Degenerative cervical spine disease

Axial neck pain

Axial neck pain with cervical spondylosis has no cure and is usually considered to deteriorate with age. Yet many patients with severe cervical spondylosis (on radiographic studies) have no axial neck pain; the presence of pain may not necessarily correlate with the degree or severity of radiographic spondylosis.[1]Matsumoto M, Fujimura Y, Suzuki N, et al. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998 Jan;80(1):19-24. https://online.boneandjoint.org.uk/doi/pdf/10.1302/0301-620X.80B1.0800019 http://www.ncbi.nlm.nih.gov/pubmed/9460946?tool=bestpractice.com [3]Braga-Baiak A, Shah A, Pietrobon R, et al. Intra- and inter-observer reliability of MRI examination of intervertebral disc abnormalities in patients with cervical myelopathy. Eur J Radiol. 2008 Jan;65(1):91-8. http://www.ncbi.nlm.nih.gov/pubmed/17532165?tool=bestpractice.com [4]Siivola SM, Levoska S, Tervonen O, et al. MRI changes of cervical spine in asymptomatic and symptomatic young adults. Eur Spine J. 2002 Aug;11(4):358-63. http://www.ncbi.nlm.nih.gov/pubmed/12193998?tool=bestpractice.com

Patients presenting with axial neck pain typically improve over time, although the pain may recur and may be severe.[19]Theodore N. Degenerative cervical spondylosis. N Engl J Med. 2020 Jul 9;383(2):159-68. http://www.ncbi.nlm.nih.gov/pubmed/32640134?tool=bestpractice.com The patient may need lifelong pain management treatment if the pain is persistent and prolonged.

Patients presenting primarily with axial neck pain rarely develop a more severe condition in the sense of the degenerative joint disease leading to either radiculopathy or myelopathy.

Cervical spondylotic radiculopathy

Long-term outcome studies suggest that cervical radiculopathy eventually resolves in most patients over 1 to 2 years if not treated surgically.[24]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72. http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com The role of surgery is therefore primarily to speed up or enhance the natural degree of recovery, particularly if the patient has severe pain.

Degenerative cervical myelopathy

Once patients undergo adequate decompressive surgery, their neurologic function typically stabilizes for many years.[65]Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013 Sep 18;95(18):1651-8. http://www.ncbi.nlm.nih.gov/pubmed/24048552?tool=bestpractice.com Clear neurologic worsening can usually be attributable to a specific cause, such as adjacent segment stenosis after limited anterior fusion, instability with subsequent spinal cord pressure, such as kyphotic angulation after laminectomy, or instability, such as C7/T1 subluxation, after C3 to C7 posterior fusion. However, unprotected levels can progressively deteriorate even with surgery and can, over time, cause new areas of spinal cord compression that may need further treatment.

Most cervical spine surgery enhances a baseline level of axial neck pain, and patients will often need long-term treatment of their difficult axial neck pain.[32]Fehlings MG, Tetreault LA, Riew KD, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Global Spine J. 2017 Sep;7(3 suppl):70S-83S. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684840 http://www.ncbi.nlm.nih.gov/pubmed/29164035?tool=bestpractice.com

Asymptomatic abnormalities

There are no studies detailing the best approach to asymptomatic patients who present with worrisome abnormalities such as cervical stenosis. Most abnormalities are of unknown significance, and treatment (particularly surgery) should not be suggested unless it is clear to the patient that the procedure is not to treat a symptom but to prevent a specific problem from occurring in the future. Surgical treatment may possibly be indicated in some patients with asymptomatic abnormalities who, when followed over time, develop new symptoms suggestive of disease progression.