Espondilosis Cervical Degenerativa

The n e w e ng l a n d j o u r na l of m e dic i n e
Review Article
Allan H. Ropper, M.D., Editor
Degenerative Cervical Spondylosis

Nicholas Theodore, M.D.
D
egenerative cervical spondylosis is a chronic, progressive de- From the Department of Neurosurgery,
terioration of osseocartilaginous components of the cervical spine that is Johns Hopkins School of Medicine, Balti-
more. Address reprint requests to Dr.
most often related to aging. Radiographic evidence of degeneration of the Theodore at Johns Hopkins Hospital,
cervical spine occurs in virtually all persons as they age; however, not all persons 600 N. Wolfe St., Meyer 7-113, Baltimore,
have the typical symptoms of neck pain or neurologic deficits that correspond to MD 21287, or at theodore@jhmi.edu.
the mechanical compression of neural elements. Symptomatic cervical spondylosis N Engl J Med 2020;383:159-68.
is initially managed with nonsurgical treatment options, which usually result in DOI: 10.1056/NEJMra2003558
Copyright © 2020 Massachusetts Medical Society.
abatement of symptoms. Surgical intervention may be indicated if there is clini-
cally significant neurologic dysfunction or progressive instability or deformity of
the cervical spine. No currently approved therapy addresses the cause of degen-
erative cervical spondylosis or reverses the deterioration. In select patients, surgi-
cal intervention can lead to favorable outcomes.
Ter minol o gy a nd Epidemiol o gy

Degeneration of the cervical spine has acquired many equivalent names, including
degenerative cervical spondylosis, cervical degenerative disease, cervical spondylo-
sis, cervical osteoarthritis, and neck arthritis. The term spondylosis comes from
the Greek word spóndylos, meaning vertebra. In general, these terms refer to age-
related wear and tear that affect elements of the cervical spine over time, including
the intervertebral disks, facet joints, and other connective-tissue structures (e.g.,
cervical spinal ligaments). However, cervical spine degeneration may also have
immune inflammatory components.1,2 The disorder may be associated with gener-
alized neck pain, mechanical or axial neck pain, compression and inflammation
of the cervical nerve roots exiting the cervical spine (cervical radiculopathy), and
compression and inflammation of the adjacent cervical spinal cord (cervical my-
elopathy).3
Although age-related degenerative changes of the spine are almost universal,
they may begin as early as in the first decade of life.4 Population-based studies
have shown that approximately 80 to 90% of people have disk degeneration on
magnetic resonance imaging (MRI) by the age of 50 years.5,6 A review of the
global burden of low back and neck pain estimated that in 2015, more than a third
of a billion people worldwide had mechanical neck pain of at least 3 months’
duration,7 underscoring the global health implications of degenerative cervical
spondylosis.8 A much smaller number of people have cervical radiculopathy (esti-
mated annual incidence, approximately 83 cases per 100,000 persons)9 and my-
elopathy (approximately 4 per 100,000)10 as a result of cervical spondylosis. Clinical
features of spondylosis are more common in men than in women, with a peak
incidence between the ages of 40 and 60 years for both men and women.11,12
n engl j med 383;2 nejm.org July 9, 2020 159

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Patho gene sis a nd annulus and decreased yield strength predis-

