Sunday 21 December 2014

Cervical Spondylosis--- An Ayurvedic apporach


Cervical region
Cervical spine due to its position, complex structure and great mobility is vulnerable to injuries. It is a complex and vital region. Vital knowledge of cervical region is essential for physician, while dealing with the patients having the problems of cervical region.
Components of the structure of cervical spine:

1.      Bony Structure
The cervical spine is composed of first seven vertebrae of the vertebral column. The seven cervical vertebrae are the smallest movable vertebrae and identifiable by their transverse processes, which are perforated by a foramen
a.       Typical cervical vertebrae- 2nd to 6th cervical vertebrae:
b.      The atlas – first cervical vertebra (C1)
c.       The axis – Second Cervical Vertebra (C2)
d.      The seventh Cervical Vertebra (C7)
e.        
2.      Musculature
The muscles of the neck are grouped according to their position. These groups are
as follows

a. Superficial and Lateral cervical muscles
b. Anterior Vertebral muscles
c. Lateral Vertebral muscles
d. Deep muscles of the back of the neck
e. Sub – occipital muscles
3. Articulations
(A) Intervertebral articulations – It is divided into two parts.
a. Articulations of vertebral bodies
b. Articulations of vertebral arches.
(B) Articulation of vertebral column with cranium:
The articulation of vertebral column with cranium involves the paired atlanto-occipital joints and ligaments connecting the axis and occipital bone.
4. Neural and Vascular contents.



Cervical Spondylosis
Definition:
Cervical spondylosis is a degenerative condition of the cervical spine. There is degeneration of inter-vertebral disc, with its protrusion and bony overgrowth of adjacent vertebrae causing compression of roots, cord or both. Occasionally it is associated with non-compressive myelopathy consequent to vascular degeneration.

Pathogenesis:
This is compound effect of the following processes:
a. The initial change is a decrease in the water content of the nucleus pulposus, the
central portion of the disc. As the disc dehydrates, it decreases in height and has
less ability to resist loading and stress,
Disc degeneration leading to its thinning and protrusion of the nucleus
pulposus posteriorly or herniation through fear in the fibrous annuloses laterally;
posterior herniation tends to produce compression of the spinal cord and lateral
bulging produces compression of roots.

b. Osteophytic spur formation on the posterior aspect of the vertebral body leading
to the ‘spondylotic bar’, which is the core pathology resulting in a horizontal
compression of the anterior aspect of the cord. Osteophytic extension of the bar,
laterally associated with articulatory hypertrophic changes or encroachment of the
intervertebral neural foramina by osteophytes developing from the rim of the
foramina, often cause additional entrapment radiculopathy. Anterior ostephytic
spur formation is usually symptom less but occasionally produces dysphagia.



c. Partical sublaxation of vertebrae causing impinging of osteophytes on the nerve
roots during movement of the neck.
d. Hypertrophy of the dorsal spinal ligament and dorsilateral facet articulation or
bucking of the dorsal spinal ligament particularly during extension of the neck.
All these may cause further narrowing of the sagittal diameter of a spinal canal,
which might have been congenitally narrow.
e. Encroachment of the vertebral foramina where the vertebral artery is lodged
producing compromise of the arterial lumen and significant vetebro – basilar
ischaemia, leading to brainstem signs like vertigo, tinnitus, intermittent blurring
of vision and occasionally episodes of retroocular pain. This apart, the
architectural pattern of the vasculature of the cervical cord may further affect the
cord lesion significantly.
f. Presence of congenital spinal canal stenosis; although the radiographic findings of
spondylosis are fairly common in the elderly, patients develop myelopathy or
radiculopathy only if spondylotic changes are associated with congenitally narrow
canal or foramina. If the shortest AP diameter is 13mm or greater, it is unlikely
that spondylotic changes are the cause of cord compression.



CLINICAL FEATURES:
The symptoms are related to

(a) Spinal symptoms – Neckpain, medial scapular pain and shoulder pain probably
originate in the disc and spine.

(b) Root compression (Radiculopahty) – The range of movement is reduced
particularly during rotation and lateral movement of the head. Pain starts from the
trapezius ridge (C4), tips of the shoulder (C5), anterior part of the arm (C6), radial
forearm (C6), and often the thumb (C8) or all the fingers (C6, C7, C8).
The pain worsens with movement of the neck, coughing or sneezing or straining.
The clinical signs are motor weakness and wasting of proximal muscles or small
muscles of the hand depending on the roots compressed. In addition, there is also
areflexia and redicular sensory impairment. Sometimes L’hermitt’s sign or
‘barber’s chair sign’ can be elicited; this consists of tingling in all four limbs or
electric shock – like feelings down the back on flexing the neck. The roots most
often affected are, in order, C6, C7, and C5, C6, C8 and D1 are infrequently
affected. Occasionally, the shoulderhand syndrome or the so – called frozen
shoulder ensues if symptoms are unattended for some time.

(c) Compressive cervical myelopathy – This condition occurs less frequently than
root syndromes. There is some evidence that the patient has to be predisposed to
compression by a congenitally narrow canal (Cervical canal stenosis) and usually
presents with a progressive spastic paraparesis; later, bladder and bowel
involvement is added to sensory inpairment with a level.

