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Spinal spondylosis

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Spinal spondylosis

Spondylosis is a dystrophic process in the spine, which, unlike osteochondrosis of the spine, begins from the outer parts of the annulus fibrosus and on radiographs is manifested by the presence of marginal bone growths (osteophytes) that surround the intervertebral disc. The size of the intervertebral disc during spondylosis does not change. The contours of the vertebral bodies during spondylosis of the spine remain even. Spondylosis is localized mainly in the thoracic spine. Somewhat less often, spondylosis can be observed in the lumbar and cervical spine.

The term spondylosis refers to several similar degenerative diseases of the spine that result in compression of the cervical spinal cord and adjacent nerve roots. Spondylosis of the cervical spine with compression of the spinal cord and nerve roots is more common in older men. It is characterized by:

  • narrowing of the intervertebral disc spaces with the formation of a hernia of the nucleus pulposus or bulging of the annulus fibrosus
  • the formation of osteophytes from the posterior surface of the vertebral bodies
  • partial subluxation of the vertebrae
  • hypertrophy of the posterior longitudinal ligament and intervertebral (facet) joints

Typical changes in the bodies of the cervical vertebrae in spondylosis.

Spondylosis is commonly seen as a sign of natural aging in the body. There are also other types of spinal spondylosis:

  • static spondylosis - a consequence of early wear of the intervertebral discs due to a violation of the normal axial load (for example, as a result of an incorrectly fused spinal fracture, with kyphosis, structural scoliosis)
  • spontaneous spondylosis - due to age-related and sometimes early wear of the discs
  • reactive spondylosis - due to damage to the vertebrae by the inflammatory process

Spondylosis can be combined with osteochondrosis of the spine. In childhood and adolescence, spondylosis is relatively rare and does not play a significant role in the occurrence of diseases of the peripheral nervous system.

Bone changes occur as a result of inflammatory changes, while there are no signs of true arthritis in the patient.

Degenerative cervical myelopathy.

The "spondylotic bar" formed by osteophytes growing from the posterior surface of the vertebral bodies causes symptoms of spinal cord injury. These osteophytes cause horizontal compression of the anterior surface of the spinal cord. The growth of osteophytes in the lateral direction, accompanied by hypertrophic changes in the intervertebral joints and its introduction into the exit points of the nerve roots of the spinal cord, often leads to the appearance of radicular symptoms.

The longitudinal size of the spinal canal can also decrease as a result of protrusion and extrusion of the disc, hypertrophy, or protrusion of the posterior longitudinal ligament, which increases with extension of the neck. Even though spinal x-ray signs of spondylosis are often found in the elderly, only in a few patients they cause compression of the spinal cord and roots with the development of myelopathy or radiculopathy clinic. This may be the result of a congenital narrowing of the spinal canal.

Spondylosis is a sign of natural aging of the spine.

Spondylosis is a sign of natural aging of the spine.

The first symptoms of the spinal cord and nerve root compression in spondylosis are usually neck and shoulder pain. These complaints can be combined with the limitation of head movement. Compression of the nerve roots is accompanied by radicular pain radiating in the hand along the C5-C7 nerves. Compression of the cervical spinal cord causes slowly progressive spastic paraparesis of the muscles of the arms, sometimes asymmetric. Compression of the cervical spinal cord is often accompanied by paresthesia in the feet and hands. Vibration sensitivity in the lower extremities is reduced in most patients. Sometimes the border of the violation of this sensitivity is determined in the upper part of the chest. When the patient coughs, sneezes, and strains, weakness in the legs and pain radiating to the arms or upper shoulder girdle can be provoked.