Pathoph ysiol o gy poses the annulus to fissuring, with resultant
herniation of the nucleus pulposus (the common
Although degenerative cervical spondylosis can condition of disk herniation), which impinges
affect any component of the cervical spine, such on the spinal cord or nerve roots.
as bone quality and joint structures,13 the most In addition, disk desiccation is associated with
clinically significant changes occur in the inter- loss of disk height, which is one reason that
vertebral disks and facet joints. The interverte- people “shrink” with age. Loss of disk height also
bral disk consists of the annulus fibrosus on the narrows the foramina, through which nerve roots
exterior border of the disk and the nucleus exit the spinal column, and leads to circumfer-
pulposus in the interior.14 Like most dense con- ential bulging of the annulus.
nective tissue (e.g., ligaments), the intervertebral Finally, nociceptive nerve fibers that are pres-
disk is essentially avascular.15,16 Nutrient and ent in the annulus and nucleus pulposus become
waste exchange occur primarily through diffu- sensitized by the cytokine milieu of the degen-
sion across the capillary beds in the adjacent erative disk, putatively leading to a syndrome of
superior and inferior vertebral end plates.17 The pure diskogenic pain.24,25 Mechanical neck pain
intervertebral disks are metabolically active tis- is more often due to the distortion of surround-
sues, and cells deep within the disk, where oxy- ing soft tissues, including muscles and liga-
gen is scarce, have adopted mechanisms to ments, and the cause of pain in patients with
compensate for the relative hypoxia, including degenerative cervical spondylosis is often diffi-
the up-regulation of hypoxia-inducible factors cult to determine. It has been suggested that the
(e.g., HIF-1α).18,19 Inner intervertebral disk cells central nervous system may become sensitized
(nucleopulpocytes) exist in a precarious state and perpetuate neck discomfort in patients with
and may die in the presence of age-related chronic spinal pain.26,27
changes such as vertebral bony end-plate calcifi- Degeneration of the cervical facet joints, a set
cation that decrease the limited exchange of of two synovial joints that stabilize adjacent ver-
nutrient and waste products.17 tebrae at every spinal level below C1, may occur
The loss of intervertebral disk cells is thought as a result of — or independent of — degenera-
to contribute to a shift from tissue homeostasis tion of the intervertebral disk. Such degenera-
toward net catabolism, leading to intervertebral tion leads to pain and radiculopathy.
disk deterioration.20 However, the events trigger- Myelopathy occurs if vertebral bodies are dis-
ing catabolic processes within the intervertebral placed, a condition termed spondylolisthesis.4
disk have not been clearly defined. Such events This process is the result of damage to several
may have a genetic basis or may be related to elements of the spinal architecture. Normally,
previous spinal trauma, including subclinical the cervical facet joints provide load-bearing
and unnoticed injuries.21,22 Up-regulation of pro- support alongside the intervertebral disk and
inflammatory cytokines within the disk, includ- stabilize the neck during flexion, extension, and
ing tumor necrosis factor α, interleukin-1β, and rotation. In the context of disk degeneration, the
interleukin-6, occurs concomitantly with the facet joints may be subjected to increased load
loss of matrix-producing cells, further promot- bearing, which leads to osseocartilaginous al-
ing the loss or senescence of native matrix-pro- terations and destabilizes the joints.13 Degenera-
ducing cells and subsequent replacement with tion of the facet joints is similar to degeneration
fibroblast-like cells.20 As a result, the production seen in other diarthrodial joints, such as the
of hydrophilic proteoglycans is decreased, lead- knee, and may be characterized by joint-space
ing to gradual desiccation of the disk and the narrowing, subchondral sclerosis, and osteo-
transfer of biomechanical loads from the nucle- phyte formation. These changes narrow the
us pulposus to the surrounding annulus.13 Fur- spinal canal and neural foramina and decrease
thermore, this degenerative process is accompa- neck mobility. Like the intervertebral disk, the
nied by the secondary up-regulation of matrix facet joints are innervated by nociceptive nerve
metalloproteinases by resident disk cells, which fibers and may be sources of cervical spine
lowers the yield strength of the annulus.23 The pain.28 Cervical facet joint syndrome, which is
combination of increased load sharing by the focal pain caused by degeneration of a cervical
160 n engl j med 383;2 nejm.org July 9, 2020

Degener ative Cervical Spondylosis
Table 1. Worrisome Signs and Symptoms in the Evaluation of Patients with Degenerative Cervical Spondylosis.*
Signs and Symptoms Cause Physical Examination

