There are many causes of neck pain but in today’s article, we are going to go through Cervical Spondylosis.
What is Spondylosis?
Put simply Cervical spondylosis is a normal part of ageing and it is effectively a posh word for arthritis in the neck. More accurately it is degeneration of the intervertebral discs in the cervical spine. Even as far back as Dunsker (1981), it was stated that ‘Cervical spondylosis is a common condition that affects all people, but to varying degrees and sometimes with no neck pain at all.
‘Effectively a posh word for arthritis in the neck.’
How much of a problem is spondylosis?
After back pain, neck pain is the second most common musculoskeletal problem, affecting two-thirds of people at some point in their lives, according to Vos et al (2007). Women have a slightly higher incidence but problems tend to occur earlier in men (Binder et al 2007). It is so common that X-rays and MRI scans find it in people with no pain. For example, Rao et al (2007) found that 25% of people under 40 have some degree of disc degeneration. Symptoms may appear as young as 30 years of age but are most commonly problematic between the ages of 40-60 years (Al-Shatoury & Galhom 2009). The most common sites of Cervical spondylosis are C4-T1 and it is thought that this is because these areas are at points of maximum motion and curvature (Vibert et al 2016).
What are the common signs and symptoms of cervical spondylosis, not just a pain in the neck?
The most obvious symptom of cervical spondylosis is neck pain and this can affect either one side or both and can even radiate between the shoulder blades with an occasional base of the skull pain. In more severe degeneration it can also cause radicular pain into an arm sometimes with vague tingling and numbness. On occasion the pain can also go in the head, most commonly the temple regions are mostly affected. Sleep is commonly affected and as per many other arthritic issues in the body stiffness and range of movement is limited and pain is worse with movement, especially into neck extension (looking up at the ceiling) (Binder, 2007). Balance can be negatively affected in some people and there can be some minor neurological changes.
The lack of movement is mostly in the lower cervical spine according to Grant et al(2002) and a kyphotic deformity (rounded upper back) develops secondary to Cervicothoracic joint stiffness. Tenderness is often hard to pinpoint as most of the pain is deep in the joints as opposed to superficial muscles etc.
What are the red flags to be aware of that may indicate more serious problems?
General red flags:
Be aware of the persons’ age when the problem started. If they were between 20 and 55 years of age then this may be a sign to investigate but only with other red flags to firm up the need to.
Check for weakness in more than one myotome (muscle nerve supply).
Check for sensation loss in more than one dermatome (skin nerve supply).
If pain is unbearable and is increasing.
Things that may indicate either malignancy, infection, or inflammation can be the following:
Unexpected weight loss.
Fever, night sweats.
previous history of malignancy, inflammatory arthritis, infection, tuberculosis, HIV infection, drug dependency or immunosuppression.
Excruciating pain and night pain.
Cervical lymphadenopathy (lymph node disease).
Hypersensitiveness over a vertebral body.
Myelopathy could be present in with the following:
No cause or reason for onset and worsening in spite of this can be something to look out for but make sure other red flags are present too.
Gait disturbance and clumsiness especially in the hands.
Loss of sexual, bladder or bowel function (often a late sign).
Lhermitte’s sign (neck flexion causes ‘electric shock’-type sensation radiating down the spine).
Abnormal neurological deficits such as:
Upper motor neurone signs in the legs (eg hyperreflexia, clonus, spasticity)
Lower motor neurone signs in the arms (eg, atrophy/fasciculation, hyporeflexia).
Sensory changes are not always consistent but look for loss of vibration and joint position sense in the hands more than in the feet.
Other features to watch out for are:
Diagnosed with or has potential for Osteoporosis.
Has had a recent violent trauma or fall from a height.
Previous neck surgery.
Dizziness when moving the neck and drop attacks.
(NICE 2015)
What causes cervical spondylosis?
This is not an easy question to answer because everyone’s neck will degenerate with time as part of normal ageing but not all people will get any symptoms. This is because pain and injury onset is more complicated than just having the issue seen on a scan. The causes are always multifactorial and can include things such as:
Postural strain: This is not bad posture per se, it is more the amount of sustained poor posture or lack of movement and variety of posture.
Work-related: Mayer et al (2012) found a strong association with manual handling, trunk flexion or rotation, repetitive movement, working in awkward or static postures & working with the hands above the head.
Sporting overload: Repetitive sporting activities involving the neck and shoulder movement or direct impact from sports such as rugby or boxing.
Psychological issues: Anxiety, depression and the number one cause is amazingly stress (Smedley et al 2003).
Structural components: Binder et al (2007) reported that some people have degenerative changes especially in the cervical discs, osteophyte formation and soft tissue structures can show some signs too. Again this has to be factored into the other causes as many people over 30 years of age show similar changes, and the boundary between normal ageing and disease is difficult to define. This is very relevant to this kind of condition with regards to how you manage and treat it.
How normal are these structural changes in the neck?
In young adulthood, the cervical discs start to fissure (split) at the back edge, due to continued shearing forces from normal life.
By a person’s late thirties, there are obvious transverse posterior fissures running between the uncovertebral joints. Only the anterior annulus and longitudinal ligaments are intact, so stability is due to the zygapophyseal (facet) joints, posterior musculature and ligaments (Taylor and Twomey 2000).
It all sounds terrible but is actually normal just like wrinkles, in fact, some people have called this wrinkles on the inside!
