Spondylosis

Spondylosis is the degeneration of the vertebral column, most commonly due to spinal osteoarthritis. This age-related degenerative process predominantly affects the vertebral bodies, neural foramina, and facet joints.

Severe cases can lead to pressure on the spinal cord or nerve roots, causing sensory or motor disturbances such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

Signs and Symptoms

Cervical Spondylosis

Cervical spondylosis often begins with dull neck pain and stiffness. As it progresses, radiculopathy or myelopathy symptoms can develop. Radiculopathy presents as numbness, tingling, or burning pain in the areas supplied by the affected spinal nerve, alongside weakness or absent reflexes. Myelopathy usually involves both upper and lower limbs, causing gait difficulties, limb stiffness, and muscle weakness.

Spurling's test is used to diagnose radiculopathy by extending and laterally flexing the patient's head and applying downward pressure. A positive result may indicate spondylosis but requires further testing. Lhermitte sign for myelopathy involves neck extension producing a shock-like sensation down the spine or arms. Other signs include muscle spasticity, hyperreflexia, Hoffmann's reflex, Babinski response, and Wartenberg's sign.

Lumbar Spondylosis

The spinal cord ends at L1 or L2; thus, lumbar spondylosis affects spinal nerves. Degenerative changes like disc bulging and osteophyte formation contribute to radiculopathy-related symptoms, such as lower back pain, leg pain, numbness, and weakness. The narrowing of the lumbar spinal canal leads to neurogenic claudication, characterised by worsening symptoms with standing or walking, and relief with sitting or lying down.

Complications

A severe but rare complication is vertebrobasilar insufficiency, where the vertebral artery becomes occluded, leading to radiculopathy. Cervical spondylosis can cause secondary osteophytes, resulting in spinal nerve stenosis.

Causes

Spondylosis arises from chronic abnormal pressure on the vertebrae and discs, often due to joint subluxation, repetitive trauma, or poor posture. The body's response to this stress is the formation of new bone, altering weight distribution and causing further degeneration. Congenital cervical spine stenosis, caused by short pedicles, can also be a contributing factor.

Diagnosis

For neck pain without neurological findings, an x-ray is generally not required. Chronic neck pain may warrant a cervical spine x-ray in various views (AP, lateral, Swimmer's, oblique). MRI and CT scans are useful for diagnosing spondylosis, showing osteophytes, disc height reduction, and spinal canal narrowing. MRI is ideal for assessing radiculopathy and myelopathy, visualising intervertebral foramina, spinal canal, ligaments, and disc herniation. CT myelography is used when MRI is contraindicated.

Treatment

Many treatments lack rigorous trial validation. Surgery is recommended for intractable pain, progressive symptoms, or weakness unresponsive to conservative therapy. For moderate-to-severe myelopathy, most clinicians prefer surgery over conservative treatment.

Physical therapy aims to restore motion, flexibility, and core strength, using manual mobilisation and mechanical traction to alleviate pain. However, it cannot cure degeneration, and postural modification is very important for maximum benefit.

Surgery

Surgical procedures aim to relieve symptoms by decompressing the spinal canal or stabilising spine movement. In cervical myelopathy, the choice of anterior or posterior approach depends on spinal alignment and the source of compression. Anterior approaches include discectomy and fusion, corpectomy, and arthroplasty for neutral or lordotic alignment. Posterior approaches, like laminoplasty or laminectomy, are used for kyphotic alignment or posterior compression sources. For multiple affected segments, a combination of approaches is used.

Decompression surgery involves removing osteophytes and intervertebral disc portions to relieve root compression. Fusion surgery is performed for spinal instability or mal-alignment, using instrumentation as required.

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Self-assessment MCQs (single best answer)

What is spondylosis most commonly due to?

Which test is used to diagnose cervical radiculopathy by extending and laterally flexing the patient's head and applying downward pressure?

What is a common symptom of lumbar spondylosis?

Which imaging modality is ideal for assessing radiculopathy and myelopathy in spondylosis patients?

What is the main goal of physical therapy in the treatment of spondylosis?

Which surgical approach is used for cervical myelopathy with neutral or lordotic alignment?

What is a severe complication of spondylosis that can lead to radiculopathy due to vertebral artery occlusion?

What is the purpose of decompression surgery in the treatment of spondylosis?

Which sign involves neck extension producing a shock-like sensation down the spine or arms, indicating myelopathy?

Which imaging technique is used when MRI is contraindicated in diagnosing spondylosis?