Cervical Spondylosis
What is meant by cervical spondylosis?
The term “cervical” refers to the spinal column in the neck region. The term “spondylosis” refers to any ailment of the spine!! The term spondylosis is used loosely for all kinds of neck pain; from the purely innocuous ones to the ones those require surgical intervention. This neck pain may be in the nape of your neck, or very often may be present between the two shoulder blades.
What causes cervical spondylosis?
Cervical spondylosis can be caused by a slipped disc or a bony overgrowth or a combination of both.
What is a slipped disc? Our spine is made up of a number of bones called vertebrae stacked one on top of another. A disc is a soft, gel-like structure present between two adjacent vertebrae. Normally, these discs act like ‘shock-absorbers’ and also allow some movement between the two adjacent vertebrae, giving the spine its flexibility. When this disc slips beyond its normal confines, it can compress the spinal cord or its nerve roots located close by and lead to problems.
Why does the disc slip out? Over the years, the disc develops small microscopic tears, which may unite together over a period of time such that with some trivial injury or some innocuous activity, the disc may slip out of its normal confines. As a part of the normal aging process, the spine may develop some extra bone growth, leading to compression of the adjacent spinal cord or its nerve roots leading to pain.
How does cervical spondylosis manifest?
One of the commonest complaints is neck pain that may be present either at the nape of the neck or between the two shoulder blades. This pain would generally be noted on some kind of neck movement or on coughing or sneezing. Similar to “sciatica” that occurs in the lower back, when the pain starts radiating down into the upper limbs, it is referred to as “radiculopathy”. Another complaint of cervical spondylosis that spine consultant generally comes across is unsteadiness while walking. This is the most important complaint to note as very often, this complaint gets relegated to the normal aging process in the older population in whom it is most frequently noted.
Any compression or problem affecting the nerves after they leave the spinal canal can also lead to pain along the hand. The most common condition that can affect the nerves after they leave the spinal canal is ‘peripheral neuropathy’, a condition wherein the nerves are ‘weakened’ secondary to diabetes, chronic alcoholism, smoking, other forms of tobacco consumption, nutritional deficiencies or other rare causes. A common complaint in patients with peripheral neuropathy is the presence of pain even at rest; pain of a burning nature or numbness in ‘glove and stocking’ distribution i.e. over the hands, just beyond the wrist joints and over the lower limbs, just beyond the knee joints. Additionally, once the nerves leave the spinal cord, they have to travel through a narrow space termed “thoracic outlet” at the base of the neck so as to reach the upper limbs. There may sometimes be compression at this level, leading to pain radiating down into the upper limbs. Neck and back are often termed the mirrors of the mind. Hence, stressful periods are likely to give you some neck or back pain as well! Poor posture is also a common culprit for neck and back pain.
An accurate history is the most important diagnostic tool. The way the pain started and progressed; specific aggravating and relieving factors of pain; distribution of pain over your body, associated complaints such as weakness or numbness over the upper or lower limbs will be a guide to short listing the possible causes of your neck pain. A very important history relates to difficulty or clumsiness while walking.
A detailed clinical examination by best spine specialist in India involving assessment of spinal motion, assessment of your neurology and certain special tests will allow to further narrow down the causes to 2-3 most probable ones.
Though this process of history-taking and clinical examination may appear boring and long-drawn, it is the most crucial part towards prescribing the correct treatment to you. So, it is essential to cooperate with your spine consultant or specialist throughout this entire procedure, which gives more information to the doctor regarding your ailment than any other investigation including an MRI.
On the first visit to spine consultant, if your problem is short-lived and there are no major signs or symptoms, you may not need any further investigation. However, if your problem has been present for some time, or if there is some history of trauma, fever, any other major illness, or any notable findings on clinical examination related to neurological dysfunction; you are likely to require some further investigations.
Commonly, plain x-rays of the spine may be ordered with or without some basic blood investigations such as hemoglobin, erythrocyte sedimentation rate [ESR], CRP, RA test, serum calcium, phosphorus and alkaline phosphatase.
Based on these tests, or sometimes, in the presence of some significant signs or symptoms, you may be asked to undergo MRI scanning. Plain x-rays demonstrate bony features; while MRI demonstrates the spinal cord, its nerve roots, the intervertebral disc between the two bones of the spine. Both these tests are complimentary in nature; doing one does not necessarily mean that the other one is not needed.
In some cases such as peripheral neuropathy or thoracic outlet syndrome, additional investigation in the form of EMG-NCV test, to assess the function of each of the various nerves in your limbs may be required.
Rarely, a Color Doppler examination of the upper limb blood vessels may be asked for by the Spine consultant or spine surgeon.
The treatment would depend on the duration of your problem, presence of similar episode in the past, neurological function, response to previous nonoperative treatment and lastly, the subjective severity of your pain. Various nonoperative means of treatment include painkillers, muscle relaxants, various modalities such as heat and electrical stimulation, cervical traction, activity restrictions, etc.
