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Neck · treated under Musculoskeletal Physiotherapy

Cervical Spondylosis

Also called Neck arthritis, Cervical spondylitis, Degenerative neck.

Wear-related change in the neck that most adult scans show, painful or not. Ordinary neck pain and pinched-nerve arm pain both settle with movement and strength work; pressure on the spinal cord is the rare presentation that needs a surgeon.

Written by , BPT, MPT · MIAP License No. 69386

Updated · Awaiting clinical review

A practitioner guiding a patient's head into a side bend during a neck assessment

What it is

Cervical spondylosis is the medical name for wear-related change in the neck: discs that have lost water and height, small bony spurs at the edges of the vertebrae, and thickened ligaments and joints [1]. It is less a disease than a description of a neck that has been used for some decades, and it is what most X-ray and MRI reports of adults say, whether or not the neck hurts. In India the same finding is very often called cervical spondylitis. The two words are not the same. Spondylosis is wear. Spondylitis means inflammation of the spine, which is a different and much rarer group of conditions. If your report says spondylosis, it is describing wear.

Neck pain itself is common. It is the fourth leading cause of disability, and more than 30% of adults have an episode in any given year [2]. Most episodes settle with or without treatment, though nearly half of people go on to have some pain or repeat episodes [2]. The wear on the scan and the pain in the neck are only loosely related, and the first job of the assessment is to work out which of three quite different things the label is covering: an aching, stiff neck; arm pain from an irritated nerve root; or, rarely, pressure on the spinal cord itself [1].

How it presents

  • A dull, aching neck that is stiff first thing and after sitting still, often spreading to the top of the shoulders and between the shoulder blades
  • Turning to look over the shoulder, reversing a car for instance, is limited and grinds or catches
  • A headache at the back of the head that starts from the neck
  • With a nerve root: sharp, electric pain in a strip down one arm, with pins and needles or numbness in a patch of the hand, most often the middle finger or the thumb and index finger, because the C7 and C6 roots are the ones most commonly involved [4]
  • Arm pain that eases when the hand is rested on top of the head, and worsens when looking up or tilting the head towards the painful side
  • Weakness in a minority: a grip that fades, or difficulty pushing a door or lifting the arm
  • With the spinal cord: clumsy hands, unsteady walking and changes in bladder control, covered under the signs to be seen sooner below [14]

Most neck pain has no arm symptoms at all, and that is the presentation that does best. Arm pain with a clear strip of pins and needles points to a nerve root. Symptoms in both hands, legs that feel stiff or heavy, or feet that do not quite know where the floor is point to the spinal cord, and that is the pattern that must not be missed.

Who gets it and why

Discs in the neck dry out and flatten with age. As they lose height, the small joints behind them and the edges of the vertebrae take more load and respond by laying down extra bone, the spurs seen on an X-ray. The openings the nerve roots leave through narrow, and the canal the spinal cord runs through can narrow too [1]. Most of this is silent. Neck pain, when it comes, is usually the muscles and joints of a stiff neck complaining about a workload they are not conditioned for, with the wear as a bystander.

The scans of people with no symptoms make the point. In an MRI study of 1211 healthy volunteers aged 20 to 70, 87.6% had a bulging disc, including 73.3% of men and 78.0% of women in their 20s, and the bulges became more frequent and more severe with each decade [3]. Compression of the spinal cord was seen in 5.3% and signal change within the cord in 2.3%, mostly after the age of 50, and none of these people had symptoms [3]. A report that says spondylosis is describing your age group, not your prognosis.

Risk factors

  • Age. Disc bulging rises through each decade and cord compression appears mostly after 50 [3]; nerve-root pain peaks between 50 and 54 [4]
  • Long hours with the head held still, at a desk, a phone or a steering wheel. This does not cause the wear, but it is the reliable trigger for the pain
  • A previous episode. In the Rochester study, 41% of people with cervical radiculopathy had a history of the same problem in the lower back, and about a third had a recurrence over a median of nearly five years [4]
  • An injury or unusual effort, though in the same study only about 15% of cases were preceded by one; most start without a clear cause [4]
  • Heavy manual work, or loads carried on the head or shoulders through the day

How it is diagnosed

The diagnosis is made in the room. The story tells us which of the three presentations we are looking at, and the examination confirms it: how far the neck moves and what each direction provokes, whether tilting or compressing the head reproduces the arm pain, and a check of the strength, sensation and reflexes supplied by each nerve root [1]. When a root is involved, that tells us which one and how irritable it is. A short screen for the spinal cord, leg reflexes, the way you walk and a few hand tests, is part of every neck assessment, because the early signs of myelopathy are subtle and easy to put down to getting older [14].

