Cervical spondylosis Definition Cervical spondylosis refers to common age-related changes in the area of the spine at the back of the neck. With age, the vertebrae (the component bones of the spine) gradually form bone spurs, and their shock-absorbing disks slowly shrink. These changes can alter the alignment and stability of the spine. They may go unnoticed, or they may produce problems related to pressure on the spine and associated nerves and blood vessels. This pressure can cause weakness, numbness, and pain in various areas of the body. In severe cases, walking and other activities may be compromised. Description As it runs from the brain down the back, the spinal cord is protected by ringlike bones, called vertebrae, stacked one upon the other. The vertebrae are not in direct contact with one another, however. The intervening spaces are filled with structures called disks. The disks are made up of a tough, fibrous outer tissue with an inner core of elastic or gel-like tissue. One of the most important functions of disks is protecting the vertebrae and the nerves and blood vessels between the vertebrae. The disks also lend flexibility to the spinal cord, facilitating movements such as turning the head or bending the neck. As people age, disks gradually become tougher and more unyielding. Disks also shrink with age, which reduces the amount of padding between the vertebrae. As the amount of padding shrinks, the spine loses stability. The vertebrae react by constructing osteophytes, commonly known as bone spurs. There are seven vertebrae in the neck; development of osteophytes on these bones is sometimes called cervical osteoarthritis. Osteophytes may help to stabilize the degenerating backbone and help protect the spinal cord. By age 50, 25-50% of people develop cervical spondylosis; by 75 years of age, it is seen in at least 70% of people. Although shrunken vertebral disks, osteophyte growth, and other changes in their cervical spine may exist, many of these people never develop significant problems. However, about 50% of people over age 50 experience neck pain and stiffness due to cervical spondylosis. Of these people, 25-40% have at least one episode of cervical radiculopathy, a condition that arises when osteophytes compress nerves between the vertebrae. Another potential problem occurs if osteophytes, degenerating disks, or shifting vertebrae narrow the spinal canal. This pressure compresses the spinal cord and its blood vessels, causing cervical spondylitic myelopathy, a disorder in which large segments of the spinal cord are damaged. This disorder affects fewer than 5% of people with cervical spondylosis. Symptoms of both cervical spondylitic myelopathy and cervical radiculopathy may be present in some people. Causes and symptoms As people age, shrinkage of the vertebral disks prompts the vertebrae to form osteophytes to stabilize the back bone. However, the position and alignment of the disks and vertebrae may shift despite the osteophytes. Symptoms may arise from problems with one or more disks or vertebrae. Osteophyte formation and other changes do not necessarily lead to symptoms, but after age 50, half of the population experiences occasional neck pain and stiffness. As disks degenerate, the cervical spine becomes less stable, and the neck is more vulnerable to injuries, including muscle and ligament strains. Contact between the edges of the vertebrae can also cause pain. In some people, this pain may be referred--that is, perceived as occurring in the head, shoulders, or chest, rather than the neck. Other symptoms may include vertigo (a type of dizziness) or ringing in the ears. The neck pain and stiffness can be intermittent, as can symptoms of radiculopathy. Radiculopathy refers to compression on the base, or root, of nerves that lead away from the spinal cord. Normally, these nerves fit comfortably through spaces between the vertebrae. These spaces are called intervertebral foramina. As the osteophytes form, they can impinge on this area and gradually make the fit between the vertebrae too snug. The poor fit increases the chances that a minor incident, such as overdoing normal activities, may place excess pressure on the nerve root, sometimes referred to as a pinched nerve. Pressure may also accumulate as a direct consequence of osteophyte formation. The pressure on the nerve root causes severe shooting pain in the neck, arms, shoulder, and/or upper back, depending on which nerve roots of the cervical spine are affected. The pain is often aggravated by movement, but in most cases, symptoms resolve within four to six weeks. Cervical spondylosis can cause cervical spondylitic myelopathy through stenosis- or osteophyte-related pressure on the spinal cord. Spinal stenosis is a narrowing of the spinal canal-- the area through the center of the vertebral column occupied by the spinal cord. Stenosis occurs because of misaligned vertebrae and out-of-place or degenerating disks. The problems created by spondylosis can be exacerbated if a person has a naturally narrow spinal canal. Pressure against the spinal cord can also be created by osteophytes forming on the inner surface of vertebrae and pushing against the spinal cord. Stenosis or osteophytes can compress the spinal cord and its blood vessels, impeding or choking off needed nutrients to the spinal cord cells; in effect, the cells starve to death. With the death of these cells, the functions that they once performed are impaired. These functions may include conveying sensory information to the brain or transmitting the brain's commands to voluntary muscles. Pain is usually absent, but a person may experience leg numbness and an inability to make the legs move properly. Other symptoms can include clumsiness and weakness in the hands, stiffness and weakness in the legs, and spontaneous twitches in the legs. A person's ability to walk is affected, and a wide-legged, shuffling gait is sometimes adopted to compensate for the lack of sensation in the legs and the accompanying, realistic fear of falling. In very few cases, bladder control becomes a problem. Diagnosis Cervical spondylosis is often suspected based on the symptoms and their history. Careful neurological examination can help determine which nerve roots are involved, based on the location of the pain and numbness, and the pattern of weakness and changes in reflex responses. To confirm the suspected diagnosis, and to rule out other possibilities, imaging tests are ordered. The first test is an x ray. X rays reveal the presence of osteophytes, stenosis, constricted space between the vertebrae, and misalignment in the cervical spine--in short, an x ray confirms that a person has cervical spondylosis. To demonstrate that the condition is causing the symptoms, more details are needed. Other imaging tests, such as magnetic resonance imaging (MRI) and computed tomography myelography, help assess effects of cervical spondylosis on associated nerve tissue and blood vessels. An MRI may be preferred, because it is a noninvasive procedure and does not require injecting a contrast medium as does computed tomography myelography. MRIs also have greater