Pathophysiology
One of the most important parts of achieving the goal of being able to meet the patient’s entire healthcare (i.e. nursing) needs is to ensure that the underlying disease’s pathophysiology is well understood by all the stakeholder groups. These groups, in this case, would include the medical and healthcare practitioners, patients, and their respective family members. It would be a lot easier to instruct a patient to have a patient undergo a prescribed healthcare routine once he understands the nature of his condition, why each procedure is being done, and how they collectively contribute to the end-goal of bringing him back to his premorbid condition. Based on previously published studies, involving different stakeholder groups in the decision-making process is an important patient compliance booster .
The first thing that one has to know about cervical spondylosis is that it actually refers to not just a single condition but a collection of musculoskeletal conditions that generally involve the process of degeneration. In terms of where this phenomenon happens, it can occur anywhere in the spine. Cervical spondylosis narrows it down to any point in the cervical region of the human spine, specifically from C1 – C7 or any junctions in between.
The cervical spine is the thinnest portion of the spine. This is mainly because it sits at the most cephalic (i.e. topmost) portion of the body; it does not support a significant amount of weight unlike the more inferior spine regions like the thoracic, lumbar, and sacral ones. The cervical spine, as far as weight distribution is concerned, only supports the weight of the head and any surrounding structures and so each of the cervical bones C1 to C7 do not have to have to be as dense and thick as the individual segments of the lumbar vertebrae; the lumbar region of the spine is by far the thickest and densest because it is responsible for carrying the most weight). The cervical spine is surrounded by muscles, soft tissues like ligaments, connective tissues, and nerves. These structures, including the bony component (i.e. the cervical spine itself) is subject to the wear and tear that comes with aging and certain overuse syndromes. Most of the degeneration occurs in the articulating surfaces such as the connection between C1 and C2, C2 and C3, and so on. Anatomically, the spine segments, across all regions, are stacked on top of each other . They are separated by an intervertebral space. This space is occupied by the intervertebral discs. These discs serve as an articulation between the individual vertebral segments; they also serve as a cushion. They are spongy and filled with water and so they absorb weight effectively; they also limit the friction and wear and tear associated with weight bearing—which is one of the major functions of the spine.
As a person ages, the structures that make up the cervical spine region tend to deteriorate . This means that anything that may be related to aging and the associated wear and tear may be classified as a pathophysiological mechanism of spondylosis. One common example of this would be the phenomenon where there is a thinning of the intervertebral discs. The thinning of these discs would lead to a decrease in the spine’s ability to consistently hold weight especially when the patient is in an upright position. Because of this, the weight-holding ability of the cervical spine becomes less efficient. The patient would still be able to function properly. However, the effect of this would be transferred over to the individual bony segments or the surrounding structures such as the nerves and blood vessels. Another consequence of this would be the narrowing of the intervertebral foramen where most nerves and blood vessels pass through. Common examples would be the spinal nerves, veins, and arteries. When the space becomes too narrow, these structures may be impinged. At that point, certain signs and symptoms may already start to appear. In all cases, the clinical manifestation that would appear would depend mainly on the type of structure that was affected and the mechanism by which the spondylosis occurred. The most important thing to note here is that there are numerous pathophysiologic mechanisms associated with spondylosis. The most general and applicable term is spine degeneration but then again, degeneration comes in many forms and may be caused by various factors. Either way, they all can lead to the same outcome which is cervical spondylosis.
Signs and Symptoms
As mentioned in the pathophysiology section, the signs and symptoms that would be manifested by a patient with a formally diagnosed case of spondylosis would depend on the nature of the degeneration and the structures that were affected . In this case, let us assume that the selected patient’s case that has been diagnosed with spondylosis was caused by the deterioration or degeneration of the intervertebral discs in the cervical region. This is one of the most common degenerative mechanisms by which spondylosis occurs .
Cervical spondylosis develops and progresses insidiously. This means that patients may not realize that they have the condition until it is already too late to make preventive and mitigation-based changes that would really make a lot of difference. Often, the only time the patient knows that they have a case of cervical spondylosis is when pain, stiffness, and limitation of motion occurs . These are the most commonly observed clinical signs and symptoms of cervical spondylosis and other conditions involving the spine. It is important to note, however, that once these symptoms become noticeable by the patient, it is already too late because this means that the degenerative changes have already reached a point where they are actually causing damage to the anatomic structures surrounding the cervical spine already . If anything, the only goal that can be realistically achieved at that point would be damage reduction in the absence of invasive procedures such as orthopedic surgeries.
