Degenerative Cervical

Disease

Anatomy
Overview

Spine
5 regions
Function: axial
support for the
body and balance
Protect spinal
cord
Flexible motion
Also known as
vertebral column

Cervical Vertebrae
7 cervical
vertebrae
Identified as C1C7
First 2 are called
atlas and axis
because they
perform different
functions
Atlas has no body and allows you to nod yes
Axis acts as the pivot for the rotation

Thoracic
Larger than
cervical
vertebrae
Articulate to
ribs
T1-T12
1-Vertebral Body 2-Spinous Process 3-Transverse Facet
4-Pedicle 5-Foramen 6-Lamina 7-Superior Facet

Intervertebral Discs
Pads of flexible
fibrocartilage
which separate
individual
vertebrae
Cushion
vertebrae,
absorb shocks,
allow for spine
flexibility

Intervertebral Discs
It is composed of :
1- Annulus fibrosus: fibrous
,tough, outer layer

2- Nucleus pulposus:
gelatinous part, with 80%
water, which decrease with
aging.

Structure changes with age;

In a young person, ~90% is water
Spongy and flexible

Water content decreases with

age, discs become harder and
less compressible
More susceptible to herniated, or
slipped, discs

Ligaments
Vertebra are also stabilized by the
following ligaments:
1- Anterior longitudinal ligament
2- Posterior longitudinal ligament
3- Ligamentum flavum; between
laminea, the strongest one.
4- Interspinous ligament; between
inner surface of spinous process.
5- Supraspinous ligament;
between tips of the spinous
process.
6- Intertransverse ligament;
between transverse processes

Facet Joints
Each vertebra has two sets of
facet joints. One pair faces
upward (superior articular facet)
and one downward (inferior
articular facet).
There is one joint on each side
(right and left).
Facet joints are hingelike and link
vertebrae together.
They are synovial joints.
This means each joint is surrounded
by a capsule of connective tissue
and produces a fluid to nourish and
lubricate the joint.

The joint surfaces are coated with

cartilage allowing joints to move
or glide smoothly articulate
against each other.

Cervical degenerative
disease
Cervical spine disorders predominantly cause
neck pain and/or arm symptoms.
Cervical disc prolapse and cervical spondylosis
are the two common cervical spine disorders.
Degenerative changes in the vertebral column
are the basic underlying pathological processes
in both these conditions.
the critical clinical feature depends on whether
there is nerve root entrapment causing arm pain
and/or focal signs of neural compression in the
upper limb.

Cervical disk prolapse

Anatomy and
pathology:
The structure of the
cervical disc consists of an
internal nucleus pulposus
surrounded by the external
fibrous lamina, the annulus
fibrosus.
The role of trauma in the
degenerative process and
disc herniation is not clear.
It is probable that
repetitive excessive
stresses do exacerbate the
normal ageing process and
cause disc degeneration.

 The cervical disc prolapse is

usually in the posterolateral
direction, because the strong
posterior longitudinal
ligament prevents direct
posterior herniation.
C1 nerve root leaves the
spinal canal between the skull
(the foramen magnum) and
the atlas, and the C8 root, for
which there is no
corresponding numbered
vertebra, passes through the
C7/T1 foramen.

 Clinical presentation:
The characteristic presenting features of a patient with an
acute cervical disc herniation consist of neck and arm pain
and the neurological manifestations of cervical nerve root
compression.
The pain begins in the cervical region then radiates to the
periscapular region and shoulder down to the arm
(brachial neuralgia )
The neck pain commonly regresses while the radiating arm
pain becomes more severe. deep, boring or aching
pain
sensory disturbance, particularly numbness or tingling in
the distribution of the dermatome affected.