History of cancer (especially breast, prostate, Cancer Variable findings, neurologic deficit,
or lung), weight loss, night sweats, fever, exquisite tenderness over vertebral
nocturnal neck pain body
History of intravenous drug use, immunocom- Spinal abscess Usually severe local pain
promised status, fever, diabetes, recent
sepsis
Decreased dexterity in hands or feet, gait and Spondylitic myelopathy Hyperreflexia, clonus, ataxia, Romberg’s
balance instability, increased urinary sign, atrophy of intrinsic hand
frequency and urgency muscles
* The information is from Childress and Becker.31
facet joint, is recognized by some clinicians as a or upper back to the proximal arm, is the most
subcategory of degenerative cervical spondylosis common symptom of cervical degenerative ra-
that calls for distinct treatment.29,30 diculopathy.9 Radicular neck pain may also be
accompanied by painful neck spasms. Patients
with cervical degenerative radiculopathy may
Cl inic a l Pr e sen tat ion a nd
Di agnosis have paresthesia, numbness, or weakness that
often — but not always — corresponds to der-
Patients with degenerative cervical spondylosis matomal distributions of the affected cervical
may present with mechanical neck pain, radicu- nerve root.31 Diminished deep-tendon reflexes,
lopathy, myelopathy, or a combination of these such as those of the biceps (C6 nerve root) or
symptoms. Mechanical neck pain may be iso- triceps (C7 nerve root), are corroborative of
lated to the neck or may radiate broadly, such nerve-root compression.
as to the shoulders, head, chest, and back. The Provocative tests used to aid in the diagnosis
source of the pain is often difficult for patients of cervical degenerative radiculopathy include
to pinpoint. This complicates management, the Spurling test, the shoulder-abduction test,
since the pain could stem from the degenerated and the cervical-traction test.33,34 In the typical
intervertebral disk (pure diskogenic pain), the application of the Spurling test, the patient’s
degenerated facet joints, or the muscular and neck is turned to the side of the radicular pain
ligamentous structures. The pain is often wors- and is then slightly extended. Downward pres-
ened by neck motion and relieved by rest and sure is applied to the top of the patient’s head,
immobilization. However, neck pain is relatively which narrows the neural foramina on the af-
common in the general population, affecting an fected side. If the pain is elicited or worsened, it
estimated 15% of people at any time, and is not can be attributed to radiculopathy. The test may
specific to degenerative cervical spondylosis.3 A be repeated by turning the patient’s head to the
patient presenting with neck pain may be asked side opposite the pain; if the pain is worsened by
about red-flag signs and symptoms, such as a this maneuver, a musculoskeletal cause is sug-
history of cancer, gait instability or sensory loss gested. The shoulder-abduction test is another
associated with myelopathy, and fever with noc- useful diagnostic tool. This test is performed by
turnal pain suggestive of spinal abscess — all of placing the palm or forearm of the affected arm
which require rapid evaluation (Table 1). on top of the patient’s head. If the radicular pain
Cervical radiculopathy from spondylosis is is relieved, radiculopathy is the likely source of
caused by mechanical compression and inflam- the pain. Manual cervical traction may be used
mation of a cervical nerve root, most commonly as a test to expand the neural foramina; if ra-
C6 or C7.31,32 The compression may be acute (e.g., dicular pain is relieved in this way, then radicu-
caused by an abruptly herniated disk) or chronic lopathy is suggested.
(e.g., the result of hypertrophied facet joints). Cervical degenerative myelopathy is the least
Pain arising from the compressed and inflamed common but most worrisome presentation of
nerve root, mainly radiating from the shoulder degenerative cervical spondylosis. It is caused by

Table 2. Differential Diagnosis for Cervical Degenerative Spondylosis.*
Clinical Feature Acute Conditions Chronic Conditions

