The neurological symptoms associated with cervical spondylosis may vary from local neck pain with muscular bracing and no neurological deficit at one end of the scale, to radicular complaints due to root compression or myelopathy secondary to cord compression at the other (1):
- typical early spondylotic neck and shoulder and neck muscle pain is followed by brachalgia, i.e. by referred or radicular pain going down into the arm and/or forearm, this suggests a progression from 'simple spondylosis', to nerve root irritation and compromise, and/or frank compression
- features of radiculopathy from spondylotic osteophytes may develop insidiously or acutely
- trauma or acute disc herniation may precipitate the symptoms
- bilateral symptoms are less common and may span several segments if more than one cervical level is involved
- neck and arm pain, along with weakness, are typical but one may exist without the other. Other features include sensory loss, paraesthesia and hyporeflexia
Degenerative features:
- reduced neck mobility
- painful, tender spine
- crepitus on movement
Radicular features:
- pain - sharp, stabbing; exacerbated by coughing; may be superimposed on a more constant deep ache over the shoulders down to the lower scapulae and down the arms; occipital headache
- paraesthesia - numbness / tingling in a root distribution
- root signs:
- dermatosensory loss
- lower motor neurone signs - according to site of lesion
- compression of vertebral artery and oesophagus may give rise to 'drop attacks' and dysphagia
Myelopathic features:
- features of cervical spondylotic myelopathy usually develop insidiously
- 75% of cases there is progression in either a stepwise (one-third) or gradual (two-thirds) fashion
- an initial phase of deterioration may be followed by a stable period, which may last for years
- patients notice impaired co-ordination of the hands and complain of difficulty with tasks such as buttoning clothes
- may be weakness and wasting of the hand muscles, and opening and closing of the fist is slowed and stiff
- arms - lower motor neurone signs at the level of the lesion with upper motor neurone signs below that level; for example, C5 lesion - wasting and weakness of biceps, reduced biceps jerk (LMN); increased finger jerks (UMN)
- legs - upper motor neurone signs; sensory signs less prominent
- sphincter - disturbance seldom seen as an early feature
- about 50% develop bladder sphincter symptoms such as urgency, but anal sphincter disturbance is rare
- in about 80% of cases there may be loss of vibration sensation in the lower extremities
- some patients may have posterior column dysfunction with impaired joint position sense and two-point discrimination
- Lhermitte's sign – paraesthesia in all extremities induced by flexion or extension of the cervical spine and caused by cord compression – is seldom found
- acute myelopathy may occur as a result of a fall in an elderly patient with pre-existing spondylosis and stenosis of the vertebral canal - may or may not have been symptomatic before the fall
- central cord syndrome typically produces weak arms and hands, but spares the peripheral corticospinal tracts, thus lower limb function is not as severely impaired.
Typically in this condition there are exacerbations of more acute discomfort, and long periods of relative quiescence.
Notes:
- there are eight cervical nerve roots and only seven cervical vertebrae. Thus, cervical roots exit above their corresponding vertebrae, and thoracic nerve roots exit below their corresponding vertebrae
- symptoms stem from compression of the sensorimotor roots at the intervertebral foramina, and clinical analysis of their distribution and the neurological findings may allow the segmental level to be defined. Approximately 90% of cases occur at the C5/6 and C6/7 levels, where the mobile cervical spine joins the immobile thoracic segments
Reference:
- ARC (January 2002). Rheumatic Disease in Practice.