Chronic pain in the affected area is a common manifestation . Heaviness and or the feeling of feeling fatigued are common chief complaints among spondylosis patients. This can be explained by the fact that the structures surrounding the cervical spine have already deteriorated and they do not work as efficiently and effectively as before when it comes to distributing the weight of the head and serving as an articulating structure for the head and the thorax. Pain upon movement can be caused by trauma that occurs whenever two bony prominences come in contact. This is where the absence of a thick-enough intervertebral discs comes in. Because the spongy structure that is the intervertebral disc has already thinned out, the individual cervical spine segments become more approximated. Whenever the patient moves, those individual segments would have the tendency to bump and rub against each other. This would definitely be felt by the patient. A patient may interpret the sensation as mildly uncomfortable to extremely painful depending on the severity of the bumping and friction between the two cervical spine segments upon the initiation of motion. This may happen during cervical flexion, extension, side flexion, and rotation. A patient who has an intervertebral disc with a damaged anterior portion would most likely feel the discomfort or pain upon flexion; patients with laterally damaged intervertebral discs would feel the noxious stimuli upon side flexion; and those who have posteriorly degenerated intervertebral discs would feel it upon cervical extension or back-leaning of the head.
Another common symptom among cervical spondylosis patients with degenerative intervertebral discs as the direct cause may involve pain in the legs and buttocks. Some patients with a milder case of cervical spondylosis than the ones who experience severe pain may report of pins and needle-like or tingling sensations instead. Generally, the more painful and uncomfortable the patient is, the more severe his condition may be . Presence of radiating pain and tingling sensation generally indicates that there is already an involvement of the nerves that pass through the damaged portion or portions of the cervical spine. Nerves run deep into the cervical spine region and their involvement is often considered as an indicator of higher levels of severity.
Treatments
The treatment for cervical spondylosis can be categorized into two: they can either be invasive or non-invasive. Invasive procedures are the ones that include orthopedic surgery. A patient who has a severely degenerated cervical spine, for example, with manifestations like presence of severe pain even when not moving, would be the ones who would be recommended to undergo invasive treatment procedures for the condition. The goal of the invasive procedure would, however, be the same as that of the non-invasive ones and that is to provide long term relief from pain, discomfort, functional and activity limitation, and or disabilities. Between the two, the invasive procedures would prove to be the one that is riskier and costlier. This is why most patients who have cervical spondylosis are often advised to undergo the non-invasive procedures first especially if the chief complaint as well as the signs and symptoms are not that disturbing or when the pain and discomfort that are being felt by the patient can still be tolerated.
Physical rehabilitation is considered as one of the main options when it comes to the process of choosing the best long term solution to cervical spondylosis. It involves educating the patient on how to prevent further damaging the cervical spine and its surrounding structures. It may also involve a work (i.e. occupational) or daily activity analysis; the results of which may help the medical team identify what is really causing the disease . The patient in this case is suffering from a form of overuse syndrome wherein his neck is being subjected to sustained neck flexion and extension as a result of poor posture when working. The patient has reported that he stays in the office for at least 8 hours a day and sits in front of the computer reading, analyzing, and revising documents to be submitted the same day. During one of the physical rehabilitation sessions, he was asked to simulate her typical day to day activities at work and how he actually performs them. This is where the people from the nursing and the physical rehab department noticed that the patient has a poor posture. He mentioned that he has already worked as an office clerk for more than twenty years at the time of consultation. Considering his posture and the time he already spent in his present job, it is unthinkable that he would later on develop this kind of condition.
Some physical rehabilitation-based treatments may also be performed by nurses in the absence of physical therapists. However, the functions of such treatments may be limited to lowering the level of pain and discomfort and helping the patient recover from the sessions. During physical rehabilitation, the patient may be asked to undergo programs meant to strengthen and stretch some of his cervical muscles, all in an effort to enable him to develop the posture needed to prevent the further deterioration of his condition . Most patients would have compensatory postures to minimize the pain; however, the problem with leaving the patient in that compensated state is that it does not address the problem in an anatomical level. It, in fact, would make the patient’s condition worse in the long run as the patient’s posture would eventually become harder to correct.
Psychological Impacts to Patient and Family
The psychological impacts of cervical spondylosis may range from being high or low depending on the severity of the patient’s condition. The main factor that a nursing professional would want to look at here would be how the patient’s condition (i.e. cervical spondylosis) affects the patient’s ability to function as an individual, perform activities of daily living, go to work, and basically perform tasks that he is normally able to fully perform because of limitations on motion among other things . Considering this, the psychological impacts of cervical spondylosis may be considered as a direct cause of the disability that, in turn, can be a direct cause of the condition. This means that the psychological impacts that may be observed from the patient are among the secondary causes of cervical spondylosis. Most of the psychological impacts may be a result of pain.
A patient with a severe-enough form of cervical spondylosis may present with risks of developing depression. Depression often occurs when the patient becomes unable to fulfill his role in the society. Symptoms of depression must be consistently observed from the patient for a minimum period of two weeks in order to be formally diagnosed, according to the National Institute of Mental Health (2016).
