve and maintain range of motion of the cervical spine.

Referral to occupational health and/or psychologist:
  • Identify and address psychosocial factors that may result in worsening of symptoms.
  • Referral to occupational health can be useful for patients whose neck pain is exacerbated by activities at work.

Surgical:
Indications for surgical management include:
  • Associated neurological deficit- due to radiculopathy (compression of a nerve) or myelopathy (compression of the spinal cord) as indicated by the patient’s symptoms, and results of MRI.
  • A minority (1-2%) of patients with cervical spondylosis require surgical management.
  • Decompressive surgical procedures used include: anterior cervical decompression and fusion (ACDF) or posterior laminectomy or laminoplasty.
  • The outcome of the most recent Cochrane review was that there is currently insufficient evidence to determine whether the risk of surgical intervention outweighs its long-term beneficial effects.
  • Whilst decompressive surgery may slow progression of neurological deficit- it will generally not result in recovery of lost function, and neurological symptoms may recur as the condition continues to progress over time.

Complications

Cervical spondylosis is a chronic condition that tends to progress slowly.

Neurological complications:
  • The incidence of radiculopathy and myelopathy is estimated at: 100 per 100 000 males and 60 per 100 000 females, and 4 per 100 000 patients respectively.
  • Without decompressive surgery significant neurological damage can occur.

Surgical complications:
  • Reduced range of movement of the cervical spine (secondary to fusion).
  • Accelerated progression of degeneration of adjacent levels (those not operated on).