As we age, we tend to develop degenerative conditions that can affect our musculoskeletal system in a variety of ways. When these degenerative conditions involve the joints of the body, we commonly refer to this condition as "osteoarthritis" or more simply, as "arthritis." The term arthritis is actually a misnomer because arthritis means 'inflammation of a joint' and osteoarthritis is actually a chronic degenerative process (not an inflammatory process) involving the bone and cartilage of the joint, resulting in pain and at times, disability. In any event, the cervical spine is unfortunately, not spared from these degenerative processes. Degenerative changes of cervical spine are not usually referred to as arthritis, but rather as cervical degenerative disc disease or cervical spondylosis.
Cervical Spondylosis is initially characterized by molecular changes within the cervical intervertebral discs. These changes primarily involve alterations in water and proteoglycan content within the disc. Ultimately these changes result in a decrease in the ability of the discs to withstand compressive loads, making the disc more susceptible to injury. Injured intervertebral discs can manifest in the acute setting as a cervical disc herniations or more typically, in the chronic setting as cervical disc degeneration, or cervical spondylosis.
Cervical Spondylosis is characterized by a loss of disc height. As the condition progresses and loads are transferred to the adjacent vertebral bodies, new bone spurs may form on the vertebral endplates. These bone spurs may become problematic due to their proximity to the cervical spinal cord and nerve roots. If the spurs become large enough as they often do, they may become compressive and result in pain, numbness, weakness, and at times even more severe neurologic symptoms. Late stages of of cervical spondylosis may affect the overall alignment of the cervical spine and result in a condition called cervical kyphosis, which was discussed in detail in the September 2019 blog post (see Archives).
I recently treated patient with cervical spondylosis that had resulted in chronic, debilitating neck pain due to advanced degeneration involving multiple discs (C3-C7). She had developed a mild kyphotic alignment (loss of lordosis). She was experiencing symptoms of cervical radiculopathy due to nerve root compression, characterized by unrelenting arm pain and numbness and tingling of the hands. She failed to improve after attempts at non-surgical care and ultimately chose to proceed with surgical correction. The preoperative image (below, left) demonstrates the abnormal curvature as well as multiple degenerative discs. The postoperative image (below, right) demonstrates a four-level anterior cervical discectomy and fusion (ACDF) from C3-C7. All bone spurs causing spinal cord and nerve root impingement were removed during the procedure and you can see the dramatic improvement in her alignment, with restoration of a normal lordotic alignment. This procedure was performed in the hospital in around 3 hours and the patient was discharged home the following morning. She is doing well and is pleased with the results of surgery.
Cervical kyphosis is a common type of spinal deformity which is characterized by an abnormal forward curvature of the cervical spine. The figure below demonstrates the spectrum of cervical alignments that patients often present with.
On the left is a normal cervical alignment (green line) in which the cervical spine is curved “back”, which allows us to maintain a normal horizontal gaze (keep our heads up in a normal position), without much pain or effort. This proper alignment is referred to as cervical lordosis. Normal cervical lordosis is about 20 degrees. Contrast this with the image on the right in which the spine is now curved forward (red line). This condition, cervical kyphosis, often results in chronic neck and/or arm pain. It makes it difficult for us to maintain a normal horizontal gaze, free of neck pain and muscle fatigue.
Cervical kyphosis is often seen acutely following soft tissue (whiplash) injuries to the cervical spine. It may also develop slowly over time as a result of cervical disc degeneration. Cervical disc degeneration is a normal part of the aging process. However, the abnormal forward curvature that may result from it is not normal, and cervical kyphosis may lead to chronic neck and/or arm pain as discussed above, and importantly, may also lead to an increased rate of disc degeneration in the cervical spine.
When patients present to my office with neck and/or arm pain and their x-rays demonstrate cervical kyphosis, they can often be successfully treated with non-operative care that may include physical therapy, chiropractic care, medications, and possibly injections. On the other hand, surgery may be indicated if the symptoms are not relieved with these modalities or if there are any significant neurologic deficits present on physical examination.
I was recently fortunate enough to have had the opportunity to treat a very pleasant 52 year-old woman with this condition. She complained of chronic neck and arm pain. Her x-rays (below) demonstrated multiple levels of cervical disc degeneration and 8 degrees of cervical kyphosis (forward curvature). Remember, normal alignment is about 20 degrees of lordosis, so she is about 30 degrees off from what would be considered normal alignment.
Her MRI also demonstrated multiple levels of nerve root impingement. Having failed to improve with the normal course of nonoperative care, she was offered surgery decompress the spinal cord and nerve roots and to correct her spinal deformity.
She underwent a 3-level anterior cervical discectomy and fusion (ACDF) in our outpatient surgery center. At the Orthopedic Surgery Center of Palm Beach County, we have to ability to monitor our patients overnight and for up to 23 hours postoperatively if necessary. This patient spent the night at our facility with a highly trained nurse at her side to monitor her for any potential complications. She was discharged home in stable condition the following morning. Her postoperative x-rays demonstrated correction of her deformity following the C4-C7 ACDF procedure.
Welcome to your Spine Lounge. I look forward to sharing my knowledge and expertise in the field of Orthopedic Spine Surgery. Please comment with any subjects or concerns you would like me to address in future posts. All ideas welcome!
Jason Billinghurst, M.D. is a Board Certified and a fellowship trained Orthopaedic Spine Surgeon. Dr. Billinghurst treats disorders of the cervical, thoracic, and lumbar spine, including degenerative disc disease, spinal stenosis, spondylolisthesis, disc herniations, radiculopathy, myelopathy, compression fractures and spinal infections.