Neurological examination of the patient reveals loss of sensitivity in the hands, atrophy of the hand muscles, increased deep tendon reflexes in the legs, and asymmetric Babinsky symptoms. In the case of pronounced organic changes in spondylosis, the patient has an urgent urge to urinate or urinary incontinence. With spondylosis of the cervical spine, the tendon and periosteal reflexes on the hands are reduced in patients. In case of compression of the C5-C6 nerves and the spinal cord at this level, the reflex from the biceps brachii will be reduced. In neurological symptoms, radicular, myelopathic disorders will be expressed. The diagnosis of spondylosis is assumed in cases when myelopathy of the cervical spinal cord develops in patients, paresthesias in the feet and hands develop, and atrophy of the muscles of the hands develops. Spondylosis often impedes walking in the elderly, causes an increase in tendon reflexes on the legs and Babinsky's reflexes.

Typical clinical symptoms and signs observed in cervical spondylotic myelopathy patients:

Symptoms
Signs
Weakness Myelopathic signs
Impairment of gait Hyperreflexia
Numbness of hands Inverted brachioradialis reflex
Spasticity Hoffmann’s sign
Incontinence Ankle clonus
Paresthesias Babinski sign
Neck pain Motor deficits
Arm pain Romberg sign
  Lhermitte’s sign
  Thenar atrophy

Nurick grades for myelopathy (1972):

Grade
Signs and symptoms
0 Signs or symptoms of root involvement but without evidence of spinal cord disease
1 Signs of spinal cord disease but no difficulty in walking
2 Slight difficulty in walking which did not prevent full-time employment
3 Difficulty in walking which prevented full-time employment or the ability to do all housework, but which was not so severe as to require someone else’s help to walk
4 Able to walk only with someone else’s help or with the aid of a frame
5 Chair bound or bedridden

 

Diagnostics of spondylosis

Diagnostics of spondylosis begin with a mandatory neurological and orthopedic examination by a doctor. During this examination, the patient's neurological status is assessed, as well as possible violations in the biomechanics of the spine are identified with a mandatory assessment of the state of the muscles of the back and gluteal region.

Computed tomography (CT) of the spine shows changes in spondylosis.

Already at this stage of the study, a patient with spondylosis of the spine and pain in the neck, thoracic or lower back can be diagnosed and treated.

Sometimes, according to the results of a neurological and orthopedic examination of a patient with a pain symptom against the background of spinal spondylosis, the following additional diagnostic procedures may be prescribed:

  • X-ray of the lumbosacral spine with functional tests
  • CT scan of the lumbosacral spine
  • MRI of the lumbosacral spine
  • Electrophysiological tests (EMG, ENG, etc.)

Often, spondylosis is accompanied by muscle pain along the nerve (along the arm or leg, in the neck, or between the shoulder blades).

In addition to muscle tone, the stability of the spinal segment can also be impaired. When the spine is unstable, the vertebra is displaced forward (anterolisthesis) or backward (retrolisthesis). To clarify the diagnosis, an X-ray of the spine with functional tests may be required.

Cetvical spondylosis with compression of the spinal cord with hypertrophy of the posterior longitudinal and yellow ligaments.

A focus of chronic inflammation in the lumen of the spinal canal can lead to the formation of its narrowing (stenosis of the spinal canal) and compression of the nerves and spinal cord passing through it. That is why in case of stenosis of the spinal canal, it is always necessary to carry out a full course of treatment with the use of a whole arsenal of different therapeutic methods, and in case of ineffectiveness, surgical treatment.

X-ray of the spine reveals spondylotic "beams", a decrease in the height of the intervertebral discs, a subluxation, changes in the physiological cervical lordosis (its straightening or kyphosis), and a decrease in the canal size to 11 mm or less, or to 7 mm when the cervical spine is extended. Cerebrospinal fluid (CSF) is not changed or contains a slightly increased amount of protein. In the study of somatosensory evoked potentials in patients with spondylosis, a normal rate of conduction of an uneven impulse along large peripheral sensory fibers and a delay in central conduction in the middle and upper cervical segments of the spinal cord is found.

Cervical spondylotic myelopathy (CMS) classification based on MRI studies:

Cervical spine MRI. Grade 0 - Physiologic alignment.

Cervical spine MRI. Grade I - Disc pathology, canal narrowing, no cord impingement.

