Cervical Spondylosis:

AIM :

To study the effectiveness of Homoeopathic medicines in the treatment of cervical spondylosis presenting with Radiculopathy

Incidence and prevalence :

Transient episodes of acute neck pain and stiffness occur in 40 – 50 % of all adults, with an increasing incidence in those over the age of 45 years. By the age 50, 25-50% of people develop cervical spondylosis; by 75 years of age, it is seen in at least 70% of people. Indeed, they are found almost universally in some degree in persons over 50 years of age.
Symptoms of cervical spondylosis may appear in those as young as 30 years and are most commonly in those aged 40-60 years. Radiological spondylotic changes increase with patient’s age. On the basis of radiologic findings, 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the form of cervical spondylosis.

Sex:

Both sexes are affected almost equally. Cervical spondylosis usually starts earlier in men than in women.

Aetiology

1. Wear and tear on joints that accompanies aging
(Osteoarthritis)
2. Arthritis (inflammation of joint)
3. Trauma such as automobile accidents with whiplash injury, athletic injuries, sudden jerks on arms and falls.

Whiplash injury is due to trauma (usually automobile accidents) causing cervical musculo-ligamental sprain or strain due to hyper flexion or hyper extension.

There are several predisposing factors, which may cause acceleration of these changes.

1. Occupations requiring repetitive motion of the cervical spine.
2. Previous injury with fracture or disc prolapsed.
3. Segmentation defects like hemivertebra or fused vertebrae.
4. There may be a hereditary predisposition to intervertebral disc disease.
5. Fluorosis may play an important part in the development of ossified posterior longitudinal ligament in India.

Signs and Symptoms

Important symptoms and signs are:
1. Neck pain and stiffness may be worse with upright activity.
2. Numbness and weakness in the arms, hands and fingers, and trouble walking due to weakness in the legs.
3. Feel or hear grinding or popping in the neck when you move.
4. Muscle spasms or headaches may originate in the neck.

The condition can make you feel irritable and fatigued, disturb your sleep and impair your ability to work. Pain caused by pressure upon the nerve in the cervical region follows a clearly defined course which depends upon the particular nerve involved, and it is usually severe.

In the assessment of sensory loss it should be remembered that the middle or long finger, representing the central axis of the limb, is innervated mainly by the seventh cervical nerve. The radial half of the hand is innervated by the proximal roots of brachial plexus( C5, C6) whereas the ulnar half is innervated from the more distal roots( C8, T1).

Motor phenomena consist of weakness and wasting of the deltoid, triceps, and biceps or forearm muscles. Wasting of small muscles of the hand is rare in pure cervical spondylosis. Involvement of the C5 segment gives rise to inversion of supinator jerk. Fasciculation may be seen over the affected muscle. Tendon reflexes are diminished. The lesion may be unilateral or asymmetrically bilateral.

On examination, patient usually exhibit restriction of neck movement, especially in extension. Downward head compression by the examiner as well as flexing the neck to the side of the involvement usually aggravates the pain. Nerve root compression in the upper cervical spine is unusual. Compression of C2 causes occipital neuralgia, but if C3and C4 is compressed, it usually causes non specific neck and shoulder pain without any muscle weakness. Compression of the C5 root leads to shoulder and deltoid pain with weakness in the deltoid muscle. The most common root compression syndromes are those involving the sixth and seventh cervical roots. With C6 root compression, the pain is in the radicular distribution down the arm, distal to the elbow, with paraesthesias or sensory loss over the thumb and index finger. Biceps weakness (flexion of elbow) as well as weakness in extension of the wrist, is present and diminution of the biceps and brachioradialis reflex may be present. With C7 root compression, the pain radiate down the back of the arm distal to the elbow. Paraesthesias in the middle finger that also involve the index finger or ring finger or both may be present. Because of the overlapping of the C6 and C8 root the sensory loss may be minimal or absent. Triceps muscle weakness (extension of the elbow) as well as weakness in flexion of the wrist is a hallmark of this root compression. Eighth nerve root compression causes pain down the arm as well as sensory changes that involve the ulnar side of the hand but they usually present with intrinsic hand muscle weakness.

Findings at physical examination may include the following:
1. Typically, the patient exhibits a head tilt away from the side of injury and holds his or her neck stiffly.
2. Increased pain with lateral bending away from the affected side can cause increased displacement of a disk herniation upon a nerve root, while ipsilateral pain would suggest an impingement of a nerve root at the site of the neural foramen.
3. Spurling sign: Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, which results in further foraminal compromise.
4. Lhermitte sign: This generalized electrical shock sensation is associated with neck extension.
5. Hoffman sign: Reflex contraction of the thumb and index finger occurs in response to nipping of the middle finger. This sign is evidence of an upper motor neuron lesion. A Hoffman sign may be insignificant if present bilaterally.
6. Many patients report a reduction in their radicular symptoms by abducting their shoulder and placing their hand behind their head. This is thought to occur by decreasing tension at the nerve root.