Neck pain Cervical strain or sprain, painful interverte- Fibromyalgia, failed surgical fusion, referred visceral
bral disk, painful facet joint pain, hypochondriasis and somatoform disorders
Radiculopathy Intervertebral disk herniation, brachial Intervertebral disk herniation, shoulder disorder,
plexitis entrapment neuropathy, focal facet hypertrophy
Myelopathy Intervertebral disk herniation, pathologic Intervertebral disk herniation, spinal instability, central
fracture, Guillain–Barré syndrome canal stenosis, multiple sclerosis, neoplasm, infec-
tion, myopathies, syringomyelia, arteriovenous
malformation, vitamin B12 deficiency
* The information is from Voorhies.3
mechanical compression and is associated with that virtually all patients older than 50 years of
inflammation and edema of the spinal cord; age have cervical degenerative changes on one or
inflammation and edema lead to slow, progres- more forms of imaging, and many findings are
sive deterioration of neurologic function as a not specific. For these reasons, diagnostic imag-
result of narrowing of the spinal canal and com- ing is often not recommended for patients who
pression of the long tracts and local segmental initially present with nontraumatic neck pain
elements of the spinal cord.35 Both static (at rest) without neurologic symptoms or signs or red
and dynamic (repetitive motion) compressive fac- flags.
tors contribute to deterioration.36,37 For example, For patients with persistent neck, shoulder, or
an already compressed spinal cord may sustain arm pain and suspected radiculopathy, an initial
further compression on neck flexion, which in- radiographic evaluation may be performed, with
creases tension on the spinal cord because of its the use of anteroposterior, lateral, and oblique
relatively fixed longitudinal position, maintained radiographs, which are relatively inexpensive
by the dentate ligaments and cervical nerve and provide information pertaining to degenera-
roots. Patients with myelopathy may present tive changes and alignment.40 Lateral flexion or
with a variety of subtle neurologic findings, extension views may also be obtained during the
which they may attribute to natural loss of func- initial evaluation and may disclose cervical in-
tion with age. These include loss of manual stability, limited range of motion, and fused
dexterity; gait and balance disturbances, espe- cervical spine segments.41 For patients with pro-
cially in the absence of visual cues (Romberg’s gressive neurologic impairments or any feature
sign); sensory loss in the hands or feet; arm or that suggests myelopathy, cervical spine MRI
hand weakness; and defecatory or urinary fre- without the administration of contrast material
quency, urgency, or hesitancy. There may be up- is the preferred imaging technique, since it pro-
per-motor-neuron signs, including clonus, hyper- vides information about osseous, soft-tissue,
reflexia, Hoffmann’s sign, and Babinski’s sign.38 and spinal cord structures (Fig. 1).42 The pres-
Patients with symptoms of myelopathy almost ence of an abnormal signal within the cervical
always have associated neck pain and stiffness cord or adjacent to the level of compression by
and may have pain in the arms or shoulders. spondylosis is considered a serious finding,
Radicular features, mentioned above, are also which may signify a less satisfactory outcome
common in the context of cervical degenerative with surgical decompression than would other-
myelopathy. Some persons have Lhermitte’s sign wise be expected. On the other hand, in some
(electrical sensations radiating down the spine cases the spinal cord seems able to withstand a
or across the shoulders) on neck flexion, and substantial degree of deformation, with few re-
other signs and symptoms that are occasionally sulting symptoms, if the deformation develops
attributable to cervical myelopathy but have slowly. The decision to surgically decompress
many alternative causes.38 the spinal canal in cases of cervical spondylosis
Table 2 outlines the differential diagnosis for incorporates, but does not entirely depend on,
the main presentations of cervical spondylosis, such factors as the degree of disability (e.g.,
with or without myelopathy.3,31,39 In evaluating impairment of activities of daily living) and the
patients with neck pain, it is useful to recognize rapidity of symptom progression. If MRI is con-

