x
x

OSTEOARTHRITIS, CERVICAL

Introduction

Cervical osteoarthritis (COA), also referred to as cervical spondylosis, is an extremely common, usually chronic, disabling, degenerative disorder that results from the breaking down of articular cartilage in the cervical spine. COA is primarily a consequence of natural, age-related degeneration of intervertebral disc(s), although repeated trauma, being overweight, and genetic factors may also contribute. Conservative approaches, including physical therapy, over-the-counter and prescription pain-relieving medications, and other therapies is generally recommended as the first-line of treatment for COA, and surgery should only be reserved for patients with more severe complications and/or those who fail to respond to conservative interventions.1,2

Pathopysiology

  • COA occurs due to age-related degeneration of intervertebral disc(s), which results in a loss of viscoelasticity and disc height with associated posterior bulging. As disc height decreases, the ligamentum flavum and facet joint capsule fold, causing a reduction in the dimensions of the canal and exit foramina3,4
    • Osteophytes also form around the disc, which combine with the disc bulge and folding of ligament and joint capsule to cause pressure on the exiting nerve roots or the spinal cord3
    • Changes occur most frequently at the C5-6 and C6-7 levels, as this is where most of the subaxial flexion-extension movement occurs5
    • Recurrent occupational trauma involving axial loading can increase the risk of COA, and there may also be a genetic predisposition to the condition5
    • Being overweight/obese may increase the risk for COA; smoking increases the rate of disc degeneration, and therefore could also be a contributing factor5

Related Anatomy

  • Intervertebral discs
  • Intervertebral ligaments
  • Articular cartilage
  • Synovium
  • Cervical plexus
  • Spinal canal
  • Facet joints
  • Cervical spinal nerves
  • Cervical nerve roots
  • Neural foramen

Incidence and Related Conditions

  • COA typically begins between ages 40-50 years, and by age 65, ~95% of individuals will display radiographic signs of COA to some degree, regardless of symptomatology6
  • COA is more prevalent in men, and they tend to develop the condition earlier than women
  • Cervical radiculopathy (CR)
  • Cervical myelopathy
  • Cervical spondylolisthesis
  • Cervical stenosis
  • Degenerative joint disease

Differential Diagnosis

  • Ankylosing spondylitis
  • Diffuse idiopathic skeletal hyperostosis
  • Rheumatoid arthritis
  • Carpal tunnel syndrome
  • Double-crush syndrome
  • Wartenberg’s syndrome which can cause paresthesias in the C6 distribution.
ICD-10 Codes

  • OSTEOARTHRITIS, CERVICAL

    Diagnostic Guide Name

    OSTEOARTHRITIS, CERVICAL

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    OSTEOARTHRITIS, CERVICAL (SPONDYLOSIS, WITHOUT MYELOPATHY/RADICULOPATHY)M47.812   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Neck pain, stiffness and headache
Impaired sensory and/or motor function
Shoulder, arm, forearm, hand pain and/or radiating tingling, numbness, +/- weakness
Myelopathy hand: dexterity loss, diffuse numbness, intrinsic muscle wasting, ulnar and flexor drift, and inability to grasp and release the fist
Typical History