Imaging is not part of the routine diagnosis. Abnormal findings are the norm on the cervical MRI of people with no symptoms [2][3], so a scan cannot tell us whether the wear it shows is the cause of your pain. It earns its place when there are focal neurological signs, when pain has not responded to a proper course of treatment, or when an injection or surgery is being considered [2].

When imaging earns its place

The exception is any suspicion of myelopathy: clumsy hands, a change in walking, or bladder symptoms alongside a stiff neck. That needs an MRI, urgently if symptoms are progressing, and a specialist opinion, because the cord recovers poorly once damaged, and in one series the average delay from first symptoms to diagnosis was over two years [14].

What the evidence says

Treatment by treatment, with the studies behind each verdict numbered to the sources at the end of the page.

  • Keeping the neck moving

    Core treatment

    The wait-and-see group in the Dutch radiculopathy trial, told to carry on with daily activities as far as possible, saw arm pain fall by about a fifth of the pain scale over six weeks with no other treatment [6]. Most episodes of ordinary neck pain settle with or without treatment [2]. Gentle movement through a comfortable range, often, does the neck no harm and stops stiffness feeding the pain.

  • Strengthening exercise

    Core treatment

    The best-supported active treatment. The Cochrane review found moderate-quality evidence that strengthening the neck, shoulder blade and arm muscles reduces chronic neck pain and improves function, and that stretching alone does not [7]. In a Finnish trial of 180 women office workers with chronic neck pain, both a strength programme and an endurance programme reduced pain and disability at one year compared with stretching and aerobic exercise alone, and the strength group's neck flexion strength improved by 110% [8].

  • Hands-on treatment

    Helps alongside

    Mobilisation and manipulation give short-term relief and produce similar results to each other; on its own, mobilisation may do no better than no treatment [9]. Manipulation of the neck carries a rare but serious risk [9], and it must not be done at all when the spinal cord is involved [14]. We use gentle mobilisation and soft-tissue work to reduce pain and guarding so that the exercise programme can start, which is how the physiotherapy guideline positions it: alongside exercise, not instead of it [10].

  • Posture and workstation advice

    Helps alongside

    Changing the desk on its own has weak evidence: the Cochrane review of workplace programmes found low-quality evidence of no difference in pain from any specific intervention [12]. How long you hold any one position matters more than which position it is, so the advice is to change position often and to build a neck that tolerates the day, which is the strengthening above [8]. A screen at eye level and a chair that supports the mid back are still worth five minutes.

  • Pain relief

    Helps alongside

    Simple analgesia or a short course of an anti-inflammatory is reasonable for comfort, and there is some evidence for a muscle relaxant in acute neck pain with spasm [2]. Nothing in a tablet changes the neck; the value is in making movement and sleep possible in the worst week.

  • A cervical collar

    Second line

    In the Dutch trial of 205 people with cervical radiculopathy of less than a month, a semi-hard collar with rest for three to six weeks and a course of physiotherapy with home exercises both reduced arm pain more than waiting, by a similar extra amount, and both reduced neck pain, which did not improve on its own in six weeks [6]. That is the case for a collar: early, severe arm pain from a root, for a few weeks at most. For ordinary neck pain it has no role, and worn for longer it weakens the muscles the neck depends on.

  • Traction

    Second line

    The Cochrane review found no trial with a low risk of bias that supports or refutes it; the one such trial, of 100 people with radicular symptoms, found no difference between traction and placebo traction [11]. We occasionally use it for short-term arm pain relief in radiculopathy, never as the plan.

  • Injections

    Second line

    The evidence for epidural steroid injections in cervical radiculopathy is conflicting [2]. Worth discussing when arm pain is too severe to sleep or to begin rehabilitation, as a bridge into it rather than a treatment on its own.

  • Surgery for a nerve root

    Second line

    In a Swedish trial of 63 people with cervical radiculopathy, surgery followed by physiotherapy improved things faster than physiotherapy alone: 87% versus 62% rated themselves better at one year, but by two years the figures were 81% and 69%, no longer a significant difference, and both groups had improved substantially [13]. The trial's own conclusion was that structured physiotherapy should be tried before surgery is chosen [13]. Surgery is for severe pain that is not settling, or a root that is losing function.

