cervical spondylosis
Introduction
Introduction to cervical spondylosis Cervical spondylosis, also known as cervical vertebra syndrome, is a general term for cervical osteoarthritis, proliferative cervical spondylitis, cervical nerve root syndrome, and cervical disc herniation. It is a disease based on degenerative pathological changes, mainly due to long-term strain of the cervical spine. Bone hyperplasia, or intervertebral disc prolapse, ligament thickening, resulting in compression of the cervical spinal cord, nerve root or vertebral artery, a series of clinical syndromes with dysfunction. The manifestation of cervical disc degeneration itself and its secondary pathological changes, such as vertebral instability, loosening, nucleus protruding or prolapse, spur formation, ligament hypertrophy and secondary spinal stenosis, etc., stimulated or oppressed Adjacent nerve roots, spinal cord, vertebral artery and cervical sympathetic nerves, and caused a variety of symptoms and signs of the syndrome. basic knowledge The proportion of sickness: 0.4% Susceptible people: no specific population Mode of infection: non-infectious Complications: hypertension autonomic dysfunction
Cause
Causes of cervical spondylosis
Cervical disc degeneration (25%):
The main pathological changes are: early cervical disc degeneration, decreased water content of the nucleus pulposus and fibrous swelling of the annulus fibrosus, thickening, followed by hyaline degeneration, and even rupture, after cervical disc degeneration, pressure resistance and tensile resistance Decreased, when subjected to the gravity of the skull and the pulling force of the muscles of the head and chest, the degenerated disc can undergo localized or extensive bulging to the periphery, narrowing the intervertebral disc space, overlapping of the articular processes, dislocation, and intervertebral foramen The longitudinal diameter becomes smaller, because the traction resistance of the intervertebral disc becomes weaker. When the cervical vertebra moves, the stability between adjacent vertebrae decreases and the intervertebral instability occurs, the mobility between the intervertebral bodies increases and the vertebral body is light. Degree slippage, followed by posterior small joints, bone hyperplasia of the hook joint and lamina, degeneration of the ligamentum flavum and ligament, cartilage and ossification.
The cervical disc is bulging around (15%):
Because the cervical disc bulges around, the surrounding tissues (such as the anterior and posterior longitudinal ligament) and the vertebral periosteum can be picked up, and a gap is formed between the vertebral body and the protruding intervertebral disc and the ligament tissue that is picked up. "Gap", in which the accumulation of tissue fluid, coupled with the hemorrhage caused by micro-damage, makes this bloody fluid mechanized and then calcified, ossified, thus forming the epiphysis, the relaxation of the anterior and posterior ligaments of the vertebral body, and the cervical vertebrae Stable, increased the chance of trauma, the bones gradually increased, the epiphysis together with the bulging fibrous annulus, the posterior longitudinal ligament and the edema or fibrous scar tissue caused by the traumatic reaction, forming a protrusion at the equivalent of the intervertebral disc The mixture into the spinal canal may have an oppressive effect on the spinal nerve or spinal cord.
The hook joint compresses the nerve root and vertebral artery (15%):
The epiphysis of the hook joint can protrude from the anterior to the posterior to the intervertebral foramen to compress the nerve root and the vertebral artery. The epiphysis of the anterior border of the vertebral body generally does not cause symptoms, but there is also a report that the anterior callus affects swallowing or hoarseness in the literature. After the spinal cord and nerve roots are compressed, they are only functional changes at the beginning. If the pressure is not relieved in time, the irreversible changes will gradually occur. Therefore, if non-surgical treatment is ineffective, surgery should be performed promptly.
Additional instructions:
Cervical spondylosis is mainly caused by degenerative changes in the cervical disc and cervical vertebrae and their accessory structures.
The pathogenesis of cervical spondylosis, like lumbar disc herniation, cannot be explained by mechanical compression alone, and vascular and chemical factors are at work, causing edema and inflammation or aggravating neurological symptoms.
Prevention
Cervical spondylosis prevention
1. Read books about cervical spondylosis and master scientific methods to prevent and treat diseases.
2. Maintain an optimistic spirit, establish an idea of contending with the disease, and cooperate with doctors to reduce recurrence.
