Cervical spondylosis (Acquired cervical spinal stenosis, Cervical spondylotic myelopathy)

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Spondylosis is a chronic disease of the spine in which there is severe thinning and wear of the intervertebral disc, which leads to the formation of bone outgrowths called osteophytes on the surfaces of the vertebral bodies. In advanced cases, they grow so much that they begin to come into contact with each other and grow together. The result of such processes is the fusion of two or more vertebrae into a single conglomerate, which leads to their complete immobilization.

Previously, spondylosis was regarded as an age-related disease. It was mainly diagnosed in older people over 65 years of age. But today the disease occurs both in older age groups and in very young people. Already at the age of 45, 20–35% of people have this disease, and recently it has been detected even in 25-year-olds.

Most often, spondylosis is diagnosed in men.

Causes and features of the development of spondylosis

The pathology is a direct consequence of degenerative changes in the intervertebral discs, i.e. osteochondrosis. Scoliosis, pathological kyphosis or lordosis, as well as the presence of certain systemic diseases increases the risk of its development. Thus, spondylosis can be partly called the final stage in the progression of osteochondrosis. Therefore, it is most typical for people leading a sedentary lifestyle, in particular, office workers and drivers.

Under the influence of various factors, biochemical changes begin to occur in the intervertebral discs, which gradually lead to a decrease in the percentage of water and proteoglycans in them. The consequence of such processes is the destruction of collagen fibers that form the fibrous membrane and a significant reduction in the shock-absorbing capacity of the disc.

At the same time, the tone and elasticity of the ligaments decrease and their fragility increases. As a result, the pressure of the vertebrae on the disc increases, especially strongly if there are concomitant pathologies of the spine, and it begins to flatten. In this case, the spinal roots inevitably suffer, which are compressed by the surrounding tissues. This leads to the development and constant progression of neurological symptoms.

As the load on the vertebral bodies increases and depreciation decreases, they begin to grow. This is how the body tries to compensate for the changes that have occurred and the remaining intervertebral disc. This begins the process of osteophyte formation. They can have a variety of shapes, and sometimes go around the intervertebral disc, taking it into a ring.

If you do not intervene in time, the osteophytes of neighboring vertebrae will fuse with each other and form a powerful bone bracket. As a result, the vertebrae will be firmly connected, which will completely eliminate the possibility of movement in the affected spinal motion segment, and will also lead to:

• injury to tendons and blood vessels;
• circulatory disorders;
• compression of the spinal roots or even the spinal cord itself;
• development of severe neurological symptoms;
• partial or complete paralysis.

Spondylosis can affect absolutely any part of the spine: cervical, thoracic, lumbar and lumbosacral. Most often, spondylosis occurs in the cervical and lumbar spine due to their high mobility.

Possible complications

The disease itself is quite serious and difficult to treat, especially in the final stages of development. At the same time, it can provoke serious complications, which include:

• intervertebral hernia;
• spinal canal stenosis;
• back muscle atrophy;
• curvature of the spine (scoliosis, hyperkyphosis and hyperlordosis);
• radiculopathy;
• sciatica;
• paresis and paralysis;
• urinary and fecal incontinence;
• erectile disfunction;
• infertility.

Thus, spondylosis is a serious but indolent disease. It is quite easy to combat it in the early stages of development and in such situations the prognosis is most favorable. But since it lasts for a long time without causing concern to a person, it is difficult to detect changes in a timely manner. The only way out is to be attentive to your own health and take preventive measures, especially if a diagnosis of osteochondrosis has already been established. And if the slightest deviation from the norm occurs, you should immediately consult a doctor.

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Symptoms and diagnosis of spondylosis

The main manifestations of the disease are pain in the neck, chest or lower back, as well as decreased flexibility of the spine in the affected area. Pain syndrome is a direct consequence of irritation of the nerve roots by osteophytes and degeneration of the intervertebral disc.

