Chapter 108  Cervical Disc Disease and Spondylosis
Chapter 108  Cervical Disc Disease
and Spondylosis
Rabia Qureshi, Jason A. Horowitz, Hamid Hassanzadeh
ICD-10-CM CODES
M43.02 Spondylosis, cervical region
M50.0 Cervical disc disorder with myelopathy
M50.1 Cervical disc disorder with radiculopathy
M50.2 Other cervical disc displacement
M50.3 Other cervical disc degeneration
M54.12 Radiculopathy, cervical region
M99.61 Osseous and subluxation stenosis of
intervertebral foramina, cervical region
M99.71 Connective tissue and disc stenosis of
intervertebral foramina, cervical region
Key Concepts
• Cervical spondylosis is degeneration affecting the interver-
tebral bodies and intervertebral discs of the cervical spine,
usually in older adult patients (Fig. 108.1).
• Cervical spondylosis is the result of wear and tear with
aging, but can be affected by various external factors.
• Symptoms of cervical degeneration can result from nerve
root and/or cord compression due to intervertebral disk
(IVD) degeneration, osteophyte formation, spinal instability,
or spinal malalignment.
• The outer portion of the IVD is the annulus fibrosis, while
the inner portion is the gelatinous nucleus pulposus. Both
components undergo degenerative changes over time that
can lead to disk space narrowing and/or disk protrusion/
herniation (see Fig. 108.1B).
• The clinical symptoms/neurological deficits in cervical
spondylosis vary greatly depending on the etiology and
extent of disease and can include neck pain radiating to
the arm, numbness/paresthesias, pathologic gait, lower
extremity weakness, and many others.
• Treatment can also vary based on severity and begins
with nonoperative treatment. Operative management is
indicated for neurological symptoms that are refractory to
nonoperative management and for “red flag” symptoms
such as bowel/bladder dysfunction and acutely progressive
symptoms.
History
• History must rule out other, nonmechanical causes of
symptoms including neoplasms, infection, metastases,
or traumatic/pathologic fractures.
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5
• Determine type of pain: axial neck pain, radiculopathy, or
myelopathy.
• Axial neck pain: exclusively in the cervical, occipital, and
scapular areas. Axial neck pain is usually musculoskeletal
in origin, resulting from muscle strain.
• More immediate onset pain
• Often persistent
• Radiculopathy: Nerve root compression (see Fig. 108.1D)
causing neck pain radiating into the arm. Can include
weakness and numbness of the arm.
• Insidious onset headache with radiating pain
• Unilateral pain, numbness and tingling, with derma-
tomal distribution
• Myelopathy: spinal cord compression with various
causes including congenital stenosis. Symptoms include
progressive gait imbalance and hand clumsiness.
• Can present with neck stiffness or occipital headache
• Instability with gait
• Progressive clumsiness, fine motor difficulty
Physical Examination
(Figs. 108.2 and 108.3)
• Look for neck pain and stiffness of muscles. Determine if
pain or spasms are present with palpation.
• Observe muscle tone and if any atrophy is present in neck,
shoulders, arms, and hands.
• Observe gait and posture changes.
• Determine range of motion.
• Full neurological examination.
• Special tests include: Spurling test, shoulder abduction
test, finger escape, and Hoffman sign among others
• Radiculopathy: examination findings are dependent upon
nerve root level.
• C5—deltoid and biceps weakness
• C6—wrist extension weakness, thumb paresthesias
• C7—wrist flexion weakness, diminished triceps reflex,
index and middle finger paresthesias
• C8—weakness of distal phalanx flexion, little finger
paresthesias
• Spurling test—pain with neck extension and ipsilat-
eral bending, relief from neck flexion with deviation
opposite to symptomatic side
• Shoulder abduction test—relief of pain/symptoms
with abduction of shoulders
• Myelopathy: motor and sensory signs along with gait
instability and upper motor neuron signs
• Weakness may be present, though difficult to ascertain 427
5 Section 5  The Spine

A B

C D
Fig 108.1  Normal (A) and degenerative (B–D) cervical spine anatomy. (A) Axial cross-section showing a normal C5-C6 level and
the relationship of nerve roots (NR), facets (F), spinal cord (SC), and vertebral artery (VA). (B) Parasagittal section showing a teardrop-
shaped disc extrusion (herniation), compressing the ganglion (G) of the C6 nerve root. (C) Coronal section showing severe disc
degeneration (DD; cervical spondylosis), collapse, and uncinate process osteophytes (arrows). (D) Axial section showing late-stage
cervical disc disease, with osteophytes centrally (small arrows) and peripherally compressing the ganglia (large arrows), as well as
thickened ligamentum flava (LF). (From Gallego J, Schnuerer AP, Manuel C. Basic Anatomy and Pathology of the Spine. Memphis:
Medtronic Sofamor Danek, 2001; photographs by Wolfgang Rauschning, MD, PhD.)

