Often mistaken for arthritis, this disorder causes decreased height of intervertebral discs in the neck.
With the continued “graying” of America, healthcare professionals are caring for more elderly patients than ever. Part of the natural aging process is cervical spondylosis, a progressive degenerative spine condition. In this disorder, vertebral bodies in the neck enlarge through osteophyte (bone spur) formation, while intervertebral discs in the neck become dehydrated, stiff, and calcified, leading to decreased disc height. This combination of processes causes stenosis of the cervical canal, resulting in spinal cord compression.
Nearly everyone who lives long enough will develop cervical spondylosis, but relatively few people will be treated for it. The condition is the most common cause of cervical spinal-cord dysfunction after age 55. Treatment depends on symptoms, which can vary from none to mild to severe, such as quadriparesis (weakness of all four limbs).
Cervical spondylosis is thought to be underdiagnosed because to a large extent its signs and symptoms are expected in the elderly. Persons with the disorder may be told they have arthritis. However, spondylosis does not involve synovial joint inflammation. Rather, it’s a complex process of intervertebral disc changes and osteophyte formation and usually includes loss of lordosis in the cervical spine. Neural elements in the cervical spinal canal are crowded and may become mildly to severely compressed.
Magnetic resonance imaging, computed tomography, or X-rays reveal cervical spondylosis in up to 95% of persons older than age 65. Yet most people with the condition lack signs and symptoms. When these do arise, the most common are neck pain and manifestations of radiculopathy (nerve root irritation or compression resulting in upper extremity symptoms) or myelopathy (spinal cord dysfunction cord resulting in neurologic deficits).
Radiculopathy may cause pain, weakness, or paresthesias varying from mild to severe. Patients describe the pain a deep aching or stabbing pain down the arm. It occurs in a dermatomal distribution and usually affects both arms. Paresthesia may cause numbness, tingling, or a pinprick sensation.
Myelopathy may result in little or no dysfunction—or severe dysfunction, with any of the following:
- gait disturbance
- difficulty with fine motor coordination
- clumsiness of the hands
- spasticity of the lower extremities
- motor weakness of all extremities
- urinary and bowel dysfunction.
Cervical symptoms usually are mechanical in nature, worsening with activity and easing with rest. Patients describe them as deep and agonizing. The pain may be so severe that patients are reluctant to turn their head to speak. They may grasp the back of the neck to demonstrate the location. In some cases, pain radiates into the head, causing cervicogenic headaches.
Signs and symptoms of cervical spondylosis usually have an insidious onset, and patients notice a slow progressive decline. (See the box below.)
On physical examination, you may find some or many of the following:
- clonus or spasticity of the lower extremities
- sensory changes (light touch, pinprick sensation, or temperature dysfunction)
- generalized weakness throughout muscle groups, especially in the extremities
- poor or pathologic tandem gait
- atrophy of the hand’s thenar prominence (the fleshy fat pad just superior to the thumb on the ventral portion of the hand)
- positive L’Hermitte’s sign (shock-like sensations down the spine or arms with rapid neck flexion or extension).
- In an otherwise asymptomatic patient, hyperreflexia, a positive Babinski test, and a positive Hoffman’s sign (hand contraction in response to tapping on distal finger joints) are early signs of cervical spondylosis. But some patients may have only mild symptoms—or none at all—despite MRIs showing severe cervical spondylosis with spinal-cord compression.
- Cervical spondylosis is diagnosed from radiologic tests, which may include cervical X-rays, computed tomography scans, magnetic resonance imaging (MRI) scans, and myelography. The condition can be diagnosed from characteristic MRI and X-ray findings, which typically reveal loss of disc height, osteophyte formation, foraminal stenosis, subluxations, and loss of lordosis or kyphosis.
Cervical spondylosis with myelopathy can be recognized early and treated either medically or surgically; waiting until later stages for treatment may make recovery less likely. If the condition progresses rapidly and causes loss of function, early treatment should be considered. Treatment may vary greatly depending on correlation of diagnostic findings with signs and symptoms. Referral for surgery depends on such factors as the degree of the patient’s neurologic dysfunction and provider preference.
Whether to use medical or surgical intervention is controversial. When surgery is recommended, the particular surgical approach may differ from one surgeon to the next. For a patient with early signs and symptoms of myelopathy, some clinicians may recommend surgery, whereas others may recommend conservative therapy first—a “watch and wait” approach to see if symptoms worsen. If symptoms persist or don’t improve to an acceptable degree with an observational or conservative approach, surgery may be recommended.
In mildly to moderately symptomatic patients, medical management usually begins with medications and physical therapy. Muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics commonly are used to treat cervical spondylosis and associated signs and symptoms. Anticonvulsants and antidepressant drugs may be given to treat neuropathic pain associated with spinal-cord and nerve-root compression.
Some physicians prescribe cervical collars to minimize injury in the event of a fall or other accident. Collars also may reduce pain by limiting motion and relieving the burden on supporting muscles. But their use can cause muscle atrophy and a decreased range of motion (ROM), ultimately leading to worse pain and contributing to worsening spondylosis.