  • Surgery for the spinal cord

    Core treatment

    Different rules apply when the cord is compressed. Decompression is recommended for moderate or severe myelopathy and for any that is progressing, because it can halt the decline and damage already done to the cord is often permanent [14]. Treatment within six months of the first symptoms gives the best chance of recovery [14]. Mild, stable myelopathy may be watched with regular review; physiotherapy in that setting is guided by the specialist, and manipulation is off the table [14].

Put together: the wear on the scan is not the target, the neck is. Keep it moving, calm the worst week with hands-on treatment and sensible pain relief, then build strength in the neck and shoulder blades and keep it, because that is what the year-long results came from [7][8]. Arm pain from a root gets the same programme with more patience, a collar for a few weeks if the pain is severe early on [6], and an injection or surgery only for the minority whose pain will not settle or whose nerve is losing function, knowing that the two-year destination was similar either way [13]. The spinal cord is the exception to all of it: that presentation belongs with a surgeon, promptly [14].

How we treat it

At The Rym Space, Bagalur

  1. 1

    Assessment

    The story, then how the neck moves and what each direction provokes, tests that load or free the nerve root, and strength, sensation and reflexes. A short screen for the spinal cord: hands, walking, leg reflexes. You leave knowing which presentation you have and what your scan means.

  2. 2

    A plan you start that day

    The two or three movements that ease the neck or draw pain out of the arm, done little and often. How to sit, how to set up the screen and phone, and how to sleep. Straight talk about pain relief, and whether a collar has a short-term place.

  3. 3

    Week 1: settle the neck

    3 to 5 sessions close together. Gentle mobilisation and soft-tissue work to calm pain and guarding, the easing movements made a habit, and walking as the main activity. Severe arm pain gets resting positions and, if needed, a few weeks of collar time agreed with you.

  4. 4

    Week 2 onwards: build strength

    Strengthening for the deep neck muscles, shoulder blades and upper back, progressed each week, with sessions spacing out as the home programme carries the work. Nerve mobility work once an irritable root allows it, and the working day rebuilt in steps: more desk time, more turning of the head.

  5. 5

    From about week 6: load up and return

    Heavier and more varied loading: carrying, overhead work, the sport or job that brought you in. A neck that turns freely to reverse the car and tolerates a full day. The programme becomes a short routine you keep up most days.

  6. 6

    Discharge, or the next tier

    Done when the neck moves freely, the arm is quiet and you are back to what you came in for. Arm pain not clearly improving by six to eight weeks, any weakness, or any sign of the cord means medical review and imaging, not more of the same.

What to expect, and when

Ranges, not promises. Where a figure comes from a study, the study is numbered.

First 6 weeks
For ordinary neck pain, most acute episodes ease within weeks with or without treatment [2]. For arm pain from a root, the Dutch trial gives the shape of it: arm pain fell by about a fifth of the pain scale in six weeks with no treatment, and by about a third with a collar or physiotherapy [6].
By 4 to 6 months
Radiculopathy from a disc improves substantially within the first four to six months in most people [5]. Pins and needles and a dulled patch of skin usually lag behind the pain.
By 1 to 2 years
In the Swedish trial, 62% of the physiotherapy-only group rated themselves better or much better at one year and 69% at two years, closing the gap on the surgical group [13]. Complete recovery from a disc-related radiculopathy took two to three years in about 83% of people [5].
The long view
At a median of nearly five years in the Rochester study, 90% of people who had had cervical radiculopathy were symptom free or only mildly troubled, though about a third had had a recurrence and 26% had had surgery [4]. For neck pain in general, nearly half of people have some pain or repeat episodes over time [2]. The aim is a neck that recovers quickly when it grumbles.

The wear itself does not reverse, and it does not need to. Pain and function follow the muscles and the nerve, not the X-ray, which is why people with identical scans have very different years. The one timeline that does not forgive waiting is myelopathy: in one series the average delay to diagnosis was over two years, and treatment within six months of symptoms gives the best chance of recovery [14].

When to be seen sooner

Signs that this is something else, or that it needs looking at now rather than after a few weeks of self-care.