• Test paresthesias and decreased pain sensation with
pinprick
• Spasticity is noted on exam; clonus or Babinski may
be present
• Hoffman sign—snap of distal phalanx of middle finger
results in flexion of other fingers
• Finger escape may occur with fingers extended and
adducted (small finger drifts away due to muscle
weakness)
• Lhermitte sign—cervical flexion will result in shock-
like pain shooting down spine and may radiate into
extremities
• Grip and release test—patients have difficulty with
making a fist and releasing in succession
• Flexion/extension imaging may reveal angular (>11 degrees)
or translational (>3.5 mm) instability and may also demon-
strate compensatory subluxation.
• Oblique view findings include foraminal stenosis, usually
not needed.
• With older age, radiographic findings of degeneration
become common in asymptomatic individuals and may
not correlate with the clinical presentation.
Computed Tomography
• Aids in evaluation of bony elements
• Can determine level of bony cord compression and foraminal
stenosis and can also evaluate ossification of posterior
longitudinal ligaments

Magnetic Resonance Imaging (see Fig. 108.4C)

Imaging • Indicated in patients with suspected disc disease or
Radiography (Fig. 108.4A and B) herniation.
• Common findings on radiography include osteophytes, • Can evaluate surrounding soft tissues, spinal cord
narrowed disc spaces, decreases in sagittal diameter, lesions, tumors, infections, and other spinal cord changes/
sagittal or coronal malalignment, and degenerative changes compression.
428 in anteroposterior and lateral views. • Disc degeneration can be evaluated.

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 Chapter 108  Cervical Disc Disease and Spondylosis 5
C5 Neurologic Level C6 Neurologic Level
Motor Motor Wrist extensors:
deltoid Biceps Biceps extensor carpi
radialis longus
and brevis

Reflex Reflex

C5
C6

Sensation Sensation

C5 C5
C7 C6 T2 C7 C6 T2
C6 C6
T1 T1
C8 C8

C7 Neurologic Level C8 Neurologic Level

Motor Motor
interosseous muscles

Triceps Wrist flexors

Finger flexors

Finger extensors

Reflex Reflex

No reflex

C7 C7
T1

Sensation Sensation

C5 C5
C7 C6 T2 C7 C6 T2
C6 C6
C8 T1 C8 T1

Fig 108.2  Upper extremity neurologic evaluation of C5-C8. (Modified with permission from Klein JD, Garfin SR. History and physical
examination. In: Weinstein JN, Rydevik B, Sonntag VKG, eds. Essentials of the Spine. New York: Raven Press; 1995:71–95.)

• Magnetic resonance imaging (MRI) findings must correlate • Discography is rarely used in cervical spondylosis
with the clinical presentation as abnormal findings on MRI patients due to the risk of esophageal puncture and
are common in asymptomatic patients. infection.

Additional Tests Differential Diagnosis

• Computed tomography myelography with contrast aids in • Neoplasm: includes metastases, primary bony tumors,
evaluation in patients where MRI is contraindicated. superior sulcus tumor, cord tumors 429

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5 Section 5  The Spine

T1 Neurologic Level • Medications also include gamma-aminobutyric acid

(GABA) inhibitors, muscle relaxants, and narcotics.
Motor • Stretching/physical therapy for patients who do show
Interosseous muscles improvement with rest and analgesics.
• Corticosteroid injections may be used for nerve root pain
relief.

Operative
• After failed conservative treatment, patients may be
considered for operative management.
• Particular indications include persisting pain, disabling
pain, neurologic symptoms (radiculopathy, myelopathy,
Reflex or weakness), gait symptoms.
• Anterior cervical discectomy with fusion—for cervical disc
disease/herniation, anterior pathology, radiculopathy, and
additional osteophyte formation.
• Posterior decompression +/− fusion—for multilevel disease,
No reflex
OPLL, foraminal disc herniation, and pseudoarthrosis.
• Total cervical disc replacement—for patients with minimal
arthrosis/less bony disease and limited pathology.
• Complications of operative management include infection,
T1 pseudoarthrosis, nerve injury, implant failure, esophageal
injury/dysphagia, vascular injury, adjacent segment disease.

