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Cervical spondylosis

 

Spondylosis, or spinal arthritis, is a medical term for the general 'wear and tear' that occurs in the joints and bones of the spine as people get older.

Cervical spondylosis refers to these age-related changes that occur in the neck (the cervical spine).

Cervical spondylosis occurs normally as you age and does not usually cause symptoms. Changes of spondylosis can be found in 15% of people in their twenties and 85% of all patients over the age of 60. Even changes on an X-ray, like disc bulges and prolapses, are common in people with no neck pain.

In some people, however, the changes of cervical spondylosis can be responsible for stiffness and pain in the neck that may spread to the shoulders and the base of the skull.

Cervical spondylosis can also, more rarely, lead to squashing of nearby nerves or the spinal cord (main bundle of nerves protected by the spine), leading to symptoms such as:

  • pain radiating from the arms, and pins and needles
  • loss of feeling in your hands and legs
  • loss of co-ordination and difficulty walking

Who is at risk?

Cervical spondylosis is an age-related condition. It is estimated that nearly all men and women will have evidence of cervical spondylosis on an X-ray by the time they reach the age of 70.

Only some people experience symptoms related to cervical spondylosis. Others have very marked cervical spondylosis on an X-ray and have no symptoms at all. 

Outlook

The pain and symptoms of cervical spondylosis vary from person to person and follow a pattern of 'good days' and 'bad days'.

In most cases, symptoms can be controlled using over-the-counter medication (such as ibuprofen or paracetamol) and exercise.

In more severe cases, where there is evidence of damage to the nerves, surgery may be needed.

Almost everyone develops cervical spondylosis as they get older and it usually does not cause symptoms.

Most people with symptoms caused by cervical spondylosis only experience episodes of neck pain and stiffness. Pain usually comes and goes, with flare-ups followed by symptom-free periods. Some people develop chronic (long-lasting) pain.

Occasional headaches may occur, which usually start at the back of the head, just above the neck, and travel over the top to the forehead.

Other more severe symptoms usually only occur if:

  • a slipped disc or other bone pinches or irritates a nearby nerve (known as cervical radiculopathy)
  • the spinal canal (bones that surround and protect the nerves) becomes narrower, compressing the spinal cord inside (known as cervical myelopathy)

These problems are described in more detail below.

Cervical radiculopathy

If a section of nerve becomes significantly pinched or irritated, this can cause pain down the entire length of the nerve in the arm. The pattern of pain will vary depending on which nerve is affected. You may also experience numbness in the part of the body the nerve travels to.

Cervical myelopathy

Cervical myelopathy occurs when severe cervical spondylosis causes narrowing of the spinal canal (also known as stenosis) and compression of the spinal cord.

When the spinal cord is compressed, it interferes with the signals that travel between your brain and the rest of your body. If it is not treated, it can lead to permanent spinal cord damage and long-term disability.

Symptoms can include:

  • a lack of co-ordination, for example you may find tasks such as buttoning a shirt increasingly difficult
  • heaviness or weakness in your arms or legs
  • problems walking

 

The biggest misunderstanding about cervical spondylosis is that it always causes symptoms. In fact, people with a lot of neck pain don't seem to have much more cervical spondylosis than people without neck pain. People with severe spondylosis may also have no neck pain.

It also used to be thought that cervical spondylosis could press against blood vessels, affecting the flow of blood to the brain and causing episodes of dizziness or brief blackouts. In fact, these ideas have been shown to be inaccurate.

Age-related changes of the spine

To better understand the causes of cervical spondylosis, it is useful to know more about the structure of your spine.

The spine is made up of:

  • vertebrae: ridge-shaped sections of bone that make up the structure of the spine (spinal column) and protect the nerves
  • discs: discs of tissue that have a tough, flexible outer shell and a softer inside that is the consistency of toothpaste. They lie in between the vertebrae, cushioning and supporting them
  • spinal cord: the main bundle of nerves carrying messages up and down your spine, between the brain and the rest of the body
  • nerve roots: the beginning sections of the nerves that come out of the spinal cord, exiting through 'key holes' all the way down the spine

As you get older, the discs tend to bulge and become susceptible to tears. Your body will also try to compensate for the wearing of the joints by producing small lumps of extra bone to better support your neck and stiffen the spine. These lumps of extra bone are known as bone spurs or osteophytes.