Is Modern technology to blame for neck pain?
Many people have started to blame modern technology and even a term has been coined for it, ‘text neck’, but this has not been substantiated as a legitimate cause because posture is only relevant in extremes and even though we do spend more time on our phones it isn’t just one position all day every day without postural change. Here is a video going more into this here:
How do you diagnose cervical spondylosis?
Diagnosis is based on clinical questioning and examination, which is what we do at our Hawkes physiotherapy clinics in Stoke-on-Trent. X-rays can also be done but they are not always that informative and most of the time not needed to make a diagnosis.
For example, Cleland & Koppenhaver (2005) reported that palpation to the facet joints in the neck is accurate to help diagnose neck injury to a probability of 82% and this is just in isolation! If you do need an X-ray then you are looking for the formation of osteophytes (spikes of bone growth), narrowing of disc spaces with the encroachment of intervertebral foraminae (holes the nerves pass through). They need to be aware as we mentioned earlier that findings are common in normal middle-aged patients so they need to tie in with the clinical examination done in your physiotherapy assessment.
If there are neurological abnormalities then a magnetic resonance imaging or MRI is the best imaging for the job but this is only done if there are signs of myelopathy, radiculopathy or there are abnormally high pain levels along with other red flags as previously mentioned.
How do you treat Cervical spondylosis?
Initially:
In the first 3 to 4 weeks, reassurance is needed to highlight that neck pain is cervical spondylosis is common and it is very likely to go away as quickly as it came on and it’s nothing to be worried about. This is very important in the beginning as fear, anxiety etc, aren’t going to help the patient to move and recover well.
Advice patients to keep active, try to maintain their normal activities and to avoid the use of a cervical collar as this will weaken and stiffen the neck making things worse not better.
Time off work can be bad so if possible try to remain at work but there will be cases where for a short period, restricted duties or time off may be needed but this should be kept to a minimum.
Mainly due to safety, driving should be avoided if the range of neck movement is restricted.
Patients often ask about pillows but the only evidence supports the use of one firm pillow at night.
As we mentioned earlier, psychological factors can be prevalent and if this is the case the there is a need to identify and address them otherwise there is more likely to be long term recovery problems.
If their working practices or environment are potentially part of the problem then this needs addressing so offer postural and movement advice.
Advice around normal daily activities and hobbies may be helpful for some patients if these are relevant.
After 4-6 weeks:
This is where physiotherapy comes in and if indicated psychology specialist referral may be needed to help management at this point.
Manual therapy:
Gross et al (2015) recommends performing spinal manipulations especially in the Thoracic spine area for best results. Studies suggest that certain joint mobilisation techniques are better than others. For example, Egwu et al (2008) found Anteroposterior mobilisations (APs) and Posteroanterior mobilisations (PAs) provide faster pain relief in patients with unilateral cervical spondylosis than rotations and transverse directions.
Exercise:
As usual strengthening exercises can be effective for neck pain and function in cervical spondylosis according to Gross et al (2015). Here is an example of neck strengthening exercises:
Acupuncture:
Trinh et al (2010) found that acupuncture was effective for short term relief of neck pain and was superior to sham (placebo) acupuncture.
Massage therapy:
We offer sports massage at both of our Stoke-on-Trent clinics and this has been shown to provide immediate effectiveness for both pain & tenderness in neck pain (Patel et al 2012).
After 12 weeks:
At this point referral to the pain clinic and a possible need to investigate things further along with continuing to examine psychosocial factors. If scan indicate the need and therefore it may be appropriate then more invasive techniques may be called for.
Surgery:
Non-operative management is the best option for those with no neural components like arm pain, pins and needles etc. (Rao, 2002) but if neural signs and symptoms still persist at this point then surgical interventions may be required.
Even if you are a candidate for surgery Cervical decompressive surgery is not amazingly successful, especially for myelopathy complicating cervical spondylosis. They have concluded that surgery can slow the progression down but surgery is not really that effective in improving any lost function and there is a likelihood that symptoms may progress at a later date. Obviously, surgery isn’t risk-free either and poor outcomes can cause irreversible damage to the cervical spinal cord or compromise to the vascular supply to the spinal cord too (Binder 2007).
Even this Cochrane review concluded there is insufficient evidence to determine whether the risks of surgery are outweighed by its benefits (Nikolaidis et al 2010).
Epidural injection:
Benyamin et al (2009) found that they can be surprisingly effective for extreme pain cases but they are more invasive than the same procedure done in the lower back area.
How likely am I to recover from Cervical spondylosis?
Luckily Cervical spondylosis is a degenerative condition meaning that it progresses very slowly but it is a chronic condition of the joints and so 100% recovery in its pure sense is not realistic but all is not lost!
After a year of 1 year from the onset of an acute flare-up and neck pain from cervical spondylosis, it was found that:
75% of people are ‘much improved’ but just under 50% still had some ongoing symptoms.
Over half of people who need time off work were back within one week.
(Vos et al 2008)
Long term issues:
Pain is to still likely to be significant after 1 year if the pain is still severe and if there is also lower back pain at the same time at the start of the problem. It is estimated that about 10% of people will develop chronic long term neck pain (Hoving et al 2004).
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So there is all you need to know about Cervical spondylosis and remember this can be helped with physiotherapy, sports massage and acupuncture and more so don’t just put up with it there is hope!
If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.
DISCLAIMER:
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.