After 6 to 12 weeks of conservative therapy, the patient should be able to determine if symptoms have improved, worsened, or stayed the same. If conservative therapy doesn’t help or if symptoms worsen during this interval, surgery may be recommended.
The goal of surgery is to arrest symptom progression and if possible, restore lost function. Depending on diagnostic findings, correlation with the patient’s signs and symptoms, and the surgeon’s preference, one of several approaches may be used.
The ultimate surgical treatment is to take pressure off the neural elements by removing bone and decompressing the spinal cord. Once that occurs, the spinal elements and bone must be restabilized with a spinal fusion procedure.
For a patient with neurologic deficits associated with cervical spondylotic myelopathy, decompression is the goal of surgery. Decompression may take place using a ventral approach to the cervical spine (discectomy or corpectomy), a dorsal approach (laminectomy or osteotomy), or both. In most cases, the patient requires a procedure to restabilize and correct the deformity, called arthrodesis or fusion.
Not all spinal fusion procedures are the same. For an elderly patient with cervical spondylosis and myelopathy, the fusion is usually instrumented. To relieve spinal-cord compression, bone is removed at multiple levels and the spine is restabilized with instrumentation. Various devices may be used, including screws, rods, cages, cadaver bone, or an autograft (the patient’s own bone).
Preoperative and perioperative care
Discuss with patients what to expect before, during, and after surgery. Explain the potential risks, complications, and expected outcomes. Encourage patients to strive to be in the best physical condition possible. Inform them that they must obtain formal medical clearance for general anesthesia and surgery.
Instruct patients to stop taking anticoagulants (including NSAIDs and herbal preparations) and to stop smoking before surgery, as instructed by the surgeon. Urge them to make arrangements for help at home after discharge. In some cases, patients may undergo special preoperative testing, such as vocal evaluation before ventral surgery to check for impaired vocal cords and anesthesia evaluation for fiberoptic intubation in cases of severe spinal-cord compression.
Inform the patient that intraoperative care commonly includes administration of antibiotics and patient positioning. Usually a supine or prone position depending on the surgical approach, with careful attention to pressure points and genitalia.
Postoperative nursing care
Postoperative responsibilities include neurologic assessment, monitoring for procedure-related complications, pain management, incision care, mobilization, constipation prevention, and discharge education. Perform neurologic assessment at intervals ordered, focusing on extremity strength and movement. Compare results to preoperative findings and correlate them with the surgical procedure performed.
Monitor for complications, including incisional hematoma, cerebrospinal fluid leakage, and wound infection. Complications specific to ventral surgery include problems with airway patency, difficulty swallowing, and vocal hoarseness. After surgery using the dorsal approach, monitor the incision site and ensure proper drain management because of the large amount of drainage expected.
Pain control is essential after spinal fusion surgery, which causes significant pain. Initially, most patients receive analgesics I.V., I.M, or by a patient-controlled analgesia (PCA) unit, and then transition to oral medications. As ordered, administer other drugs, which may include muscle relaxants and NSAIDs. For neuropathic pain, expect to give anticonvulsants and antidepressants. Other pain-management techniques may include heat or ice application and frequent position changes.
Postoperative ambulation and mobility are crucial to help control the patient’s pain and decrease the risk of complications associated with bed rest. Mobility can vary greatly and may depend on the level of preoperative mobility and procedure performed. Patients are at increased risk of constipation due to analgesics, anesthesia, and reduced mobility.
Incision care varies with the procedure. Keep the incision site clean and dry. If drains are present, know that output should decrease daily. Monitor for signs and symptoms of infection.
Be aware that a physical therapist should evaluate the patient the day after surgery. Occupational therapy should be ordered as needed; some patients have no postoperative upper-extremity deficits or symptoms. Cervical collar use depends on the surgeon’s preference and type of procedure performed. Some patients may require acute or subacute inpatient rehabilitation before discharge. Elderly patients should expect to need assistance at home for several weeks after surgery, even after discharge from a rehabilitation facility.
When providing discharge teaching, discuss limitations and restrictions set by the surgeon, such as permitted cervical-spine ROM, use of a cervical collar, driving, medication management, and return to activities of daily living. Instruct patients to report wound drainage, fever, or other signs or symptoms of infection, severe pain, or new neurologic decline or deficit. (For prognosis, see the box below.)
Going the nonsurgical route
A patient who’s mildly to moderately myelopathic with stable symptoms may opt not to have surgery unless symptoms become unstable and a downward neurologic decline resumes. Such a patient commonly asks, “What’s my risk for becoming paralyzed?” This question can’t be answered definitively. But it’s reasonable to tell patients they have a slightly higher risk of neurologic injury or compromise than persons without cervical spondylosis. (At the same time, you might want to remind them we’re all at risk for catastrophic injury each time we walk across the street or drive a car). Despite their slightly elevated risk, patients with stable mild to moderate symptoms should be able to live without severe restrictions and continue to engage in enjoyable activities without fearing a catastrophe.
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Ann M. Harrington Henwood is a Clinical Nurse Specialist at the Center for Spine Health at the Cleveland Clinic in Cleveland, Ohio.