  • Hands becoming clumsy: new difficulty with buttons, keys, a phone or handwriting, especially in both hands. This is a typical early sign of pressure on the spinal cord, and it is often mistaken for carpal tunnel syndrome [14]
  • Walking that has become unsteady or wide-based, new falls, or legs that feel stiff or heavy [14]
  • Any new difficulty passing urine, urgency, or loss of bladder or bowel control [14]
  • An electric-shock sensation down the spine or into the limbs when you bend the neck [14]
  • Arm weakness that is getting worse, or arm pain with numbness that has not begun to improve after six weeks of treatment
  • Neck pain after a fall or accident, or in someone with osteoporosis or long-term steroid use, until a fracture is excluded
  • Fever, unexplained weight loss, a history of cancer, or pain that is unrelenting at night

Common questions

My X-ray report says cervical spondylosis. Is it serious?
Almost never on its own. It describes wear that most adults share: in the MRI study of 1211 people with no symptoms at all, 87.6% had bulging discs [3]. The report tells us what your neck looks like. The examination tells us why it hurts and what to do about it.
Is spondylosis the same as spondylitis?
No, though in India the words are often used interchangeably. Spondylosis is wear-related change and is what an X-ray report almost always means. Spondylitis means inflammation of the spine, as in ankylosing spondylitis, a separate condition with different features and different treatment. A report that says spondylosis is describing wear, not diagnosing an inflammatory disease.
Should I wear a collar?
Only for early, severe arm pain from a nerve root, and only for a few weeks. In the Dutch trial a semi-hard collar with rest for three to six weeks reduced arm pain about as much as physiotherapy did over the first six weeks [6]. For ordinary neck pain it has no role, and worn for longer it weakens the muscles your neck depends on.
Do I need an MRI?
Not to start treatment. Abnormal findings are the norm on the scans of people with no symptoms [3], so a scan cannot tell us what is causing your pain. It earns its place when there are neurological signs, when a proper course of treatment has not worked, or when an injection or surgery is being considered [2], and urgently if there is any sign of the spinal cord [14].
Will I need surgery?
Most people do not. For arm pain from a root, surgery relieves pain faster, but by two years the results of surgery and physiotherapy were no longer significantly different in the Swedish trial [13], and in the Rochester study 26% of people ever had an operation [4]. Myelopathy is different: surgery is the treatment for moderate, severe or progressing cases [14].
Will it get worse as I get older?
The wear on the scan increases with age in everyone [3]; the pain does not have to. A neck that is kept moving and strong copes with more wear, not less, and the Finnish gains at one year came from the women who trained, not those who only stretched [8]. Flare-ups happen. The aim is a neck that recovers quickly from them.

Further reading

Sources

Guidelines, systematic reviews and trials only. Each number in the text links to the entry here.

  1. 1.Binder AI. Cervical spondylosis and neck pain. BMJ. 2007;334(7592):527-531. pubmed.ncbi.nlm.nih.gov ↗
  2. 2.Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc. 2015;90(2):284-299. pubmed.ncbi.nlm.nih.gov ↗
  3. 3.Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine. 2015;40(6):392-398. pubmed.ncbi.nlm.nih.gov ↗
  4. 4.Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(Pt 2):325-335. pubmed.ncbi.nlm.nih.gov ↗
  5. 5.Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014;14(8):1781-1789. pubmed.ncbi.nlm.nih.gov ↗
  6. 6.Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009;339:b3883. pubmed.ncbi.nlm.nih.gov ↗
  7. 7.Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015;1:CD004250. pubmed.ncbi.nlm.nih.gov ↗
  8. 8.Ylinen J, Takala EP, Nykänen M, et al. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA. 2003;289(19):2509-2516. pubmed.ncbi.nlm.nih.gov ↗
  9. 9.Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;9:CD004249. pubmed.ncbi.nlm.nih.gov ↗
  10. 10.Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision 2017. Clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. pubmed.ncbi.nlm.nih.gov ↗
  11. 11.Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008;3:CD006408. pubmed.ncbi.nlm.nih.gov ↗
  12. 12.Aas RW, Tuntland H, Holte KA, et al. Workplace interventions for neck pain in workers. Cochrane Database Syst Rev. 2011;4:CD008160. pubmed.ncbi.nlm.nih.gov ↗
  13. 13.Engquist M, Löfgren H, Öberg B, et al. Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine. 2013;38(20):1715-1722. pubmed.ncbi.nlm.nih.gov ↗
  14. 14.Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018;360:k186. pubmed.ncbi.nlm.nih.gov ↗

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