A B
Figure 1. MRI Scans of the Cervical Spine in a Patient with Cervical Spondylosis.
A 75-year-old man presented with a 2-year history of progressive upper-extremity paresthesias and radicular pain.
He reported having dropped items recently from both hands and noted dexterity and balance deficits but no bowel
or bladder incontinence. A sagittal T2-weighted MRI scan shows stenosis of the central spinal canal at C4–C7, with
an osteophyte, deformation of the cord, disk material, and spondylolisthesis at C5–C6 (Panel A, arrow). An axial T2-
weighted image shows severe foraminal stenosis (Panel B, arrow) and severe encroachment on the spinal canal by
osteophyte, ligamentous, and facet hypertrophy.
traindicated or unavailable, a computed tomo- the absence of signs of nerve-root or spinal cord
graphic (CT) study or CT myelography of the compression. The care of patients with chronic,
cervical spine (Fig. 2) is an alternative imaging degenerative neck pain can be challenging and
approach.43,44 Electrodiagnostic testing may be frustrating for both patient and health care pro-
helpful in evaluating cervical radiculopathy by vider, especially given the difficulty in identify-
showing denervation in muscles specifically refer- ing the cause. Many patients benefit from a re-
able to a single cervical nerve root.45,46 Guide- ferral to a specialist in chronic pain management,
lines for the use of injections and other ap- and many have improvement when coexisting
proaches, including advanced imaging studies psychiatric disorders, including anxiety and de-
such as single-photon emission CT to identify pression, are treated.52-54 In general, surgical
“pain generators,” are ill defined and lack evi- outcomes for patients with chronic neck pain
dence-based support.3,47,48 are limited, especially when the source of the
pain cannot be identified.
Most patients with degenerative cervical ra-
T r e atmen t A pproache s
a nd Ou t c ome s diculopathy have reduced pain and improved
neurologic function with nonsurgical care, in-
Various treatment algorithms have been created cluding oral analgesics, epidural glucocorticoid
for managing degenerative cervical spondylosis injections, physical therapy, cervical traction or
and mechanical neck pain, radiculopathy, or brief immobilization in a cervical orthosis, and
myelopathy.31,49-51 The management of degenera- other options, such as massage.9,31,55 Few high-
tive neck pain in patients who have no neuro- quality studies have evaluated these conservative
logic deficit is typically a “tincture of time,” therapies to provide a recommendation, and the
along with analgesics and other conservative various approaches may offer similar rates of
options, including physical therapy.3 Some pa- symptomatic improvement.
tients have worsening or chronic pain, even in The severity and rate of progression of neuro-

logic deficits are the main aspects of the evalu- Figure 3 (facing page). Cervical Spine Decompression
ation of patients with degenerative cervical ra- and Fusion.
diculopathy, since clinically significant motor Anterior cervical diskectomies at C3–C4 and C4–C5,
weakness or worsening neurologic symptoms with the placement of bone-graft spacers where disks
usually indicate the need for surgical evaluation. were removed and stabilizing screw–plate instrumen-
The timing for surgical evaluation is not clear, tation, are shown schematically in Panel A and in a lat-
eral radiograph in Panel C. Posterior laminectomies
although advancing nerve-root compression in and lateral mass screw–rod instrumentation and fu-
association with weakness, atrophy, or sensory sion at C3–C6 are shown schematically in Panel B and
loss, in addition to deteriorating neurologic sta- in an anteroposterior radiograph in Panel D.
tus at any time, generally prompts referral to a
spine surgeon. In patients with identifiable
causes of nerve-root compression — for exam- In view of the progressive natural history of
ple, a herniated disk — surgical outcomes are nerve-root or spinal cord compression or pain in
often good.56 most patients, surgical treatment for degenera-
Patients with degenerative cervical myelopa- tive cervical myelopathy can be a good op-
thy are also typically referred to a spine surgeon. tion.35,36 For patients with moderate-to-severe
A B
Figure 2. Postmyelography CT Scans of the Cervical Spine.

A 68-year-old woman had increasing hand weakness, intrinsic hand-muscle atrophy, and hand numbness. She had
begun falling and had Romberg’s sign. She was unable to undergo MRI. A midsagittal CT myelogram (Panel A)
shows multilevel cervical spondylosis with osteophytes, disk protrusion, and cord compression at C4–C5 (arrow).
An axial image at the C3–C4 disk space shows a right lateral osteophyte (Panel B, arrow) encroaching on the neural
foramen, and a similar image at the C4–C5 disk space shows marked cord compression (Panel C).