Osteophytes can cause the spine to become too rigid, leading to stiffness and neck pain. The changes in bone structure can also squash nearby nerves and the spinal cord. This tends to be more common in older people.

Herniated (slipped) disc

A slipped disc, also called a prolapsed or herniated disc, occurs when one of the discs of the spine is ruptured (splits) and the softer inside spills out.

If this soft material presses against a nerve in the neck, it can cause severe radiating arm pain, and can occasionally result in compression of the spinal cord (cervical myelopathy). This is generally seen in younger people and is not as common as the process of osteophyte formation described above.

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Cervical spondylosis is usually suspected if there are typical symptoms of neck pain and stiffness. It will also be considered as a cause of radiating arm pain, problems with the use of the hands or difficulty walking.

Various tests, which are outlined below, can be used to rule out other conditions and confirm the diagnosis.

Physical examination

Cervical spondylosis can limit the range of movement in your neck. Your GP may ask you to try and rotate your head from side to side and tilt your head towards your shoulders.

Your GP may also test your reflexes in your hands and feet and check you have full sensation in all your limbs. Problems with your reflexes or a lack of sensation could indicate nerve damage.

Your GP may also study how you walk, as cervical myelopathy can often affect walking and balance.

X-ray

An X-ray may show characteristic features of spondylosis, such as the presence of osteophytes (lumps of extra bone).

However, the spinal cord and nerve roots cannot be seen on an X-ray, and X-rays cannot show a herniated disc.

MRI scans

Magnetic resonance imaging (MRI) scans are arranged if your radiating arm pain is severe and not settling, or if your doctor is concerned about cervical myelopathy.

The spinal cord and nerve roots can be seen on an MRI scan, which can also show a herniated disc.

Myelogram

An X-ray dye is injected inside your spine to make the spinal cord and nerve roots more visible during an X-ray or CT scan. This procedure is known as a myelogram.

It is an invasive test (involves going into the body) and requires admission to hospital as a day case. It is only done if an MRI scan is not possible or, occasionally, after an MRI scan when a specialist requires additional information if surgery is being considered. 

Treatment for symptoms due to cervical spondylosis aims to relieve pain and prevent any permanent damage to your nerves.

Pain relief

Over-the-counter painkillers

Non-steroidal anti-inflammatory drugs (NSAIDs) are thought to be the most effective painkillers for symptoms due to cervical spondylosis. The NSAID ibuprofen is normally recommended instead of aspirin, as there is less chance of adverse side effects.

However, NSAIDs may not be suitable if you have asthma, high blood pressure, liver disease, heart disease or a history of stomach and digestive disorders. In these circumstances, paracetamol would probably be more suitable. Your pharmacist or GP will be able to advise you.

Codeine

If your pain is more severe, your GP may prescribe a mild opiate painkiller called codeine. This is often taken in combination with NSAIDs or paracetamol.

A common side effect of taking codeine is constipation. To prevent constipation, drink plenty of water and eat foods high in fibre, such as wholegrain bread, brown rice, pasta, oats, beans, peas, lentils, grains, seeds, fruit and vegetables.

Codeine may be unsuitable for a number of people, especially if taken for long periods of time. Your GP will be able to advise whether it safe for you to take codeine.

It is generally not recommended for people who have breathing problems (such as asthma) or head injuries, particularly those that increase the pressure in the skull.

Paracetamol

Paracetamol is a medicine that is used to ease mild to moderate pain or to control a fever. It works as a painkiller by affecting chemicals in the body called prostaglandins. Prostaglandins are substances released in response to illness or injury. Paracetamol blocks the production of prostaglandins, making the body less aware of the pain or injury. Paracetamol reduces temperature by acting on the area of the brain that is responsible for controlling temperature.

Muscle relaxants

If you experience spasms, when your neck muscles suddenly tighten uncontrollably, your GP may prescribe a short course of a muscle relaxant such as diazepam.

Muscle relaxants are sedatives that can make you feel drowsy and dizzy. If you have been prescribed diazepam, do not drive. Also, do not drink alcohol as the medication can exaggerate its effects.