sensitivity for detecting disk problems and spinal cord involvement, and the test allows the physician to create images of a larger area from various angles. However, these images may not show enough detail about the vertebrae themselves. Computed tomography myelography yields a superior image of the bones involved in cervical spondylosis. Added benefits include that it takes less time to perform and tends to be less expensive than an MRI. A good diagnosis may be reached with either a computed tomography myelography or an MRI, but sometimes complementary information from both tests is necessary. Nerve conduction velocity, electromyogram (EMG), and/or somatosensory evoked potential testing may help to confirm which nerve roots are involved. Treatment When possible, conservative treatment of symptoms is preferred. Conservative treatment begins with rest--either restricting normal activities to a less strenuous level or bed rest for three to five days. If rest is not adequate to relieve symptoms, a cervical orthosis may be prescribed, such as a soft cervical collar or stiffer neck brace to restrict neck movement and shift some of the head's weight from the neck to the shoulders. Cervical traction may also be suggested, either at home with the advice of a physical therapist or in a health-care setting. Pain is treated with nonsteroidal anti-inflammatory drugs, such as aspirin or ibuprofen. If these drugs are ineffective, a short-term prescription for corticosteroids or muscle relaxants may be given. For chronic pain, tricyclic antidepressants can be prescribed. Although these drugs were developed to treat depression, they are also effective in treating pain. Once any pain is resolved, exercises to strengthen neck muscle and preserve flexibility are prescribed. If the pain is severe, a short treatment of epidural corticosteroids may be prescribed with discretion. A corticosteroid such as prednisone can be combined with an anaesthetic and injected with a long needle into the space between the damaged disk and the covering of the nerve and spinal cord. Injection into the cervical epidural space relieves severe pain that is not managed with conventional treatment. Frequent use of this treatment is not medically recommended and is used only if the more conservative therapy is not effective. If pain is continuous and does not respond to conservative treatment, surgery may be suggested. Surgery is usually not recommended for neck pain, but it may be necessary to address radiculopathy and myelopathy. Surgery is particularly recommended for people who have already developed moderate to severe symptoms of myelopathy, although age or poor health may prohibit that recommendation. The specific details of the surgery depend on the structures involved, but the overall goal is to relieve pressure on the nerve root, spinal cord, or blood vessels and to stabilize the spine. Alternative treatment Alternative therapy is not meant to replace conventional medical treatment, but it can be a useful adjunct. Its main roles are to relieve tension, manage pain, and strengthen neck and back muscles. Massage is one way to relieve tension, and yoga provides the additional benefit of strengthening muscles. Chiropractic and acupuncture have been reported to relieve the pain associated with disk problems, although great care needs to be taken to avoid exacerbating them. Practitioners of the Alexander technique or the Feldenkrais method can provide instruction on correct posture and exercise that may help prevent further symptoms. Vitamin and mineral supplementation along with herbal therapies and homeopathy can help build and rebalance the weakened structure. Prognosis The gradual progression of cervical spondylosis cannot be stopped; however, it doesn't always cause symptoms. For the individuals who do experience problems, conservative treatment is very effective in managing the symptoms. Nearly all people with neck pain, approximately 75% of persons with radiculopathy, and up to 50% of people with myelopathy find relief through therapy alone. For the remaining people with radiculopathy or myelopathy, surgery may be recommended. Surgery is deemed successful in 70-80% of cases. Prevention Since cervical spondylosis is part of the normal aging process, not much can be done to prevent it. It may be possible to ward off some or all of the symptoms by engaging in regular physical exercise and limiting occupational or recreational activities that place pressure on the head, neck, and shoulders. The best exercises for the health of the cervical spine are noncontact activities, such as swimming, walking, or yoga. Once symptoms have already developed, the emphasis is on symptom management rather than prevention. Key Terms Alexander technique A technique developed by Frederick Alexander that focuses on the variations in body posture, muscles, and breathing. Defects in these functions can lead to stress, nervous tension or possible loss of function. Bone spur Also called an osteophyte, it is an outgrowth or ridge that forms on a bone. Cervical Referring to structures within the neck. Computed tomography myelography This medical procedure combines aspects of computed tomography scanning and plain-film myelography. A CT scan is an imaging technique in which cross-sectional x rays of the body are compiled to create a three-dimensional image of the body's internal structures. Myelography involves injecting a water-soluble substance into the area around the spine to make it visible on x rays. In computed tomography myelography or CT myelography, the water-soluble substance is injected, but the imaging is done with a CT scan. Disk A ringlike structure that fits between the vertebrae in the spine to protect the bones, nerves, and blood vessels. The outer layer is a tough, fibrous tissue, and the inner core is composed of more elastic tissue. Feldenkrais method A therapy based on creating a good self image by correction and improvements of body movements. Magnetic resonance imaging (MRI) An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures. Myelopathy A disorder in which the tissue of the spinal cord is diseased or damaged. Orthosis An external device, such as a splint or a brace, that prevents or assists movement. Osteophyte Also referred to as bone spur, it is an outgrowth or ridge that forms on a bone. Radiculopathy Sometimes referred to as a pinched nerve, it refers to compression of the nerve root--the part of a nerve between vertebrae. This compression causes pain to be perceived in areas to which the nerve leads. Spine A term for the backbone that includes the vertebrae, disks, and spinal cord as a whole. Stenosis A condition in which a canal or other passageway in the body is constricted. Traction A medical treatment that exerts a pulling or extending force. Used for cervical problems, it relieves pressure on structures between the vertebrae and muscular tension. Vertebrae The ringlike component bones of the spine. For Your Information Resources Periodicals McCormack, Bruce M., and Phillip R. Weinstein. "Cervical Spondylosis: An Update." Western Journal of Medicine 165 (July-August 1996): 43.