3. Strengthen the exercise of the neck and shoulder muscles. During the work or during work, the flexion, extension and rotation of the head and the upper limbs can alleviate the fatigue and strengthen the muscles and strengthen the toughness, thus facilitating the neck. The stability of the segmental spine enhances the ability of the neck and shoulder to conform to sudden changes in the neck.
4, to avoid bad habits of high sleep, high pillow makes the head flexion, increase the stress of the lower cervical vertebrae, there is the possibility of accelerating cervical degeneration.
5, pay attention to the neck and shoulders to keep warm, avoid head and neck load, avoid excessive fatigue, do not doze off when riding.
6, early, thorough treatment of neck and shoulder, back soft tissue strain, to prevent its development into cervical spondylosis.
7. Prevent flashing and contusion when working or walking.
8. Long-term desk workers should change their head position regularly and exercise their neck and shoulder muscles on time.
9. Pay attention to the posture of the head, neck, shoulders and back. Do not shrug your shoulders, talk, or look at the book when you read. Keep the integrity of the spine.
10, Chinese medicine believes that walnut, hawthorn meat, raw land, black sesame, etc. have the function of tonifying the kidney marrow, reasonable use of a small amount can play a strong bones and muscles, delay the kidney and joint degeneration.
Complication
Cervical spondylosis complications Complications, hypertension, autonomic dysfunction
1. Swallowing disorder: dysfunction when swallowing, foreign body sensation in the esophagus, a few people have nausea, vomiting, hoarseness, dry cough, chest tightness, etc. This is because the anterior cervical vertebra directly compresses the posterior wall of the esophagus and causes esophageal stricture. It may be caused by the stimulating reaction of the soft tissue around the esophagus due to the excessive formation of bone spurs.
2, visual impairment: manifested as decreased vision, eye pain, fear of light, tears, pupil size, and even reduced visual field and sharp vision loss, individual patients can also occur blindness, which caused autonomic nervous disorders and cervical vertebrae The ischemic lesion of the visual occipital occipital lobe caused by insufficient blood supply to the basilar artery.
3, neck and heart syndrome: manifested as pain in the precordial area, chest tightness, arrhythmia (such as stroke, etc.) and ECG ST segment changes, easily misdiagnosed as coronary heart disease, which is the stimulation and compression of the cervical dorsal root spurs by the cervical spine Caused.
4, high blood pressure cervical spondylosis: can cause blood pressure to increase or decrease, which is more high blood pressure, known as "cervical hypertension", because cervical spondylosis and hypertension are common diseases of the elderly, so two They often coexist.
5, chest pain: manifested as a slow onset of unilateral pectoralis major muscle and breast pain, examination of pectoralis major muscle tenderness, which is related to neck 6 and neck 7 nerve roots are affected by cervical vertebrae spur compression.
6, lower limb paralysis: early manifestations of lower limb numbness, pain, lameness, some patients feel like walking cotton when walking, individual patients may also be accompanied by defecation, dysuria, such as frequent urination, urgency, poor urination or urine Incontinence, etc., because the lateral beam of the vertebral body is stimulated or compressed by the neck spur, resulting in lower limb movement and sensory disturbance.
7, tripping: often when standing or walking, suddenly turned around and the body loses support and stumbles, can be quickly awake after falling to the ground, without conscious disturbances, no sequelae, such patients may be accompanied by dizziness, nausea, Symptoms of autonomic dysfunction such as vomiting and sweating. This is due to the hyperplasia of the cervical vertebrae, which causes the vertebral artery to cause the basilar artery blood supply disorder, resulting in a temporary lack of blood supply to the brain.
Symptom
Symptoms of cervical spondylosis Common symptoms Neck twisting neck pain Hands and feet numb arm numb facial lightning pain Cervical physiology curvature straightening right leg numb shoulder back heavy feeling back head pain facial muscle and neck muscle tension
The symptoms of this disease vary widely, thus causing diagnostic difficulties. The age of onset is generally over 40 years old, and those younger are less common. The onset is slow, and it does not cause attention at the beginning. It is only the neck discomfort, and some of the performances are often "sleeping". After a period of time, the upper extremity radiation pain gradually appears. Lesions of the upper cervical vertebra can cause pain in the posterior occipital region, neck stiffness, dizziness, tinnitus, nausea, hearing impairment, visual impairment, and paroxysmal coma and tripping. The epiphysis of the middle cervical vertebra can produce 3 to 5 pains in the neck and atrophy of the posterior and paraspinal muscles, and the diaphragm can also be affected. Lesions of the lower cervical vertebrae can cause pain in the posterior neck, upper back, scapular region, and thoracic region, as well as radicular pain in the neck 5 to chest. The lesion of the middle and lower cervical vertebra can compress the spinal cord and produce paralysis.