Muscle relaxants should not be taken continuously for longer than a week to 10 days at a time.

Amitriptyline

If pain persists for more than a month and has not responded to the above painkillers, your GP may prescribe a medicine called amitriptyline.

Amitriptyline was originally designed to treat depression, but doctors have found that a small dose is also useful in treating pain. You may experience some side effects when taking amitriptyline, including:

  • drowsiness
  • dry mouth
  • blurred vision
  • constipation
  • difficulty urinating

Do not drive if amitriptyline makes you drowsy. Amitriptyline should not be taken by people with a history of heart disease.

Gabapentin

Gabapentin (or a similar medication called pregabalin) may also be prescribed by your GP for helping radiating arm pain or pins and needles caused by nerve root irritation. This medicine is otherwise used as an anti-epileptic drug.

Some people may experience side effects that disappear when they stop the medication, such as a skin rash or unsteadiness. Gabapentin needs to be taken regularly for at least two weeks before any benefit is judged.

Injection of a painkiller

If your radiating arm pain is particularly severe and not settling, there may be an option of a 'transforaminal nerve root injection', where steroid medication is injected into the neck where the nerves exit the spine. This may temporarily decrease inflammation of the problem nerve root and reduce pain.

Side effects include headache, temporary numbness in the area and, in rare cases, spinal cord injury (limb paralysis).

Your GP would have to refer you to a pain clinic if you wished to explore this as an option.

Exercise and lifestyle changes

You could consider:

  • doing low-impact aerobic exercises such as swimming or walking
  • using one firm pillow at night to reduce the strain on your neck
  • correcting your posture when standing and sitting

The long-term use of a neck brace or collar is not recommended as it can make your symptoms worse. Do not wear a brace for more than a week, unless your GP specifically advises you to.

Surgery

Surgery is usually only recommended in the treatment of cervical spondylosis if:

  • you have severe radiating arm pain that is not settling and nerve root compression is shown on your MRI scan
  • you have symptoms and signs of a progressive myelopathy

Surgery can sometimes be useful for radiating arm pain due to cervical spondylosis, but it does not benefit neck pain. Most people with radiating arm pain and cervical radiculopathy will actually get better themselves eventually. Therefore the idea of surgery is simply to speed up natural recovery.

Cervical myelopathy does not always need an operation either. If the symptoms are mild or not progressing, it may be better to leave things alone and 'wait and see'.

If surgery for cervical myelopathy is carried out, the surgeon will usually tell the patient that the operation is to stop things getting worse rather than to improve any symptoms that have already occurred.

The type of surgery used will depend on the underlying cause of your pain or nerve damage, such as a slipped disc or a narrowing of your spinal canal. Surgical techniques that may be used include:

  • Anterior cervical discectomy, which is used when a slipped disc or osteophyte (lump of extra bone) is pressing on a nerve. The surgeon will make an incision in the front of your neck and remove the problem disc or piece of bone. This procedure results in a fusion across the disc joint.
  • Cervical laminectomy. The surgeon will make an incision (small cut) in the back of your neck and remove the pieces of bone contributing to compression of your spinal cord.
  • Cervical foraminotomy. This is where a particular nerve root is released by making a cut in the back of your neck. It is used in more select circumstances than an anterior cervical discectomy.
  • Prosthetic intervertebral disc replacement. This relatively new surgical technique involves removing a worn disc in the spine and replacing it with an artificial disc. The results of this technique have been promising, but as it is still a very new technique, there is no evidence about how well it works in the long term or whether there will be any complications.

Like all surgical procedures, surgery on the cervical spine carries some risk of complications, including:

  • rare complications associated with general anaesthetic, such as heart attack, blood clot in the lung or an allergic reaction
  • paralysis, which could occur if there is bleeding into the spinal canal after surgery or the blood supply of spinal nerves is damaged
  • infection of your wound after surgery, which is not usually serious and can be treated with antibiotics (deeper spinal infection is more serious but very rare)
  • damage to nerves and blood vessels, which occurs in rare cases

If it is decided that you could benefit from surgery, your consultant will discuss the specific risks and benefits in your situation.


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.