During the disease there are 3 stages:

1. The bony protrusions do not yet protrude beyond the boundaries of the vertebra. In such situations, there are practically no symptoms or only mild pain in the affected area.
2. Osteophytes extend beyond the boundaries of the vertebral bodies. This is accompanied by the regular appearance of pain, which tends to intensify after physical activity.
3. The formation of a large bone growth connecting 2 or more vertebrae, which leads to limited mobility and strong reflex muscle tension.

Thus, spondylosis at different stages of development can make itself felt:

• sharp, piercing pain in the neck, shoulder blades or lower back, tending to radiate to the head, shoulder girdle, arms, chest or legs, respectively;
• reflex muscle tension in the area of ​​the affected spinal motion segment;
• numbness of the innervated parts of the body by nerves arising from the compressed spinal root;
• sensory disturbances, limb weakness;
• limited mobility of the back, legs (with lumbar spondylosis) and arms (with spondylosis of the cervical or thoracic spine);
• increased pain when walking, doing physical work, prolonged sitting or standing, turning the body or changing weather;
• increased fatigue;
• breathing problems, control of urination, defecation;
• decreased immunity;
• the development of diseases of internal organs, the innervation of which is carried out by nerve roots at the level of the affected spinal motion segment.

Because spondylosis affects the nerves, damage to the thoracic vertebrae can lead to the pain characteristic of angina or a heart attack.

For an experienced neurologist or vertebrologist, detecting spondylosis is not difficult, even taking into account the fact that its symptoms are similar to the clinical picture characteristic of various diseases of the internal organs. But to accurately confirm the diagnosis and choose the right treatment tactics, the patient must be referred to:

• X-ray;
• CT;
• MRI.

Based on the research data obtained, the doctor can assess the severity of the lesion and develop an adequate treatment strategy.

Treatment of spondylosis

To combat the disease, both conservative therapy and surgery can be used. The operation is a last resort, which is used only in the presence of strict indications. Therefore, initially, patients are most often prescribed conservative treatment. It is most effective in the 1st stage of spondylosis, but since at this stage the symptoms of the disease are still slightly expressed, it is rarely detected.

Conservative therapy is developed for each patient individually, taking into account the level of damage, the number of vertebrae involved in the pathological process, the presence of concomitant diseases, age and a number of other factors. Therefore, only a highly qualified specialist can correctly draw up treatment tactics and take into account all the nuances. As a rule, conservative therapy for spondylosis includes:

• drug therapy;
• exercise therapy;
• physiotherapy;
• manual therapy.

But such treatment cannot lead to a complete recovery, since the already formed bony protrusions can only be removed surgically. But conservative therapy for spondylosis makes it possible to significantly improve the patient’s condition, stop the progression of the pathology and prevent the development of complications.

Drug treatment for spondylosis

Treatment of spondylosis is very similar to the treatment of osteochondrosis, since this disease lies at the origins of the formation of osteophytes. Therefore, therapy is aimed not only at eliminating the symptoms of pathology, but also at improving metabolic processes in the structures of the spine.

Thus, patients are prescribed medications of certain groups that help slow down the progression of degenerative processes in the intervertebral discs and improve the quality of transmission of bioelectric impulses along nerve fibers. This:

• NSAIDs – help reduce the severity of pain and have an anti-inflammatory effect, used in the form of tablets, ointments, gels and injections;
• corticosteroids – have a powerful anti-inflammatory effect;
• muscle relaxants – eliminate reflex muscle spasms, which leads to a reduction in back pain;
• psychotropic drugs – increase the effectiveness of muscle relaxants and NSAIDs, and also improve the quality of sleep, have a positive effect on the psycho-emotional state of patients who often suffer from long-term and persistent spondylosis;
• chondroprotectors – contribute to the normalization of metabolic processes in the tissues of the intervertebral discs and their restoration (there is no indisputable clinical evidence of effectiveness);
• drugs that improve microcirculation in the affected area - activate blood circulation, which provides better tissue nutrition and reduces the risk of disease progression.