On palpation, tenderness usually is noted along the cervical paraspinals and usually is more pronounced along the ipsilateral side of the affected nerve root. Muscle tenderness may be present along muscles where the symptoms are referred (eg, medial scapula, proximal arm, lateral epicondyle). Associated hypertonicity or spasm on palpation in these painful muscles may occur.

Manual muscle testing is an important aspect of determining a nerve root level on physical examination. Perform manual muscle testing to detect subtle weakness in a myotomal distribution.Weakness of shoulder abduction suggests a C5 radiculopathy. Elbow flexion and wrist extension weakness would occur with C6 radiculopathies. Weakness of elbow extension and wrist flexion would occur with a C7 radiculopathy, and weakness of thumb extension and ulnar deviation of the wrist would be seen in C8 radiculopathies.

On sensory examination, a dermatomal decrease or loss of sensation should be noted in patients with clear-cut radiculopathy. In addition, patients with radiculopathy may have hyperesthesia to light touch and pin prick examination. However, the sensory examination can be quite subjective since it requires patient response.

Deep tendon reflexes, or more properly muscle stretch reflexes, since the reflex occurs after a muscle stretch is obtained (most commonly by tapping the distal tendon of a muscle), are helpful in the evaluation of patients presenting with limb symptoms suggestive of a radiculopathy. The examiner must position the limb properly when obtaining these reflexes and the patient needs to be as relaxed as possible. Any grade of reflex can be normal, so it is the asymmetry of reflexes, which is most helpful.The biceps brachii reflex, is obtained by tapping the distal tendon in the antecubital fossa. This reflex occurs at the C5-6 level. The brachioradialis is another C5-6 reflex that can be obtained by tapping the radial aspect of the wrist. The triceps reflex can be obtained by tapping the distal tendon at the posterior aspect of the elbow with the elbow relaxed at about 90° of flexion. This tests the C7-8 nerve roots. The pronator reflex can be helpful in differentiating C6 and C7 nerve root problems. If it is abnormal in conjunction with an abnormal triceps reflex, then the level of involvement is more likely to be C7. This reflex is performed by tapping the volar aspect of the distal radius with the forearm in a neutral position and the elbow flexed. This results in a stretch of the pronator teres resulting in a reflex pronation.

Myelopathy has been classified in various ways and depends on the involvement of the lateral or medial cord or vascular involvement. The signs may be a mixture of upper motor neuron signs in the lower limbs and lower motor neuron signs in the upper limbs and may simulate MND or syringomyelia. Occasionally the presentation may be that of Brown-Sequard syndrome.

The Pain and stiffness in neck with a gritty feeling in the tip of fingers is typical to spondylosis. Patients will complain of stiffness and loss of dexterity, with unsteadiness of gait. Neck pain may not be a major feature. Bladder involvement is unusual. Combination of radicular and cord symptoms are found in radiculomyelopathy. Vertebrobasilar insufficiency due to spondylitic compression of the vertebral artery is uncommon, though popularly diagnosed.

In patients that demonstrate concern about possible myelopathy, lower extremity reflexes and Hoffman and Babinski reflexes also should be assessed. Diffuse hyperreflexia and/or positive Hoffman and abnormal Babinski reflexes would indicate that the patient has a cervical myelopathy.

MATERIALS AND METHODS

The present study was carried out at clinics of Homeocare International from June 2007 to November 2007

Materials
The materials for this study were selected from the patients who attended our clinic. Patients belonging to the age group 30-70 were included in the study. Both sexes and patients of all socioeconomic classes were considered.

Methods
All cases among the prescribed age group with the clinical features fitting to cervical radiculopathy were taken up for the study and the diagnosis was confirmed on the basis of positive X-ray findings visualized in anterio-posterior and lateral view of X- ray cervical spine.
Systemic examination was done in all cases to exclude possibility of other diseases. Detailed history was taken in each case with special reference to past history, family history, occupational history, physical generals and mental generals.

In each case selection of medicines were based on the data such as aetiological factors, mental generals, physical generals, concomitants, characteristic particulars, reportorial approach and clinical indications from different authorities.

In all cases selection of potencies and repetition of medicines were done according to the Homoeopathic principles.

In between the period of medication all patients were kept under blank tablet continuously. Out of 300 cases selected there were 9 dropouts and a total of 291 subjects completed the study.

The tools and technique of Research

Cervical radiculopathy assessment tool was developed after literature review and discussion with our specialist consultants. Six major areas were identified as important parameters

1.
Pain:
No tenderness -0
Patient complains of pain -1
Patient complains of pain and winces -2
2.
Stiffness:
No stiffness -0
Morning stiffness -1
Stiffness occurring later in the day-2
3.
Numbness:

Absent -0
Moderate -1
Severe -2
4.
Cracking on movement:
absent -0
Present -1
5.
Movements of neck:
all movements possible -0
Restricted movements -1
Movement impossible-2
6.
Associated symptoms:
no associated symptoms-0One associated symptom-1
More than one associated symptoms-2

Follow up
All patients were reviewed on a fortnightly basis, to asses the subjective and objective improvement. Each case was followed up for a minimum of 6 months from the commencement of the treatment.

Diet and regimen
All patients were directed to continue the normal diet. They were also directed to stop the use of other medicines prior to the start of this treatment.