Semmes and Murphy have stimulated the posterior longitudinal ligament or annulus fibrosis during surgery to cause pain in the medial aspect of the scapula, posterior occipital region and thoracic region. Some people have procaine after the nerve root is closed and pulled open. The posterior longitudinal ligament on the object can also cause pain in the rim of the shoulder blade, shoulders, occiput, neck and chest wall. If there is no rupture of the annulus fibrosus and posterior longitudinal ligament, the pain is lighter and more ambiguous, indicating that these symptoms are not related to the nerve roots.
For the convenience of description, cervical spondylosis is divided into nerve root type, spinal cord type, vertebral artery type and sympathetic type. However, a mixed type in which various types of symptoms and signs are doped with each other is often seen in the clinic.
(a) nerve root type
This is caused by the protrusions on the posterior aspect of the cervical spine that stimulate or compress the cervical spinal nerve roots. The incidence rate is the highest, accounting for about 60% of cervical spondylosis.
There are paroxysmal or persistent pain or severe pain in the neck and neck and neck and shoulder. Along the direction of the affected cervical spinal nerve, there is a burning or knife-like pain, or an electric shock or acupuncture-like numbness. When the neck activity or abdominal pressure increases, the symptoms are aggravated. At the same time, the upper limbs feel depressed and weak. The neck has varying degrees of stiffness or painful torticollis deformity, muscle tension, and limited mobility. The affected cervical spinal nerve has tenderness at the exit below the corresponding transverse process and next to the spinous process. The brachial plexus traction test was positive, and the intervertebral foramen crush test (also known as the posterior neck test) was positive. In addition, the affected innervation area has sensory disturbances, muscle atrophy and tendon reflexes.
(two) spinal type
This is caused by the compression of the spinal cord by the protrusion. The clinical manifestation is that the spinal cord is compressed, and there are different degrees of quadriplegia, accounting for about 10 to 15%. This type of symptoms is also more complicated, mainly due to limb numbness, soreness, burning sensation, stiffness, weakness and other symptoms, and more often in the lower limbs, and then to the upper limbs. But it also occurs first on one side of the upper or lower limbs. In addition, there may be symptoms such as headache, dizziness or abnormal bowel movements. 1 unilateral compression of the spinal cord: typical spinal hemisection syndrome (Brown-séquard Syndrme) can occur. 2 bilateral compression of the spinal cord: early symptoms are mainly caused by sensory disturbances, but also those with motion disorders, and the latter are more. Later, it manifests as different degrees of upper motor neurons or nerve bundle damage, such as inflexible limbs, clumsy gait, unstable walking, and even bedridden, urinary can not self-solve. Physical examination revealed increased muscle tone in the extremities, weakened muscles, hyperreflexia, and shallow reflexes. Pathological reflexes such as Hoffmann, Babinski, etc. were positive, and sputum and sputum were positive. The sensory disorder plane often does not conform to the diseased segment and lacks regularity. In addition, the feeling of the waist and waist is also a common complaint.
(three) vertebral artery type
This is caused by the protrusion of the vertebral artery, which can be caused by the lateral epiphysis of the intervertebral disc. 2Zygapophyseal osteophytes in front of the joint. 3 unstable joint subluxation of the posterior joint may also be caused by the reflexive arterial spasm caused by the stimulation of the cervical sympathetic nerve, accounting for 10 to 15% of the cervical spine patients. Simple compression may not cause symptoms, and it is accompanied by atherosclerosis. Symptoms of vertebral artery insufficiency include paroxysmal vertigo, nausea, vomiting, etc. Symptoms occur when the head stretches back or turns the head to a certain position. And the symptoms disappear when the head turns away from the orientation. When turning the head, the patient suddenly feels weakness and falls, and when he falls, his mind is mostly awake, and the patient can often sum up the position of the attack. Brainstem symptoms include numbness of the limbs, abnormal sensation, landing of the subject, and paralysis of the contralateral limbs. In addition, there are hoarseness, aphasia, difficulty swallowing, eye muscle spasm, unclear vision, narrow vision, diplopia and Horner syndrome.