The typical patient is a 67-year-old man who complains of intermittent neck pain and radiating tingling, numbness, and weakness down his right arm and into his hand. His symptoms have gradually become more debilitating and now complicate basic daily activities like opening doors and grasping objects, thus limiting his overall functionality.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Cervical Osteoarthritis with anterior osteophytes (1), narrow disk space (2) and posterior osteophytes (arrow)
    Cervical Osteoarthritis with anterior osteophytes (1), narrow disk space (2) and posterior osteophytes (arrow)
Treatment Options
Conservative
  • Initial management should be conservative for the first 3 months and tailored according to the pathology, symptoms, and physical condition of the patient, with the goal of preventing further progression5
  • Non-steroidal anti-inflammatory drugs (NSAIDs) should be recommended as the first line of medication
  • Physical therapy, including 15–20 sessions of 30-45-minute duration over 3 months, should focus on isometric strengthening exercises for neck muscles and supporting ligaments, stretching exercises for the neck and upper back, proprioceptive reeducation, manual therapy, and mechanical traction.
  • Passive modalities: thermotherapy, cryotherapy, ultrasound, and electrical stimulation3
  • Anticonvulsants (gabapentin, topiramate)
  • In patients who are refractory to other medications, corticosteroids are recommended 1-2 times per week, tapered after 3 days; epidural steroid injection may be needed for patients with radiculopathy or those that do not respond to other measures
  • Muscle relaxants should be aimed at relieving any associated spasm of the trapezius and paraspinal muscles and to improve sleep; owing to their habit-forming properties, treatment duration should be tapered quickly (maximum, 2 weeks)
  • Opioid analgesics may be indicated for patients with significant underlying structural osteoarthritis and moderate-to-severe axial neck pain refractory to non-opioid agents and nonpharmacological therapies; use should definitely be limited due to possible ineffectiveness in neuropathic pain and high risk of addiction
  • Antidepressants
  • Acupuncture
  • Chiropractic manipulation
  • Occupational therapy
  • Collar immobilization 
  • Low-power laser therapy7
Operative
  • Reserved for patients who have failed to improve after conservative treatment, especially moderate-to-severe myelopathy patients and those with radicular pain and demonstrated root compression with neurological deficits
  • Anterior approach
    • Anterior cervical discectomy with fusion (ACDF)
      • Aimed at achieving neural decompression, maintaining cervical lordosis, and providing segmental stabilization
      • May accelerate symptomatic degenerative progression at other levels and cause some patients to require further surgery at the adjacent level
    • Anterior cervical discectomy with arthroplasty (ACDA)
      • Alternative surgical option to ACDF that could preserve segmental mobility at the diseased level and theoretically decrease the incidence of adjacent level degeneration2
      • Useful when an anterior decompression is necessary for myelopathy or radiculopathy
    • Anterior cervical discectomy without fusion
    • Anterior foramenotomy without complete discectomy
  • Posterior approach
    • May be required if pathology is lateral to the spinal cord
    • Decompressive laminectomy and foraminotomy
    • Hemilaminectomy
    • Laminoplasty
    • Lateral mass screw fixation
Complications
  • Infection
  • Pseudarthrosis
  • Epidural hematoma
  • Spinal cord infarction
  • Vertebral artery injury
  • Vascular injury
  • Neuropraxia
  • Ischemia
  • Dysphagia
  • Odynophagia
  • Recurrent laryngeal nerve injury
  • Hypoglossal nerve injury
  • Neck pain
  • Progressive degeneration and spinal deformity
  • Horner’s syndrome
  • Adjacent segment disease
Outcomes
  • Low-power laser therapy effectively reduces pain in COA7
  • There is stronger evidence supporting the use of cervical steroid epidurals than systemic corticosteroids for CR, with moderate symptom improvements, although injections still carry a risk3
  • Randomized trials have shown that patients treated surgically for axial neck pain, CR, and mild cervical myelopathy experience greater improvements in pain, muscle strength, and sensory function in the early follow-up period than those treated with physical therapy; however, after 1 year, there is no difference between patients objectively or in terms of patient satisfaction3
  • Anterior surgical approach is considered the most effective for treating cervical disc disease, and studies have suggested that ACDF is well tolerated with satisfactory results in a high proportion of patients8
  • Results from a recent study suggest that ACDA was superior to ACDF in terms of overall success rate and VAS pain score despite prolonged surgical duration; there were no significant between-group differences in mean blood loss, mean hospitalizations, patient satisfaction, neck disability index, reoperation, or complications8
Key Educational Points
  • Patients with axial pain should exhaust all conservative treatment options first and ideally have only 1 or 2 levels of disease on their imaging studies if considering surgery; they should also have a confirmatory test, usually a positive response to facet injections, to be sure the abnormalities on the imaging studies are the source of their pain5
  • Patients frequently have a combination of pain and myelopathy/radiculopathy, and surgical plans needs to take these factors into consideration, as well as the spinal alignment and condition of the bone and segments adjacent to the surgical fusion5
References

Cited

  1. Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. J Clin Orthop Trauma 2014;5(4):221-6. PMID: 25983502
  2. Fallah A, Akl EA, Ebrahim S, et al. Anterior cervical discectomy with arthroplasty versus arthrodesis for single-level cervical spondylosis: a systematic review and meta-analysis. PLoS One 2012;7(8):e43407. PMID: 22912869
  3. Hirpara KM, Butler JS, Dolan RT, et al. Nonoperative modalities to treat symptomatic cervical spondylosis. Adv Orthop 2012;2012:294857. PMID: 21991426
  4. Ferrara LA. The biomechanics of cervical spondylosis. Adv Orthop 2012;2012:493605. PMID: 22400120
  5. Takagi I, Eliyas JK, Stadlan N. Cervical spondylosis: an update on pathophysiology, clinical manifestation, and management strategies. Dis Mon 2011;57(10):583-91. PMID: 22036114
  6. Garfin SR. Cervical degenerative disorders: etiology, presentation, and imaging studies. Instr Course Lect 2000;49:335-8. PMID: 10829187
  7. Ozdemir F, Birtane M, Kokino S. The clinical efficacy of low-power laser therapy on pain and function in cervical osteoarthritis. Clin Rheumatol 2001;20(3):181-4. PMID: 11434469
  8. Ma Z, Ma X, Yang H, et al. Anterior cervical discectomy and fusion versus cervical arthroplasty for the management of cervical spondylosis: a meta-analysis. Eur Spine J 2017;26(4):998-1008. PMID: 27771787

New Articles

  1. Ma Z, Ma X, Yang H, et al. Anterior cervical discectomy and fusion versus cervical arthroplasty for the management of cervical spondylosis: a meta-analysis. Eur Spine J 2017;26(4):998-1008. PMID: 27771787
  2. Singh S, Kumar D, Kumar S. Risk factors in cervical spondylosis. J Clin Orthop Trauma 2014;5(4):221-6. PMID: 25983502

Reviews

  1. Fallah A, Akl EA, Ebrahim S, et al. Anterior cervical discectomy with arthroplasty versus arthrodesis for single-level cervical spondylosis: a systematic review and meta-analysis. PLoS One 2012;7(8):e43407. PMID: 22912869
  2. Kelly JC, Groarke PJ, Butler JS, et al. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop. 2012;2012:393642. PMID: 22162812

Classics

  1. Rand RW, Randall PH. Surgical treatment of cervical osteoarthritis. Calif Med 1959;91:185-8. PMID: 14436128
  2. Rowe CR. Current concepts in therapy: cervical osteoarthritis. N Engl J Med 1963;268:1178-9. PMID: 13982806
Subscribe to OSTEOARTHRITIS, CERVICAL
⇡