Cultural Information
The patient is a Caucasian living in the United States. His cultural practices show that he is hardworking, clocking in more than the average 40 hours per week at his job. Considering that he does his job every day with the poor posture that he showed during the work simulation, it may be safe to conclude that his prevalent culture of being too work-centric, a common finding among people living in the busiest cities in the United States, is being a barrier to the improvement of his condition . This is a common observation among patients working in office-based settings. They tend to have poor posture and they also tend to clock in a lot of time in their respective jobs. As a result, the deterioration of their spine becomes more progressive.
Nurses may play a significant role in addressing this patient development hindrance by conducting assessments on how their and their patient’s working environment can be modified so that it would be more accommodating for changes and adjustments . At some point, nurses may always walk the extra mile by helping patients conduct assessments on their work and everyday activities and tell them the right and most efficient ways to do it based on the principles of biomechanics and ergonomics. Most patients with cervical spondylosis suffer from the chronic habit of maintaining bad posture be it in their house or work and this has been a part of their culture already especially for busy people who do not have time to exercise and perform self-assessments. At some point nurses may also be guilty of the same cultural hindrance or obstacle and this is why these practices that address cultural and habit-related obstacles may be beneficial for both the patients and the nurses .
Safety Measures
Pain is the most common clinical manifestation of a formally diagnosed case of cervical spondylosis. It is one of the body’s main lines of defense mechanism aimed at informing the person that there is something wrong with his body. In this case, the pain is caused by the degeneration of any one of the structures surrounding the cervical spine region. To relate it to the selected patient’s case, it is caused by the degeneration of the intervertebral discs causing it to thin excessively. The thinning is what is causing the individual segments of the cervical spine to move closer together and approximate. Every time the patient moves, his bones almost get fused, rubbing with and bumping against each other—an abnormal phenomenon and this is what is believed to be the cause of the pain and discomfort .
As the patient’s pain becomes more severe, he may suffer from cervical instability. In which case, a cervical brace or support may be prescribed as a form of safety measure . Patients with cervical spondylosis exhibiting signs of instability have higher risks of cervical fracture—because of lack of movement control. The neck, because of excessive degeneration, becomes unable to steadily hold the weight of the head (including all of its anatomical contents and components). This makes the patient susceptible to involuntary ballistic movements primarily caused by the weight of the head and the patient’s inability to steadily hold it.
A cervical collar may be prescribed to the patient for milder causes of instability. A cervical brace would be the preferred option for safety measures if the instability is more evident .
Patient education would be the most important safety measure in this case. This would greatly prevent the risk of falls and other secondary injuries that the patient may suffer from.
The patient education should focus on how to maintain proper posture in doing activities of daily living and whenever the patient is at work.
Training the patient on how to make adjustments on his work and daily activities in order to avoid pain and exacerbating his cervical spondylosis would be highly important. This would enable him to continue functioning as if he is normal and prevent further injury to his cervical spine at the same time.
References
Adams, M., & Roughley, P. (2006). What is intervertebral disc degeneration, and what causes it? Spine, 2151-2161.
Cramer, J., & Rosenheck, R. (2006). Compliance with Medication Regimens for Mental and Physical Disorders. Psychiatric Services.
Hodder, J., Holmes, M., & Keir, P. (2010). Continuous assessment of work activities and posture in long-term care nurses. Ergonomics, http://www.ncbi.nlm.nih.gov/pubmed/20737335.
Kieft, R., Brouwer, B., Francke, A., & Delnoij, D. (2014). How nurses and their work environment affect patient experiences of the quality of care: A qualitative study. BioMed Central, http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-249.
Mork, P., & Westgaard, R. (2009). Back posture and low back muscle activity in female computer workers: a field study. Clinical Biomechanics, 169-175.
Muzin, S., Isaac, Z., Walker, J., & Baima, J. (2008). When should a cervical collar be used to treat neck pain. Curr Rev Musculoskeletal Med, 114-119.
NIMH. (2016). Depression. NIMH, https://www.nimh.nih.gov/health/topics/depression/index.shtml.
Perry, M. (2016). Spondylosis - Definition and Overview of Spondylosis. Laser Spine Institute, https://www.laserspineinstitute.com/back_problems/spondylosis/definition/.
Rao, R., Currier, B., Albert, T., Bono, C., Marawar, S., Poelstra, K., et al. (2007). Degenerative Cervical Spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am, 1360-1378.
Vokshoor, A., & Goldstein, J. (2014). Spondylolisthesis, Spondylolysis, and Spondylosis. MedScape, http://emedicine.medscape.com/article/1266860-overview.