(four) sympathetic
It is caused by stimulation of sympathetic nerve fibers on the cervical spinal nerve root, meninges, and small joint capsules. Symptoms include dizziness, migratory headache, blurred vision, hearing changes, difficulty swallowing, arrhythmia and sweating disorders. It is also thought that it is caused by the stimulation of nerves on the wall of the vertebral artery, and it can also be an intermittent blood flow change of the vertebral artery, which is caused by nerves around the artery. This type of diagnosis is difficult and often requires a successful treatment test before a diagnosis can be made.
Examine
Cervical spondylosis
First, the cervical spine test
The test of cervical spondylosis is a physical examination, without the aid of instruments. It includes:
1. Pre-flexion neck test: The patient's neck is flexed forward, and it is rotated to the left and right, such as pain in the cervical vertebra, indicating that the cervical facet joint has degenerative changes.
2. Intervertebral foramen crush test (cylinder test): the patient's head is biased to the affected side, the examiner's left palm is placed on the top of the patient's head, and the right hand clenches the fist and gently rubs the left hand back, then there is radiation pain or numbness of the limb, indicating that the force is transmitted downward. When the intervertebral foramen becomes smaller, there is root damage; if the root pain is severe, the examiner puts both hands on the top of the head and presses it down to induce or aggravate the symptoms. When the patient's head is in the neutral position or the rear extension position A positive compression test is called a positive Jackson test.
3. Brachial plexus pull test: the patient bows, the examiner holds the patient's head and neck with one hand, and the other hand holds the wrist of the affected limb, pushing and pulling in the opposite direction to see if the patient feels radiation pain or numbness. This is called the Eaten test. Pulling and then forcing the affected limb for internal rotation is called the Eaten Strengthening Test.
4. Upper limb extension test: The examiner is placed on the shoulder of the healthy side to fix the other hand, and the other hand is held on the wrist of the patient, and is gradually extended backwards and outwards to increase the traction of the cervical nerve root. Radiation pain in the affected limb indicates compression or damage to the cervical nerve root or brachial plexus.
Second, X-ray examination of cervical spondylosis
Normal men over 40 years old, about 90% of women over the age of 45 have spurs of the cervical vertebrae, so there is a change in X-ray film, not necessarily clinical symptoms, now the X-ray findings related to cervical spondylosis As described later:
Orthotopic: Observing the presence or absence of pivotal joint dislocation, odontoid fracture or absence, whether the seventh cervical transverse process is too long, with or without cervical ribs, whether the hook-and-cone joint and the intervertebral space are widened or narrowed.
Third, lateral position
1. Change in curvature: The cervical vertebra is straight, and the physiological protrusion disappears or reverses.
2. Abnormal activity: In the X-ray film of the cervical vertebrae overextension and overextension, the elasticity of the intervertebral disc can be seen to change.
3. Osteophytes: Osteophytes and ligament calcification can occur in the vertebral body near the intervertebral disc.
4. The intervertebral space is narrowed: the intervertebral disc can be thinned due to the nucleus pulposus, the water content of the intervertebral disc is reduced and fibrosis is formed, and the intervertebral space is narrowed on the X-ray film.
5. Semi-dislocation and intervertebral foramen become smaller: After intervertebral disc degeneration, the stability between the vertebral bodies is low, and the vertebral body often undergoes subluxation, or is called a vertebral column.
6. ligament calcification: ligament calcification is one of the typical lesions of cervical spondylosis.
Fourth, the oblique position
The left and right oblique slices of the spine were used to observe the size of the intervertebral foramen and the hyperplasia of the hook joint.