Sensation
C5 When to Refer
C6 T2 • Patients who do not improve with initial treatment, rest,
C7 C6
T1 and analgesics should be referred.
C8
• Patients with progressive neurologic symptoms should be
referred.
Fig 108.3  Upper extremity neurologic evaluation of the T1 level. • Signs of cervical myelopathy, including pathologic gait,
(Modified with permission from Klein JD, Garfin SR. History and should indicate a necessary referral.
physical examination. In: Weinstein JN, Rydevik B, Sonntag • More serious signs requiring evaluation include pain at
VKG,eds. Essentials of the Spine. New York: Raven Press; 1995: night, pain at rest, or progressive pain not relieved by
71–95.) conservative treatment, all of which could indicate a
nondegenerative etiology such as trauma, malignancy, or
infection.
• Emergency evaluation is required if patients suffer from
• Infection: includes osteomyelitis, abscess of surrounding acute onset of neurological dysfunction, loss of bowel/
tissue, diskitis bladder function, or acute loss of gait.
• Traumatic: brachial plexus injury, muscle sprain/strain,
instability
• Inflammatory disease: rheumatoid arthritis, other Prognosis
arthropathies • Axial neck pain usually resolves with conservative treatment.
• Neurologic disease: anterior horn cell disease, demyelinating • Approximately 75% of patients with radicular symptoms
diseases recover within 12 weeks of conservative/nonoperative
• Misc: rotator cuff tear, instability, peripheral nerve disease, treatment.
thoracic outlet syndrome • Patients requiring operative treatment have variable
outcomes.
• Anterior cervical discectomies are the gold standard
Treatment (Fig. 108.5) treatment for radiculopathy and have favorable outcomes.
Nonoperative Methods • Posterior foraminotomies have favorable outcomes in
• A majority of patients recover without operative intervention. a large majority of patients.
• Most patients recover within 12 weeks of conservative • Recurrence is often not predictable.
treatment.
• Rest or decrease in activity, soft collar may be used
• Some patients benefit from immobilization for short Troubleshooting
periods. • A proper and thorough history and physical should be
• Ice/heat with or without antiinflammatory medications for conducted to rule out nondegenerative etiologies.
added pain relief, including nonsteroidal antiinflammatory • Patients should have adequate follow-up visits after initial
430 drugs (NSAIDs) or steroids for more severe pain diagnosis.

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 Chapter 108  Cervical Disc Disease and Spondylosis 5

X-TABLE
SUPINE

C
Fig 108.4  (A) Sagittal and anteroposterior (AP) cervical spine radiographs of a patient complaining of left upper extremity pain,
numbness, and tingling with evidence of disc space narrowing and loss of lordosis. (B) Postoperative sagittal and AP cervical
radiographs showing anterior cervical discectomies and fusion spanning C3-C7. (C) Cervical spine magnetic resonance imaging
showing degenerative disc disease as well as central canal narrowing at C3-C4, C4-C5, C5-C6, and C6-C7.

431

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5 Section 5  The Spine

A Epidural Steroid Injection

Spinal needle

Steroid injected
into epidural space

Nerve root
Spinous process

Dura and spinal cord

B Anterior Cervical Discectomy with Fusion or Total Disc Replacement

Anterior plate
Prosthetic disc
and screws

Bone graft
Vertebral body

C Posterior Foraminotomy

Foraminotomy for
nerve root
Vertebral body
decompression

Nerve root

Fig 108.5  Treatment modalities. (A) Epidural corticosteroid injection. (B) Anterior cervical discectomy with fusion or total disc
replacement. (C) Posterior foraminotomy.

• Particularly patients with neurological symptoms to allow

for assessment of progression Patient Instructions
• Surgical complications can occur and postoperative • Patients should be counseled on conservative treatment
management must include close in-hospital monitoring and the benefits of rest and physical therapy.
and follow-up office visits. • Patients should be given information regarding operative
• Dysphagia is particularly common and patients should management in case conservative treatment fails.
be treated accordingly. • Preoperatively, patients should be counseled regarding
• Patients at risk for infection should be monitored more surgical risks and postoperative expectations in terms of
432 closely for postoperative infection. both functionality and pain.

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 Chapter 108  Cervical Disc Disease and Spondylosis
• Whether undergoing operative or nonoperative treatment,
patients should be given instructions to return for follow-up
in the event that symptoms persist after treatment.
Considerations in Special Populations
• Patients with chronic pain/pain syndromes need to be
counseled on expectations and should have close follow-
up. If pain does not subside after surgery, referral to pain
management may be necessary.
• Additionally, chronic pain patients should undergo
physical therapy and conditioning both before and after
surgery.
• Close attention should be paid to pain medications,
particularly narcotics consumption.
• Patients with inflammatory arthritis should be evaluated
more carefully for trauma and neurologic dysfunction.
5
Suggested Readings
Bohlman HH, Emory SE, Goodfellow DB, Jones PK. Robinson anterior
cervical discectomy and arthrodesis for cervical radiculopathy. J Bone
Joint Surg. 1993;75(9):1298–1307.
Burkett CJ, Greenberg MS, et al. Cervical and thoracic spine degenerative
disease. In: Baaj AA, Mummaneni PV, Uribe JS, eds. New York:
Thieme; 2011:146–150.
Nakashima H, Yukawa Y, Suda K, et al. Abnormal findings on magnetic
resonance images of the cervical spines in 1211 asymptomatic
subjects. Spine. 2015;40(6):392–398.
Toledano M, Bartleson JD. Cervical spondylotic myelopathy. Neurol Clin.
2013;31(1):287–305.
Woods BI, Hilibrand AS. Cervical radiculopathy: epidemiology, etiology,
diagnosis, and treatment. J Spinal Disord Tech. 2015;28(5):E251–E259.

433

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