Cervical spine MRI. Grade II - Spondylosis, anterior cord impingement.

Cervical spine MRI. Grade III - Spondylosis, restricted motion, anterior or posterior impingement.

Cervical spine MRI. Grade IV - CSM, anterior and/or posterior impingement.

 

Spondylosis treatment

Depending on the severity of the manifestations and causes of pain in the neck, thoracic region or lower back against the background of spondylosis of the spine, the patient may have the following therapeutic actions:

  • drug therapy (NSAIDs, analgesics, hormones)
  • therapeutic injections - injections of drugs into the cavity of the intervertebral joint, spinal canal, trigger points in the muscles
  • manual therapy (muscle, articular and radicular technique)
  • physiotherapy (UHF, TENS, etc.)
  • acupuncture
  • surgical treatment

In the treatment of back and lower back pain associated with spondylosis, elimination of swelling, inflammation, soreness, restoration of range of motion in the joints and muscles of the lower back is accelerated with the use of physiotherapy.

Intervertebral joints (facet joints) can also be treated with blockages when conventional treatment is not beneficial. Usually, low doses of anesthetic and cortisone injected into the lumen of the affected joint are sufficient for this.

Cervical spondylosis is often diagnosed in patients. Many patients with spinal cord lesions at the cervical level, especially with amyotrophic lateral sclerosis, multiple sclerosis, and subacute associated degeneration, undergo surgery to remove part of the vertebral arch (laminectomy). This operation is performed to decompress the spinal cord. Often after this operation, there is a temporary improvement in neurological status, which suggests a partial significance of spondylolytic compression. But if myelopathy was caused by an underlying disease, then it will begin to progress again. Slight increasing disturbances in gait and sensitivity in a patient can be mistaken for manifestations of polyneuropathy.

The use of acupuncture is very effective in the treatment of back and lower back pain associated with spinal spondylosis.

With a mild course of spondylosis, rest and immobilization of the cervical spine using a soft corset (collar or Shants) are effective. Sometimes such patients are shown traction (traction) of the cervical spine with a Glisson loop. Surgery for spondylosis is recommended when:

  • pronounced gait disturbances appear
  • there is a significant weakness in the hands
  • there is a disorder of the bladder function
  • the full cerebrospinal fluid (spinal) block is revealed on myelography and MRI of the spinal cord

When combined with a properly selected physiotherapy regimen, these therapeutic blockages can have a good and long-term effect in relieving the aggravation of pain in spondylosis.

In the treatment of pain in the leg and buttock with spondylosis, the elimination of pain, tingling, and restoration of sensitivity in the leg with sciatic nerve neuritis in case of compression by a hernia or disc protrusion is accelerated with the use of physiotherapy.

Wearing a semi-rigid lumbosacral brace in the treatment of back and lower back pain associated with spinal spondylosis helps to limit the range of motion in the lumbar spine. This primarily helps to reduce pain in the area of inflammation of the intervertebral joints and relieve excessive protective tension and spasm of the back muscles.

A variant of a semi-rigid lumbosacral brace, which helps in the treatment of back and lower back pain associated with spondylosis of the spine.

In such a corset, a patient with back and lower back pain against the background of spondylosis of the spine can move independently at home and on the street and even sit in the car and at the workplace. The patient no longer needs to wear a corset as soon as the back pain subsides.

But it must be remembered that during the period of exacerbation of pain in the back and lower back against the background of spondylosis of the spine, workloads should be avoided and rest should be observed. This is a temporary limitation, but it significantly shortens the recovery time and, against the background of the treatment being carried out, does not allow the disease of the spine to develop further.

A variant of a semi-rigid lumbosacral brace, which helps in the treatment of back and lower back pain associated with spondylosis of the spine.

There are several types of semi-rigid lumbosacral braces. All of them are selected individually in size and can be used repeatedly in case of recurrence of pain in the back and lower back against the background of spondylosis of the spine, as well as for the prevention of possible exacerbations of the pain symptom.