5. Electromyography of cervical spondylosis
The electromyogram of cervical spondylosis and cervical disc herniation is due to the fact that cervical spondylosis or cervical disc herniation can cause long-term compression of the nerve root and degeneration, thereby losing the inhibition of the dominant muscle, thus losing the innervation. Muscle fiber, due to the stimulation of a small amount of acetylcholine in the body, can produce spontaneous contraction. Therefore, the fiber potential appears in the muscles of the upper limbs on one or both sides, occasionally a few bundles of tremors appear. When the force is contracted, the multiphase potential is normal, and there is no huge When the potential is contracted by force, it is completely disturbed. The average time and average potential of the motor unit potential are normal, and the amplitude is 1~2 millivolts. The cervical vertebrae cause extensive degeneration of the intervertebral disc, causing bone hyperplasia and damage to the nerve root. There are more muscles that are denervated. In patients with advanced lesions and longer course, in the case of active self-contraction, wave number reduction and amplitude reduction may occur, and cervical disc herniation is often a single disc herniation. For one of the upper limbs, the denervated muscles have a distinct segmental distribution.
Sixth, CT examination of cervical spondylosis
CT has been used to diagnose vertebral insufficiency, bone hyperplasia, vertebral rupture, ossification of the posterior longitudinal ligament, spinal stenosis, spinal canal enlargement or bone destruction, bone mass measurement to estimate bone density The degree of osteoporosis, in addition, because the transverse tomographic image can clearly see the soft tissue inside and outside the dural sheath and the subarachnoid space, it can correctly diagnose the intervertebral disc herniation, neurofibroma, spinal cord or medullary cavity The disease has certain value for the diagnosis and differential diagnosis of cervical spondylosis.
[Clinical examination] includes the following aspects.
(1) tenderness point paravertebral or spinous process tenderness, tenderness position is generally consistent with the affected segment.
(2) The range of cervical vertebra activity is the examination of flexion, extension, lateral flexion and rotational activity. The neck activity of cervical spondylotic radiculopathy is more limited, while the vertebral artery type cervical spondylosis can be active in a certain direction. Dizziness occurs.
(3) The intervertebral squeezing test allows the head of the patient to tilt to the affected side. The left palm of the examiner is placed flat on the top of the patient's head. The right hand grips the palm and gently slams the back of the left arm. If there is root pain or numbness, it is positive. In patients with severe radicular symptoms, the hands may be gently pressed against the head to cause pain, and numbness may be exacerbated.
(4) Intervertebral separation test For patients with suspected root symptoms, the patient sits, hands hold the head and pull up, if the upper limb pain is numb, it is positive.
(5) nerve root pull test. Also known as brachial plexus pull test, the patient sits, the head turns to the healthy side, the examiner holds the hand against the back of the ear, and holds the wrist in one hand and pulls in the opposite direction. If there is limb numbness or radiation The pain is positive.
(6) Hoffman's expedition to check the right arm of the patient's forearm, the index finger of one hand grips the middle finger, and the thumb is used to slam the middle finger nail. If there is a positive four-finger buckling reflex, it indicates the spinal cord and nerve damage.
(7) Spinal neck test, also known as vertebral artery twist test, patient sitting position, active rotation of the neck activity, repeated several times, if vomiting or sudden fall, it is a test positive, suggesting vertebral artery type cervical spondylosis.
(8) Sensory dysfunction examination The skin sensation examination of cervical vertebra patients can help to understand the extent of the lesions. The sensory disturbances in different parts can determine the segment of the cervical vertebrae. The pain usually appears early, and when it appears numb, it has entered the middle stage and feels completely. The disappearance is already in the late stage of the lesion.
(9) Muscle strength examination Cervical spondylosis injury nerve root or spinal cord, muscle strength decreased, if the nerves are lost, the muscle strength can be zero, according to the different nerves of each muscle can determine the location and segment of nerve damage.
Diagnosis
Diagnosis and diagnosis of cervical spondylosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory findings.
[diagnostic typing]
1, neck type:
1 main complaints, neck, shoulder pain and other abnormal feelings, accompanied by corresponding tender points.
The 2X line upper cervical vertebra showed changes in curvature or intervertebral joint instability.
3 should exclude other diseases of the neck (shoulder, frozen shoulder, rheumatic myofibrillar tissue, neurasthenia and other shoulder and neck pain caused by non-intervertebral disc degeneration).
2, nerve root type:
1 has more typical root symptoms (numbness, pain), and the range is consistent with the area dominated by the cervical spinal nerve.
2 Indenter test or brachial plexus pull test is positive.
3 The findings of imaging are consistent with clinical manifestations.
4 pain point closure is not effective (can not be diagnosed if the diagnosis is clear).
