Instrumental diagnostics
The first step in diagnosing degenerative changes is cervical spine radiography. The standard examination includes lateral (lateral), anteroposterior (AP), and oblique (oblique) projections. Flexion and extension functional views (flexion/extension views) are extremely important—they help identify anterior vertebral displacement, or anterolisthesis (anterolisthesis), which develops against the background of facet joint degeneration.
Radiographs can be used to determine the main criteria for stenosis:
- Absolute stenosis (absolute stenosis): anteroposterior diameter less than 10 mm.
- Relative stenosis (relative stenosis): from 10 to 13 mm.
- Torg-Pavlov ratio (Torg-Pavlov ratio): less than 0.8.
Magnetic resonance imaging (MRI) is the method of choice for assessing nerve root compression and visualizing spinal cord edema. However, MRI should not be used for screening: many patients over 40 years of age exhibit asymptomatic changes, so tomograms are interpreted only in conjunction with the clinical picture.
Non-contrast computed tomography is good for assessing bony stenosis, but poorly visualizes soft tissues. If MRI is contraindicated, invasive CT myelography with contrast administration into the intradural space is used.
Epidemiology and disease course
Cervical spinal stenosis is widespread and often asymptomatic. It occurs in approximately 5% of the adult population, and in individuals over 70 years of age, this figure reaches 9%. If spinal cord compression is discovered incidentally during an examination for neck pain, approximately a quarter of such patients develop clinical signs of myelopathy within two years.
Cervical myelopathy manifests at different ages depending on sex: symptoms appear earlier in men (50–59 years) than in women (60–69 years). The peak incidence of cervical radiculopathy also occurs in the sixth decade, with men affected twice as often.
Differential diagnosis
The clinical presentation of spondyloarthrosis with neurological deficit should be differentiated from a number of other conditions:
- Vitamin B12 deficiency: characterized by decreased proprioception, tingling, and numbness, while motor impairments are mild or absent.
- Multiple sclerosis (Multiple sclerosis): sensory disturbances do not correspond to dermatomal innervation zones (non-dermatomal), and the disease itself proceeds with remissions and exacerbations, unlike progressive myelopathy.
- Stroke (Stroke): can mimic motor and sensory cortex lesions, but neck pain is entirely uncharacteristic of it. Aphasia and altered mental status are more frequently present.
- Movement disorders (Movement disorders): in elderly patients, bradykinesia and tremor come to the forefront.
- Peripheral nerve syndromes: carpal and cubital tunnel syndromes. To differentiate them from radiculopathy, electromyography (EMG) and nerve conduction velocity (NCV) testing are ordered.
Treatment and red flags
Before planning therapy, it is necessary to rule out red flags (Red Flags): any weakness after neck trauma, history of cancer (risk of metastases), or extensive neurological deficit suspicious for vascular events.
Management tactics depend on symptom severity:
- Incidental findings: asymptomatic stenosis does not require treatment.
- Mild course (or contraindications to surgery): conservative therapy including rest, muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), and therapeutic exercise.
- Radiculopathy: selective corticosteroid injections (nerve blocks) into the nerve root area show good efficacy.
- Severe impairments: surgical decompression is indicated.
Among surgical interventions, anterior cervical discectomy and fusion (ACDF) is frequently used. The method is highly effective for single-segment lesions, but the risk of failure increases in multilevel disease. In such cases, it is technically more correct to use the term "attempted fusion" (attempted fusion), since reliable bony union is not always achieved. Alternative methods include laminectomy, laminoplasty (enlargement of the intervertebral foramen by removing a portion of the lamina), and disc arthroplasty.
Briefly: answers to topical questions
What spinal cord and structural changes can be visualized using MRI in cervical stenosis?
MRI in cervical stenosis can visualize the anatomy and pathological changes of the spinal cord as well as its nerve roots. Tomograms reveal:
- Cervical canal stenosis — narrowing of the spinal canal (e.g., due to a posterior osteophyte-disc complex).
- Spinal cord edema — a characteristic sign of developing myelopathy.
- Disc herniation — its exact localization.
- Structural compression — the degree of dural sac and vascular compression.
Which pathological reflexes and physical examination findings indicate the development of cervical myelopathy?
The development of cervical myelopathy on physical examination is indicated by motor and sensory impairments, as well as reflex changes. The main symptoms include:
- Hyperreflexia (hyperreflexia) — increased reflexes.
- Muscle weakness — may be mild, accompanied by impaired fine motor skills (fine motor function).
- Impaired proprioception (abnormal proprioception) — detected during the finger-to-nose test with eyes closed.
- Sensory disturbances — bilateral numbness and tingling in a non-dermatomal distribution (non-dermatomal distribution).
- Coordination impairment — decreased ability to perform rapid alternating movements, gait instability.
Which spinal nerve roots are most frequently compressed in cervical spondyloarthrosis?
Sources indicate that cervical degenerative changes are most commonly observed at the C5, C6, and C7 levels. With a disc herniation at the C5/C6 level, both central and lateral protrusions can compress the C6 root. In the cervical spine, roots exit above the pedicle of the corresponding vertebra.
How does the clinical presentation of a C6 root lesion differ from that of a C7 root lesion?
The clinical presentation of C6 and C7 root lesions differs in the involved indicator muscles, reflexes, and dermatomal areas.
| Sign | C6 root | C7 root |
|---|---|---|
| Indicator muscles | Biceps brachii muscle (m. biceps brachii), brachioradialis muscle (m. brachioradialis) | Triceps brachii muscle (m. triceps brachii), pronator teres muscle (m. pronator teres), thenar muscles (thenar) |
| Reflex | Biceps reflex (elbow flexion) | Triceps reflex (elbow extension) |
| Dermatome | Lateral forearm, thumb (I) and radial half of the index finger (II) | Middle finger (III) and adjacent areas of the hand |
Class and exam questions
Should spinal stenosis be treated if there are no symptoms at all?
No, an incidental asymptomatic cervical stenosis detected on diagnostic imaging is not an indication for treatment.
What is the difference in the clinical presentation of stroke versus cervical radiculopathy?
The key difference is that neck pain does not occur in stroke. Additionally, vascular events are often accompanied by aphasia and altered mental status.
Why are functional flexion radiographs of the neck ordered?
Functional tests help identify anterolisthesis — anterior displacement of a vertebra due to joint degeneration, which further narrows the spinal canal.
Is the use of EMG justified for screening cervical pathologies?
No, electromyography is used strictly to localize peripheral nerve lesions (e.g., to differentiate from tunnel syndromes) and answer specific questions regarding surgical tactics.
What else to study on this topic
- Torg-Pavlov ratio: measurement technique and limitations
- Types and surgical technique of anterior cervical discectomy and fusion (ACDF)
- Differences between laminectomy and laminoplasty in multilevel stenosis
- Performing invasive CT myelography: indications and complications
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