All medications for spondylosis are selected exclusively by a doctor who has complete data on the patient’s health status. Therefore, to reduce the side effects of certain drugs, patients are often prescribed cover with others, for example, proton pump inhibitors.

You should not self-prescribe medications. This can negatively affect the general condition and cause serious disruptions in the functioning of internal organs.

For very severe pain that is not relieved by other means, patients may be prescribed paravertebral blockades. The procedure involves injections of anesthetics and corticosteroids into the spine at strictly defined points. It is carried out exclusively in a medical facility by specially trained medical personnel, since violation of the technique of paravertebral blockades or performance in unsterile conditions is fraught with the development of severe complications.

The procedure allows you to almost instantly eliminate even very severe pain, and the injected corticosteroids have a pronounced anti-inflammatory effect. After it, the patient can almost immediately return to performing daily duties. But the blockade should be regarded solely as a means of emergency assistance. It can be done no more than 4 times a year, with some exceptions when paravertebral injections are prescribed in courses.

Exercise therapy for spondylosis

Physical therapy is one of the main areas of conservative treatment of spondylosis. Classes are held daily, but all exercises are selected strictly individually by a specialist. This takes into account not only the characteristics of the course of the disease, but also the level of physical development of the patient, his weight, type of professional activity, as well as the presence of other disorders in the functioning of the musculoskeletal system.

Initially, patients are recommended to engage in therapeutic exercises under the supervision of a doctor. He will help you master the correct technique for performing each exercise, and choose the optimal duration and frequency of classes. Only after this, patients are allowed to continue exercising at home and are explained how to properly increase the load to achieve optimal results.

Thanks to exercise therapy for spondylosis, it is possible to:

• strengthen the muscle corset and ligaments without harming the affected segment of the spine;
• reduce back muscle tension in the affected area;
• increase mobility and flexibility of the spine;
• reduce pressure on the intervertebral discs and vertebrae, which reduces compression of the nerve roots and leads to a significant improvement in the patient’s condition;
• activate blood circulation and metabolism, which creates favorable conditions for high-quality nutrition of a depleted intervertebral disc and stopping the progression of the pathological process;
• normalize the motor abilities of the arms and legs if spondylosis has led to their impairment;
• improve posture, which allows you to learn how to correctly distribute the load on the spine and reduce pressure on all intervertebral discs.

Exercise therapy is not a short-term measure. If you have spondylosis, you should do gymnastics every day until the end of your life. This will stop the progression of the disease and significantly reduce the intensity of pain. But even if it was possible to achieve complete normalization of the condition, you cannot stop daily exercise. Otherwise, relapse of the pathology cannot be avoided.

Additionally, patients may be recommended to swim.

Physiotherapy

Patients with spondylosis must undergo physiotherapeutic treatment. This, in combination with other methods of conservative therapy, makes it possible to achieve a significant improvement in the patient’s condition and stable remission of the disease. Physiotherapy for spondylosis makes it possible to:

• improve the course of metabolic processes;
• reduce or completely eliminate pain;
• remove muscle tension;
• reduce fatigue;
• improve blood circulation and lymph flow;
• eliminate swelling and inflammation;
• improve the quality of signal transmission along nerves;
• increase range of motion;
• strengthen the immune system.

For these purposes, patients are prescribed courses of physiotherapeutic procedures, the type of which, as well as the frequency and duration of the procedure, is selected individually. On average, 10 to 15 sessions are required to achieve positive dynamics and maintain the achieved results.

As a rule, patients with spondylosis are advised to:

• electrophoresis with novocaine;
• electropulse therapy;
• shock wave therapy
• electromyostimulation;
• UHF;
• magnetic therapy;
• laser therapy;
• UV irradiation.

Manual therapy

Outside the period of exacerbation of the disease, manual therapy sessions are recommended. A simple therapeutic massage for spondylosis is not effective, since it involves working only the back muscles. Manual therapy can also have a positive effect on the condition of the spine and the position of the vertebrae relative to the central axis.