5 Excluding cervical extra-cervical lesions (thoracic outlet syndrome, tennis elbow, carpal tunnel syndrome, cubital tunnel syndrome, frozen shoulder, biceps tenosynovitis, etc.) caused by upper extremity pain.
3. Spinal cord type:
1 clinical manifestations of strong cervical spinal cord damage.
2X-ray showed the posterior margin of vertebral body hyperplasia, spinal stenosis, and imaging confirmed the presence of spinal cord compression.
3 except muscle atrophic spinal sclerosis, spinal cord tumor, spinal cord injury, secondary adhesive arachnoiditis, multiple peripheral neuritis.
4, vertebral artery type: the diagnosis of vertebral artery type cervical spondylosis is a problem to be studied.
1 had a tripping episode with cervical vertigo.
2 The neck test was positive.
3X line shows segmental instability or bone hyperplasia of the joint.
More than 4 with sympathetic symptoms.
5 except for eye-derived, otogenic vertigo.
6 Excluding the vertebral artery segment I (the vertebral artery segment before entering the neck 6 transverse process) and the vertebral artery segment III (the cervical vertebrae entering the intracranial vertebral artery segment) under pressure caused by basilar artery insufficiency.
7 vertebral angiography or digital subtraction vertebral artery angiography (DSA) is required before surgery.
5, sympathetic type: clinical manifestations of dizziness, vertigo, tinnitus, hand numbness, tachycardia, pain in the precordial area and other sympathetic symptoms, x-ray film instability or degeneration. Vertebral angiography negative.
6, other types: cervical vertebral body anterior ovary-like hyperplasia oppression caused by dysphagia (via esophageal sputum examination confirmed) and so on.
Differential diagnosis
First, nerve root type cervical spondylosis needs to be identified with the following diseases
1. Cervical rib and anterior scalene muscle syndrome: The patient is younger, mainly characterized by dry compression under the brachial plexus, numbness of the medial extremity, atrophy of the intermuscular and interosseous muscles, due to the simultaneous subclavian artery Under pressure, the affected limb is pale, cold, and the brachial artery beats weakened or disappeared. The Adson test (head turned to the affected side, temporary inspiratory after deep inhalation, weakened or disappeared radial artery beat) was positive, and the neck film confirmed the neck rib. .
2. Extramedullary subdural tumors in the spinal canal, intervertebral foramen and peripheral neurofibromatosis, and tumors near the lung tip (Pancoast tumor) can cause pain in the upper extremities, and cervical spine may find lesions in the spinal canal. Signs and intervertebral foramen enlargement without cervical degenerative changes, CT or MRI can directly display tumor images, Pancoast tlamor patients are also accompanied by Horner's syndrome.
3. Neuropathic muscle atrophy: often involving the C5 distribution area, causing severe pain, shoulder muscle weakness and atrophy, but the sensory disturbance is mild, the symptoms can often be relieved quickly, and generally do not involve the neck.
4. angina pectoris: pain can be radiated to the upper limbs and shoulders and neck, but mostly episodes, oral nitroglycerin tablets can be relieved, patients have a history of coronary heart disease, generally not difficult to identify.
5. Tendon sleeve syndrome: mainly manifested as shoulder abduction weakness and abduction more than 30, after the pain, tendon local tenderness, different from nerve root pain.
6. Rheumatic polymyalgia: similar to brachial plexus neuralgia, but without dyskinesia.
Second, cervical spondylosis should be identified with the following diseases
1. Amyotrophic lateral sclerosis: mainly with spastic quadriplegia, no sensory disturbance, and often invades the medulla and causes the lower cranial nerve symptoms.
2. Multiple sclerosis: Symptoms of brain and spinal cord often occur at the same time, and bladder dysfunction occurs before limb dyskinesia.
3. Intraspinal tumor: can occur at any age, the symptoms develop faster, a variety of imaging examinations help to identify.
4. Spiral stenosis: mainly manifested as sensory disturbance, dyskinesia appears later, MRI can clearly show the thickening of the central tube of the spinal cord.
Vertebral artery type cervical spondylosis is relatively rare, and it needs to be differentiated from vertebrobasilar insufficiency caused by other causes, such as vertebral atherosclerosis and dysplasia. Vertebral angiography is the most reliable method of identification.