3 month anniversary

How depressing. Today it is 3 months since this literal pain in the neck started. I also had my second epidural today. At the moment I'm in agony but thought I should move around a little before lying down again. Need to ice as that seems to help, it feels very sore. I have had two acupuncture appointments in the last few weeks. The first one seemed to help loosen up my trapezius muscles which was good, so we did another appt 12 days later, and I'm not sure if it was that or the combination of going to 2 Depeche concerts in a row and overdoing the whole week with the work move, etc. but the last two weeks have been v. painful. That and I'm incredibly depressed from gaining almost 5 lbs in four weeks! So NOT good. My muscles are atrophying and I lose my breath so easily, worse than normal.

During the procedure the dr says to tell him if/when you feel anything painful or uncomfortable. Last time I had pins and needles shoot all the way down my right arm when the needle was going in. This time it was so strange, it was my chest and back on the right side, it felt like an electrical shock. Freaked me out completely but thankfully as soon as he moved the needle it stopped. It's not a fun procedure but if it works I will be very happy about having to deal with it!

Anyway Dr. Ahmed said the procedure went well today and the medicine went where he wanted it to go. I know the first few days can be worse after the local wears off, but am hoping they are not too bad and that I will feel much better in a few days. Please, please, please. It's 7 weeks until Italy and I REALLY don't want to be feeling like this, as it will completely limit me as to what I want to do. So fingers, and everything else, is crossed.