Additional instructions
Practice neck exercise regularly, limiting occupational or recreational activities that play pressure on the head, neck, and shoulders.
Effectiveness
Effectiveness was assessed on the basis of clinical improvement, relief of symptoms and change in score taken before and after treatment.

Analysis
Various facts drawn out from this study were treated according to statistical principles.

OBSERVATION AND DISCUSSION:
AGE WISE DISTRIBUTION OF PATIENTS

AGE

NO

 PERCENTAGE (%)

31-40

27
9

41-50

55
19

51-60

58
20
61-70
151
52

Out of the 291 patients studied 27patients (9%) were between the age group 31-40. 55 patients (19%) were between the ages 41-50. 58 patients (20%) were between the ages 51-60. And 151 patients were between the ages 61-70


DISTRIBUTION OF PATIENTS ACCORDING TO SOCIOECONOMIC STATUS

Socio Economic status

NO

 PERCENTAGE (%)

Lower

4
19

Lower middle

6
20

Middle

11
52
Upper middle
0

0

Out of the 21 patients studied 4 patients (19%) were under the low socioeconomic status. 6 patients (29%) belongs to lower middle class and 11 patients (52%) belongs to middle class.

Classification of patients as per their presenting complaint

Symptoms

NO

 PERCENTAGE (%)

Pain

291
100

Numbness

291
100

Stiffness of neck

291
100
Weakness of upper limb
180

62
Cracking in joints
151
52
Vertigo, nausea
70
24
Restricted neck movements
291
100

Out of the 291 patients studied all of them presented with pain, numbness, restricted neck movements and stiffness of neck. 180 patients (62%) had Weakness of upper limb and 151 patients (52%) had cracking at inter-vertebral joints on movement and 70 patients (24%) presented with nausea and vertigo.

DISTRIBUTION OF MEDICINES USED IN THE STUDY

NO

Medicine

 No of Patients PERCENTAGE (%)
1 Sulphur
52
18
2 Pulsatilla
47
16
3 Lachesis
26
9
4 Silicea
12
4
5 Calcarea carb
29
10
6 Rhus tox
26
9
7 Lac caninum
20
7
8 Phosphoric ac
18
6
9 Phosphorus
20
7
10 Bryonia
23
8
11 Lycopodium
18
6

Sulphur was effective in 52 patients (18%), Pulsatilla was found effective in 47 (16%). Calcarea carb in 29 (10%), Lachesis in 26 (9%), Phosphoric acid and Lycopodium in 18 (9%) cases each, Silicea was found useful in 12 patients (4%), Rhus tox was effective in 26 (9%), Lac caninum and Phosphorus were effective in 20 patients (20) and Bryonia was found effective in 23 (8%).

EFFECTIVENESS OF VARIOUS POTENCIES

Potency

No: of > / D

 PERCENTAGE (%)
30

87
30
200

117
40
1M

72
25
10M
15

5


> - Amelioration of symptoms, D – Disappearance of symptoms


Changes in clinical features after 6 months of treatment

S.No Symptoms * > % < % S % D %
1 Pain
291
96
33
0
0
0
0
195
67
2 Numbness
291
168
57
0
0
29
10
96
33
3 Stiffness of neck
291
0
0
0
0
35
12
256
88
4 Weakness
180
0
0
0
0
16
8
164
92
5 Vertigo, Nausea
70
0
0
0
0
1
2
69
98
6 Cracking in joints
154
0
0
0
0
31
20
123
80
7 Restricted neck movements
291
0
0
0
0
29
10
262
90

* - Number of patients
> - Amelioration
< - Aggravation
S - No change
D – Disappearance

Inference
The efficacy of Homoeopathic medicines in the treatment of cervical radiculopathy due to cervical spondylosis is evident by the reduction in the score after 6 months of treatment. Therefore the treatment is effective.

SUMMARY AND CONCLUSION
In the present study 291 patients who attended the treatment at our clinics from June 2007 – to November 2005 were included. These patients belonged to various socio-economic statuses and of age group between 30-70 years. The results of the study were evaluated using statistical principles.

In this study the efficacy of homoeopathic treatment in cervical spondylosis presenting with radiculopathy was evaluated. Assessment was based on the changes in score noted before and after treatment using the cervical radiculopathy assessment tool.
Thus, this study provides an evidence to say that homoeopathic medicines are effective in managing this condition.
Medicinal management was found to be very much effective.
Sulphur was effective in 52 patients (18%), Pulsatilla was found effective in 47 (16%). Calcarea carb in 29 (10%), Lachesis in 26 (9%), Phosphoric acid and Lycopodium in 18 (9%) cases each, Silicea was found useful in 12 patients (4%), Rhus tox was effective in 26 (9%), Lac caninum and Phosphorus were effective in 20 patients (20) and Bryonia was found effective in 23 (8%).

CONCLUSION
The following salient conclusions have been drawn from the present study after summarizing its findings.
1) Homoeopathic medicines are effective in the management of cervical spondylosis presenting with radiculopathy
2) Age group mostly affected is between 31 to 70 years.

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