Therefore it is used for:

• activation of blood circulation and metabolism in the affected area;
• increasing the distance between the vertebrae and reducing pressure on the intervertebral disc;
• eliminating the prerequisites for the progression of degenerative processes in the spine;
• eliminating compression of nerve roots;
• improved posture;
• normalization of the functioning of internal organs;
• strengthening the immune system.

Prevention

Treatment of cervical spondylosis is a long and complex process . It is easier to prevent a disease than to figure out in the future how to normalize the condition.

Basic methods of prevention:

• use of orthopedic mattresses for sleep and rest;
• yoga classes;
• swimming;
• maintaining correct posture.

It is important to walk more, while keeping your back and head straight. People working at a computer should warm up their neck and shoulders at least once every 1-2 hours: make circular movements with their shoulders, tilt their heads in different directions.

Surgery for spondylosis

Surgical intervention is recommended if conservative treatment is ineffective and there is no improvement in the patient's condition. In addition, urgent surgery for spondylosis is indicated for:

• severe spinal canal stenosis;
• severe compression of the nerve root;
• large intervertebral hernias;
• violations of control over the functioning of the pelvic organs, including the genitals, bladder and rectum;
• paresis of the limbs;
• serious disorders of internal organs caused by the development and progression of spondylosis.

In such situations, depending on the root cause of the development of spondylosis, decompression and/or stabilizing operations of various kinds can be performed:

• microdiscectomy;
• laminectomy;
• endoprosthetics;
• autotransplantation.

Microdiscectomy

Microdiscectomy is the most commonly performed operation for spondylosis, during which a thinned intervertebral disc is removed microsurgically. It involves making a minimal incision to provide access to the spine. Its size does not exceed 3 cm. This allows you to significantly minimize surgical trauma, minimize the risk of developing postoperative complications and significantly facilitate and reduce the duration of rehabilitation.

The essence of the operation is as follows:

• the patient is put under general anesthesia;
• under the control of the image intensifier, a soft tissue incision is made in the projection of the affected spinal motion segment;
• the muscles are carefully moved apart and fixed in the desired position with special instruments, this eliminates the risk of damage and helps reduce pain in the early postoperative period;
• under the control of a special surgical microscope with 8x magnification, the neurosurgeon carefully pushes back the nerve root and, using miniature surgical instruments, removes the intervertebral hernia and, if necessary, the entire disc;
• a thorough sanitation of the surgical field is carried out followed by the installation of endoprostheses or autografts;
• suturing.

Microdiscectomy takes 45–60 minutes. The duration of hospitalization is 7 days, after which the patient is discharged from the hospital. At the same time, he always receives a list of recommendations on how to behave during the rehabilitation period, what medications to take and what physical procedures to undergo.

The outcome of the operation largely depends on the correctness of the recovery period. Therefore, it is recommended not to neglect medical recommendations and undergo rehabilitation under the supervision of a rehabilitation specialist.

Laminectomy

Laminectomy is an operation designed to eliminate compression of the spinal cord and nerve roots caused by various diseases. Elimination of high pressure is carried out through resection of the vertebral arches, spinous processes and intervertebral discs. Thanks to this, they stop compressing the spinal cord and the nerve roots extending from it, which leads to normalization of the transmission of bioelectric impulses and the elimination of neurological symptoms, including pain, sensory disturbances, and paralysis.

Depending on the severity of the situation, laminectomy may remove part or all of the compressive element. This creates additional space for the spinal structures, which ensures a sufficient decompression effect. Often, to maintain normal spinal mobility and physical capabilities of the patient after laminectomy, special stabilizing systems are installed.

Often this operation is combined with other surgical interventions on the spine, in particular the correction of its deformities. But laminectomy is a highly traumatic operation, since it involves excision of important structural elements of the spine.