Painkillers will be prescribed to allow a smoother and easier return to normal function. You would generally be prescribed these on a shorter term or on a longer-term tapering program so as to guard against possible over dependence on these agents, as these are associated with significant side effects if used excessively in the long term. These side effects may range from hyperacidity, gastric ulcer, kidney damage, bleeding disorders, constipation, addiction, etc. In addition, based on individual merit, you may also be prescribed muscle relaxants so as to relax and soothe your neck and back muscles. This is so because whenever you have neck or back pain, your muscles tend to go into spasm [sustained contraction] and hence, lead to pain. It is essential to break this spasm with a muscle relaxant so as to give effective pain relief.
Physiotherapy modalities may be used. This consists broadly of passive and active physiotherapy. During acute pain, generally, only passive physiotherapy would be used. This would be in the form of heat or electrical stimulation in various forms such as SWD [short-wave diathermy], TENS [transcutaneous electrical nerve stimulation] and IFT [interference therapy]. Cervical traction too, aids in relaxing the aching neck. In severe cases, you may be recommended to get admitted in the hospital for a day or two to get this physiotherapy on a more aggressive note. After pain relief, you would be prescribed active physiotherapy i.e., spinal exercises. Based on your complaints, your exercise protocol would be decided by your Spine Consultant.
You would need to have some activity modifications and restrictions to help your spine get back into shape and stay that way!! If you have a job on hand that requires you to sit continuously for hours on end, then you can sit for 15-20 minutes and then get up and walk around for about 5 minutes, gently shrug your shoulders and perform circular movements in the air with your shoulders, first in the clockwise direction and then in the anticlockwise direction. Bifocal lenses in spectacles would require you to bend your neck backwards while reading which is not a very healthy practice for your neck spine. Smoking interferes with the nutrition of the disc in between the vertebrae and hence, would need to be abandoned forever! Try to sit in a chair that has a high backrest that supports your neck as well. Try to keep the computer at your eye-level. Do not stack up pillows underneath your head so as to be able to read while sleeping! Ideal position to sleep is sideways with a pillow underneath the head just about adequate to fill up the gap between the side of your head and your shoulder. While lying down with the face upwards, use a very thin pillow or just fold a bed sheet and keep it underneath the head.
Surgery would be indicated by the spine surgeon when there is no pain relief despite symptomatic treatment as mentioned above or, when there is significant neurological deficit or, repeated episodes of pain so as to get a permanent solution to the problem.
Microdiscectomy is the usual surgery for cervical spondylosis. This is a surgery performed through the microscope so as to make this a relatively safe procedure. When many levels are involved, the surgery may be done from the backside, otherwise, it would be from the front. Is it a major surgery? We were told that we should not get a spine surgery done as it can lead to paralysis! Or, in other words, what are the risks involved? The option for surgery would be offered only if the benefits of surgery significantly outweigh the risks. Rather than asking as to what are the risks of going in for surgery, it would be more prudent to ask your spine surgeon or consultant, what are the risks and benefits of getting the surgery done as compared to not getting the surgery done? Spine surgery has had a lot of advances in the past decade or two; there are better imaging facilities like MRI, better surgical instruments, surgical microscope to aid vision in the surgery, computer navigation system to further increase the safety level of surgery, better training and information in an overall sense making spine surgery no longer the taboo that it once was! So, if you have a problem that genuinely requires surgery, there is no point in tying yourself down to the bed for days or months on end; because ultimately life is mobility and mobility is life! Discuss the details of your surgery with the best spine specialist in Bangalore and its attendant risks with your doctor to quell any fears and to clear any and every doubt of yours! If you so desire, your doctor can even arrange to give you references of patients who have undergone similar surgeries. Can we not replace the disc back into its place; in other words, won’t it be harmful to remove the disc? The disc that has slipped out can no longer carry out its normal function; rather, it is causing harm to the body rather than doing anything good! So, trying to replace the disc back into its position is not a viable option. However, it is possible to replace the damaged disk with an artificial disk that would function similar to the natural disk.
Generally, you would be admitted one day prior to the day of surgery. You would be advised to stay starving after dinner the previous night. Surgery would generally be carried out by spine surgeon next day morning. After surgery, on 2nd or 3rd day, you would be made to walk with a cervical collar. You may be discharged after 3-4 days. Sutures [stitches] would be removed generally on the 10th–14th day following the surgery. By this time, you would be walking around and essentially be independent in doing activities of daily life. You would be allowed to take bath 48 hours after the suture removal. For 3-4 weeks, you would be allowed restricted mobilization within the house. During this period, you would be encouraged to increase all your activities in gradual weekly increments. 1 month later, you would be started on spinal strengthening exercises. You would have to use the cervical collar for about 1-3 months at all times other than while taking bath. You would not be allowed to smoke for lifelong!
Death has been reported following violent manipulation of the neck by some people. Hence, it is not at all recommended. As long as no neurological deficit [loss of sensation, weakness or clumsiness while walking] is present, alternative medicines may be tried. However¸ procrastination in the presence of neurological deficit is not recommended.
Microscope allows for the use of both eyes while working, giving binocular vision and thereby, good depth perception that is very essential for the safe performance of these surgeries. This binocular vision is lacking in endoscopic discectomy. Percutaneous laser discectomy has not been proven to be scientifically superior to microdiscectomy. Rather than doing the conventional surgery of fusion at the level of discectomy, it is possible to replace the disk with an artificial one. This would simulate normal spinal function and hence, is a better surgery than the conventional fusion. However, it is costlier than the conventional fusion surgery.