 Examination features:
Cervical spine movements will be restricted and the head is
often held rigidly to one side
Usually moderately flexed, and tilted towards the side of the
pain in some patients but occasionally away from it in
others. Lateral tilt relaxes the roots on the side of the
concavity but diminishes the intervertebral foraminae, and
flexion slightly separates the posterior part of the
intervertebral space and lessens the tension in the prolapse.
If the disc herniation is long standing there may be wasting
in the appropriate muscle group, particularly the triceps in a
C7 root lesion.
The patient is then examined for weakness in each of the muscle groups

 The deep tendon reflexes provide

objective evidence of nerve root
compression in the following
distribution.
Biceps reflex C5
Brachioradialis (supinator) reflex C6
Triceps reflex C7

Summary of clinical features:

*C6/C7 prolapsed intervertebral disc (C7 nerve root)
Weakness of elbow extension
Absent triceps jerk
Numbness or tingling in the middle or index finger.
*C5/6 prolapsed intervertebral disc (C6 nerve root)
Depressed supinator reflex
Numbness or tingling in the thumb or index finger
Occasionally mild weakness of elbow flexion.
*C7/T1 prolapsed intervertebral disc (C8 nerve root)
Weakness may involve long flexor muscles triceps, finger extensors and intrinsic
muscles
Diminished sensation in ring and little finger and on the medial border of the hand
and forearm
Triceps jerk may be depressed.

 A full neurological examination must be

performed and particular care taken to assess the
presence in the lower limbs of long tract signs,
such as increased tone, a pyramidal pattern of
weakness, hyperreflexia or an upgoing plantar
response.
If there is a cervical disc herniation these
features will indicate that it is compressing the
spinal cord.

 Spinal cord compression due to cervical disk

prolapse:
Central posterior cervical disc herniation causes a
rapidly progressive paralysis with upper motor neurone
features below the level of the compression and lower
motor neurone features at the level of the compression.
The patient often presents following the sudden onset of
severe neck pain with rapidly progressive paralysis.
Urgent MRI is the best investigation and will show the
disc prolapse and anterior cord compression, which is
usually at the C5/6 or C6/7 level
Urgent surgery is necessary to relieve the compression.

 Radiological investigations:
High-quality MRI is now the investigation of choice and
has almost completely replaced both myelography and
CT
The cervical myelogram using water-based non-ionic
iodine contrast material was a most useful investigation
for determining the presence and site of the disc
herniation
CT scanning by itself is frequently not helpful, but if
performed following intrathecal iodine contrast it will
demonstrate a disc herniation, and smaller volumes of
intrathecal contrast are necessary than with
myelography

Differential diagnosis:
cervical nerve root compression by a spinal
tumour (e.g. meningioma, neurofibroma)
thoracic outlet syndrome
Pancoasts tumour infiltrating the roots of the
brachial plexus
peripheral nerve entrapments, such as carpal
tunnel
syndrome, median nerve entrapment in the cubital
fossa

 Management:
conservative treatment:
This should include bed rest, a cervical collar, simple analgesic
medication, non-steroidal anti-inflammatory medication and muscle
relaxants.
The following are indications for further investigation and surgery.
1 Pain:
(a) continuing severe arm pain for more than 10 days without benefit
from conservative therapy
(b) chronic or relapsing arm pain.
2 Significant weakness in the upper limb that does not resolve
with conservative therapy.
3 Evidence of a central disc prolapse causing cord compression
this should be investigated urgently.

 Surgery :
1) Cervical foraminotomy with excision of
the disc prolapse.
Advantages :
the nerve is directly decompressed both
by removal of the disc herniation and by
enlargement of the foramen
Disadvantages :recurrent disk herniation

 Anterior cervical discectomy:

Fusion at the level using bone taken from
the iliac crest, bovine bone, artificial bone.
Major disadvantage is that the fusion will
result in additional stress at the adjacent
cervical levels, thereby rendering them
more prone to degenerative disease.
An anterior approach with disc excision is
mandatory for a central disc protrusion.

Cervical spondylosis
Cervical spondylosis is a degenerative arthritic
process involving the cervical spine and affecting
the intervertebral disc and the facet joints.
Radiological findings of cervical spondylosis are
present in 75% of people over 50 years of age
who have no significant symptoms referable to
the cervical spine.

Pathological changes
1) Reduced water
content and
fragmentation of the
nuclear portion of the
cervical discs are
natural ageing
processes
2)Degeneration of the
disk result in greater
stress on the articular
cartilages of the
vertebral end-plates

 3) osteophytic spurs develop

around the margins of the
disintegrating end-plates,
projecting posteriorly into the
spinal canal and anteriorly into
the prevertebral space.
The intervertebral foramen
may be narrowed by these
osteophytes, so causing
compression of the nerve root.
(hard disk protrusion)
Narrowing of spinal canal may
result from spondylitic
processes (osteophytes and
hypertrophy of ligamentum
flavum) this may result in
compression of spinal cord
(cervical myelopathy )

Presenting features
1)Neck pain
2)Radiating arm pain
3)cervical myelopathy

Neck pain
This is the most common clinical manifestation of
cervical spondylosis and its onset may be
precipitated by minor trauma.
The pain usually settles over a period of a few
days or weeks but frequently recurs and is
associated with increasing stiffness of the neck.