There are several types of laminectomy. The specific one is selected depending on the reasons for the development of spondylosis:

• hemilaminectomy – removal of the arch of one vertebra on one or both sides while preserving the spinous processes;
• interlaminar - involves incision of the yellow ligament of the spine and removal of the arches of the most affected vertebra and neighboring ones;
• total – removal of the vertebral plates with the spinous processes.

Laminectomy involves making a soft tissue incision and skeletonizing the vertebrae of the affected segments under general anesthesia. The surgeon exposes the structures to be resected: arches, spinous processes, facets.

The most complex and time-consuming process is the skeletalization of the vertebrae of the cervical spine, since the tops of their arches are bifurcated and deeply embedded in the muscles.

During laminectomy, the fascia is often injured, which complicates the recovery period. The incision made is expanded with a retractor. The exposed spinal structures are cut with special forceps and removed from the patient's body. In each case, it is individually determined which fragments must be removed in order to eliminate spondylosis. In some cases, it is enough to remove only the osteophytes and install an endoprosthesis between the vertebral bodies; in other situations, especially with very advanced spondylosis, it is necessary to resort to a total laminectomy.

Endoprosthetics

Because with spondylosis, the intervertebral discs are usually so destroyed that they are completely unable to perform their functions, they are often completely removed. But this requires the introduction of an implant to close the resulting defect. For this purpose, it is preferable to use endoprostheses that help stabilize the operated spinal motion segment, maintain mobility and shock absorption within natural values. Today they are the best alternative to spinal fusion, i.e. complete fusion of the vertebrae.

Modern prostheses completely take over the functions of the removed disc. Their huge advantage is the elimination of overload in neighboring segments and reducing the risk of developing degenerative processes in them.

Today, implants are used for endoprosthetics:

• M6;
• Bryan;
• DCI;
• DePuy et al.

The most advanced are the M6 ​​and Bryan models, which completely replicate the structure and structure of natural intervertebral discs. They are available in different sizes, which allows you to choose the most suitable prosthesis for a particular patient. Such devices are capable of qualitatively softening axial loads and providing mobility in 6 planes. Their compression and elongation indicators are not inferior to natural discs, which guarantees the preservation of normal biomechanics.

The operation is performed under general anesthesia immediately after removal of the intervertebral disc in one way or another. It takes 2–3 hours. Different types of prostheses have different installation techniques, with which the operating neurosurgeon must be thoroughly familiar. Such operations have a high level of security. With them, the risk of complications is no more than 1–2%.

You can usually move after surgery on the 5th day, and complete fusion of the endoprosthesis with the vertebral bodies is observed on average after 3 months. But for proper implantation of an expensive device, it is necessary to strictly follow the doctor’s recommendations and strictly adhere to the rules throughout the entire recovery period.

Autotransplantation

Decompression surgeries often leave behind defects that must be closed to maintain normal spinal height and support function. Sometimes, for this purpose, fragments taken from the patient’s own bones are used and placed into the resulting defect. Most often, part of the ilium is taken for these purposes.

Over time, the autograft takes root and firmly fuses with the remaining bone structures of the spine, i.e., spinal fusion is achieved. As a result, movements in the operated spinal motion segment become impossible, but when only one or two are fixed, patients usually do not notice a difference in the possible range of movements.

Nevertheless, whenever possible, spinal fusion is abandoned in favor of the installation of endoprostheses, since rigid stabilization of the spinal motion segment increases the risk of developing degenerative processes at adjacent levels of the spine. The fusion of two or more vertebrae makes significant changes in the biomechanics of the ridge, so after this often destructive processes begin or worsen in the osteochondral structures of the overlying and underlying segments.

The vertebrae can also be fixed in the desired position with metal structures, which are a set of plates and screws. As a result, spinal fusion is also achieved.

Thus, the prognosis largely depends on at what stage of development of the pathological process it was detected. With early diagnosis and the beginning of adequate treatment, the vast majority of patients manage to maintain the functionality of the spine, normal performance and continue to lead a normal lifestyle.