A B
C1
C1
C2
C2
C3
C3
C4 C4 Bone
Bone spacer
graft
Metal rod
C5 and screws
C5
C6
C6
Metal plate C7
C7
and screws
C D

neurologic deficits, consensus statements have hypertrophy. Why only some patients have symp-
suggested that nonsurgical management, as toms after these changes occur is unclear. Cer-
compared with surgery, leads to inferior clinical tain anatomical configurations, such as a con-
outcomes. However, data from well-performed genitally narrow spinal canal, short pedicles,
randomized trials, such as those that have been and small neural foramina, are almost certainly
conducted for lumbar spine disease, are lacking, contributors to the development of symptoms
and so this suggestion is driven largely by clini- for a given degree of spondylosis. Staying physi-
cal experience.57 cally active, maintaining good posture, and pre-
Surgical approaches to the treatment of de- venting neck injuries may all help prevent symp-
generative cervical radiculopathy, myelopathy, or tomatic degenerative cervical spondylosis. In
both include anterior, posterior, and anteropos- addition, smoking and obesity have been found
terior techniques (Fig. 3).58-60 Each technique has to be associated with spondylosis; therefore,
its proponents and inherent drawbacks, related managing these risk factors may offer benefits.62
mainly to the adequacy of decompression of the
spinal cord and nerve roots, maintenance of C onclusions a nd
stability of the spinal column, duration of the R ec om mendat ions
procedure and blood loss, and time required to
recover from surgery and be discharged from Degenerative cervical spondylosis is caused by
the hospital. In some instances, the surgeon’s arthritic changes in the osseocartilaginous com-
facility and experience with a certain procedure ponents of the cervical spine, which may com-
are considerations in choosing the approach. press spinal nerve roots, the spinal cord, or both,
The goals of surgery are to decompress the nerve causing neck pain, radiculopathy, or myelopathy.
roots or spinal cord and stabilize the spine, Treatment is generally nonsurgical, especially
while attempting to restore or maintain rela- for pain and mild radiculopathy, which are typi-
tively normal spinal alignment. Outcomes de- cally self-limiting. However, surgery is generally
pend on the severity and duration of the neuro- indicated to treat myelopathy and may be indicated
logic deficit at the time of surgery. Advanced for persistent and severe nerve-root compression.
age, smoking, and coexisting conditions such as
obesity and diabetes mellitus have been shown Dr. Theodore reports receiving royalties and consulting fees
from Globus Medical and royalties from Depuy Synthes; and
to negatively affect outcomes.61 holding patent US20130345718A10 on a surgical robot platform,
licensed to Globus Medical, for which royalties are received, and
holding patent US 2019/0090907 A1 on a revision connector for
Pr e v en t ion spinal constructs, licensed to Depuy Synthes, for which royalties
are received. No other potential conflict of interest relevant to
In general, virtually all people have some degree this article was reported.
of cervical degeneration with age, including in- Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
tervertebral disk desiccation, neural foraminal I thank Dr. Ethan Cottrill for assistance with the literature
narrowing, osteophyte formation, and facet joint review and preparation of an earlier version of the manuscript.
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Espondilosis Cervical Degenerativa

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The n e w e ng l a n d j o u r na l of m e dic i n e

Allan H. Ropper, M.D., Editor

Degenerative Cervical Spondylosis

Ter minol o gy a nd Epidemiol o gy

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Patho gene sis a nd annulus and decreased yield strength predis-

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Signs and Symptoms Cause Physical Examination

* The information is from Childress and Becker.31

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Table 2. Differential Diagnosis for Cervical Degenerative Spondylosis.*

Clinical Feature Acute Conditions Chronic Conditions

* The information is from Voorhies.3

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Figure 2. Postmyelography CT Scans of the Cervical Spine.

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The New England Journal of Medicine

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images in clinical medicine

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* The information is from Childress and Becker.31

* The information is from Voorhies.3