Radiating arm pain

Brachial neuralgia results from a nerve root being
compressed in the neural foramen by osteophyte
formation
The clinical features are similar to the neuralgia
caused by an acute soft disk prolapse
There may be other features of nerve root
compression, including numbness and tingling in the
appropriate dermatome distribution, and weakness
of the arm.
Wasting of a muscle group in the appropriate nerve
root distribution is more common because of the
longer history

Cervical myelopathy
o Cervical myelopathy results from cervical cord
compression due to a narrow cervical vertebral canal.
o Causes of narrowing canal :
congenital narrowing
cervical spondylosis involving hypertrophy of the facet
joints and osteophyte formation
hypertrophy of the ligamenta flava
bulging (or prolapse) of a cervical disc
o The myelopathy results from:
direct pressure on the spinal cord
ischaemia of the cord due to compression and
obstruction of small vessels within the cord

 Clinical features:
1) Neck pain.
2) Muscular weakness:
The patient initially notices clumsiness involving the hands and
fingers, particularly in fine skilled movements According to the
level and extent of the cord lesion the signs in the upper limbs
will be predominantly of a lower or upper motor neurone type
and there will be a spastic paraparesis of the lower limbs.

3) Sensory symptoms:
diffuse numbness and paraesthesiae in the hands and fingers.

Radiologic findings

narrowing of the disc

space (the C5/C6 and
C6/C7 levels are the
most commonly affected)
osteophyte formation
with encroachment into
either the spinal canal or
neural foramen
reduced mobility at
positions of fusion and
increased mobility at
adjacent levels.

 The indications for further radiological

investigations depend on the clinical
presentation.
CT scan is not indicated for the
investigation of cervical spondylosis which
is causing only neck pain.
Nerve root entrapment, causing arm pain,
is best visualized by high-quality MRI.

Management
Neck pain due to cervical spondylosis
The pain usually resolves with simple
conservative measures, including the use of nonsteroidal anti-inflammatory medication and
simple analgesics.
During an acute episode the patient may be more
comfortable in a soft cervical collar.
As the pain subsides the patient should be
encouraged to perform simple mobilizing
exercises which may be best undertaken with
the supervision of a physiotherapist.

 Arm pain
The symptoms frequently settle with the management
described above. The following are indications for
surgery :
Severe pain that does not settle with conservative
treatment over 23 weeks.
Chronic or recurrent pain.
Progressive weakness in the arm which causes
functional disability.
The most frequently involved nerve root producing
significant functional weakness is the C7 root

 Surgery:
1) Cervical foramenotomy : with
decompression of the nerve root,
excision of the osteophytes and
enlargement of the neural foramen, is
an effective surgical technique.
2)anterior cervical discectomy :
with excision of the osteophyte
extending into the neural foramen.

Thoracic disc disease

less common than at the cervical and lumbar regions.
Despite the decreased mobility and increased stability of
the thoracic compared with the cervical and lumbar spine,
it is still subject to the overall stresses applied to the
spine as well as the processes of aging.
As in other spinal levels, this degeneration can manifest
as osteophyte formation or disc herniation.
Radicular pain, back pain, spasticity, and bowel or bladder
dysfunction are all common manifestations of thoracic
disc disease.

Causes
The progressive wear and tear that is noted with
degenerative disc disease increases the risk of
injury via trauma.
Contributing factors to disc injury include the
following:

Age
Trauma
Smoking
Obesity
Sedentary lifestyle
Poor physical fitness

Follow Up
Prevention
Exercises; including cardiovascular training
and abdominal/lumbar muscle training, are
the primary preventive measure for thoracic
disc disease.

Prognosis
Thoracic disc disease is essentially self-limiting
and rarely requires surgical intervention. Most
cases resolve within the first 4-6 weeks
following onset.