Also had a quick scare this week with a possible abscess again. It started hurting a few weeks ago but went away, so I let it go, then this Monday/Tuesdsay I was in a lot of pain. The dr wasn't in until Thursday so I made an appt then, but strangely by Wednesday it felt better. The dr said it did feel a bit "weird" on that side but that he couldn't find anything "surgical" that he needed to do, so I yet again completely perplexed another dr. At least he's v. nice and said, even b/f the exam, that he always wants me to come in if I suspect something, even if it's nothing, b/c he'd rather deal with the beginning of a bad thing than me putting it off. HUGE relief it was nothing though.

Must go ice and lay down again, in mucho pain.

No changes

The good news is I had an MRI last Saturday and it showed nothing. No rotator cuff tear (I knew that but everyone kept jumping to that), no bursitis (surprising since everyone's told me I've had that for ages). All good, and I am definitely relieved b/c if it was a tear then I'd have to contemplate shoulder surgery and who has the time (or energy) for that? I've already decided to push back my hand surgery till the new year so I will have a full FSA account and days off.

But the question still remains, what the F*** is going on w/ my neck??? I see Dr. Ahmed (the anesthesiologist/pain dr) on the 6th. The other drs think he will want to do another epidural. Fun stuff! But if it works then it's fine because the pain has actually been really bad this week, especially in my shoulder and upper arm. I am praying that it will work this time because tomorrow is 10 weeks and I'm seriously going to lose my mind, or what's left of it!

9 weeks and still (sadly) counting

Well I just don't know what to do anymore. I'm at a complete loss. Did the epidural injection work? It might have helped a little with the inflammation in the nerve in my spine, but I still have pain in my shoulder and down my arm, as well as pins and needles. My trapezius muscles are v. v. tight. I asked Dr. P what to do and he said I could try at home traction (don't have one), muscle relaxers, or dry needling. So I tried the muscle relaxers. Of course the next day when he got back to me he said which ones to try, and the one I used was left over from my hip surgery. All it did was give me restless leg syndrome and I was up all night from it, dry as a bone, eyes hurting from being so dry and dehydrated. Must remember to toss out any remaining pills. It was something w/ at T. Anyway then I rang my acupuncturist. He said that he could try some treatment that wouldn't increase the inflammation. I went last night, and felt a little better after, even though the needles hurt like hell - surprising because they don't really normally hurt. But today my neck /spine hurts and the shoulder hurts and the pins and needles are still the same. I'm am going to lose what is left of my mind. Mark did notice last night that my right side seemed weaker - I told him I'm not surprised b/c I've been guarding it and using my left side - which explained why when he touched my left trapezius muscle I screamed - it's been working overtime. Thank goodness it is Friday and I don't have to sit for two days at a computer. I am getting very worried though because time is running out to sort this before October and Italy. There is no way I'll survive that trip like this. Something must be done! Two weeks until I see the anesthesiologist again, perhaps I should see if I can get an appointment sooner. He might have to do another epidural. I also definitely need an MRI of my shoulder, so wondering if I should have that arranged because perhaps this is coming from there as well and a shot in there would be good? I don't mean the one Dr. P. did a month ago, I mean like they did with my hip where they really get into the joint. I have to ask someone and hopefully get some information because I am so worn out I could just give up at this point - and I'm sadly not even trying to be dramatic.

Beyond frustration

The injection so far hasn't seemed to do much of anything to my body. Last night I thought perhaps I had less pain in my neck, but that is probably because my shoulder was killing me it was taking all the attention away. This morning I have pain in my neck and also stabbing pain in my shoulder. I never heard back again from Dr. P about what to do w/ exercising at home so I've not done anything as when I was in PT they told me to not do anything if I was in pain. I am so confused. Granted I've heard it could take another week or so for the injection to kick in but yes, I'm slightly impatient. (At this point I have a right to be, it's been 8 weeks of this crap!) The pain in my neck does seem a bit higher today though and not in the joint where they injected it. I'm losing my mind. Part of me thinks I should call Dr. Kelly up and have him check out my shoulder, perhaps it is surgical after all, but then again, there's nothing I could do until after October because of my trip. I go back to see Dr. Ahmed on the 6th August, perhaps he'll have some ideas then. My head is spinning, as was the rest of my insides this morning when I had a massive blood pressure drop from out of nowhere. I hate when that happens. Feeling a bit better now but just want to rest, not be sitting in the office uncomfortably.
Ok, I am done with the whinging for now. I just want my life back!