(d) Combined root and cord compression – In a few cases, clinical features of both
radiculopathy and myelopathy are combined. In such a combined lesion occurring
at C5 level, the C5 root is compressed by lateral protrusion and the cord below
this level is compressed by medial lesion. The reflexes are asymmetrical, with
classically abscent or decreased supinator and exaggerated triceps jerks;
occasionally an inverted supinator jerk is elecited when on testing for supinator
response, there is finger flexion in the absence of the normal supinator response,
indicating a lesion of C5 with myelopathy below.

(e) Vascular insufficiency – Some times a completely different category of symptoms
may occur, viz. evidence of vertebro basilar insufficiency, this may be due to
permanent narrowing or kinking of the vertebral artery due to inter-vertebral
foraminal encroachment by ingrowing osteophytes from the bony wall of the
vertebral canal; it may produce intermittent or perpetual vertigo. Neck movement
may initiate or exacerbate vertigo by temporary compression of the vertebral
artery leading to further insufficiency.
The other symptoms like tinnitus, visual blurring, etc. have already been
referred too. As discussed earlier, there may be a non compressive myelopathy
due to compromised vasculature. In such cases, pain is usually absent and
myelography fails to reveal any spinal block; this is sometimes referred to as
cervical myelopathy (or cervical spondylotic myelopathy).
Nystagmus, though rare, is sometimes seen and is probably due to
involvement of the posterior longitudinal bundle in a high cervical lesion.



Cervical region
Cervical spine due to its position, complex structure and great mobility is vulnerable to injuries. It is a complex and vital region. Vital knowledge of cervical region is essential for physician, while dealing with the patients having the problems of cervical region.
Components of the structure of cervical spine:

1.      Bony Structure
The cervical spine is composed of first seven vertebrae of the vertebral column. The seven cervical vertebrae are the smallest movable vertebrae and identifiable by their transverse processes, which are perforated by a foramen
a.       Typical cervical vertebrae- 2nd to 6th cervical vertebrae:
b.      The atlas – first cervical vertebra (C1)
c.       The axis – Second Cervical Vertebra (C2)
d.      The seventh Cervical Vertebra (C7)
e.        
2.      Musculature
The muscles of the neck are grouped according to their position. These groups are
as follows

a. Superficial and Lateral cervical muscles
b. Anterior Vertebral muscles
c. Lateral Vertebral muscles
d. Deep muscles of the back of the neck
e. Sub – occipital muscles
3. Articulations
(A) Intervertebral articulations – It is divided into two parts.
a. Articulations of vertebral bodies
b. Articulations of vertebral arches.
(B) Articulation of vertebral column with cranium:
The articulation of vertebral column with cranium involves the paired atlanto-occipital joints and ligaments connecting the axis and occipital bone.
4. Neural and Vascular contents.

Cervical Spondylosis
Definition:
Cervical spondylosis is a degenerative condition of the cervical spine. There is degeneration of inter-vertebral disc, with its protrusion and bony overgrowth of adjacent vertebrae causing compression of roots, cord or both. Occasionally it is associated with non-compressive myelopathy consequent to vascular degeneration.

Pathogenesis:
This is compound effect of the following processes:
a. The initial change is a decrease in the water content of the nucleus pulposus, the
central portion of the disc. As the disc dehydrates, it decreases in height and has
less ability to resist loading and stress,
Disc degeneration leading to its thinning and protrusion of the nucleus
pulposus posteriorly or herniation through fear in the fibrous annuloses laterally;
posterior herniation tends to produce compression of the spinal cord and lateral
bulging produces compression of roots.

b. Osteophytic spur formation on the posterior aspect of the vertebral body leading
to the ‘spondylotic bar’, which is the core pathology resulting in a horizontal
compression of the anterior aspect of the cord. Osteophytic extension of the bar,
laterally associated with articulatory hypertrophic changes or encroachment of the
intervertebral neural foramina by osteophytes developing from the rim of the
foramina, often cause additional entrapment radiculopathy. Anterior ostephytic
spur formation is usually symptom less but occasionally produces dysphagia.
c. Partical sublaxation of vertebrae causing impinging of osteophytes on the nerve
roots during movement of the neck.
d. Hypertrophy of the dorsal spinal ligament and dorsilateral facet articulation or
bucking of the dorsal spinal ligament particularly during extension of the neck.
All these may cause further narrowing of the sagittal diameter of a spinal canal,
which might have been congenitally narrow.
e. Encroachment of the vertebral foramina where the vertebral artery is lodged
producing compromise of the arterial lumen and significant vetebro – basilar
ischaemia, leading to brainstem signs like vertigo, tinnitus, intermittent blurring
of vision and occasionally episodes of retroocular pain. This apart, the
architectural pattern of the vasculature of the cervical cord may further affect the
cord lesion significantly.
f. Presence of congenital spinal canal stenosis; although the radiographic findings of
spondylosis are fairly common in the elderly, patients develop myelopathy or
radiculopathy only if spondylotic changes are associated with congenitally narrow
canal or foramina. If the shortest AP diameter is 13mm or greater, it is unlikely
that spondylotic changes are the cause of cord compression.
CLINICAL FEATURES:
The symptoms are related to

(a) Spinal symptoms – Neckpain, medial scapular pain and shoulder pain probably
originate in the disc and spine.

(b) Root compression (Radiculopahty) – The range of movement is reduced
particularly during rotation and lateral movement of the head. Pain starts from the
trapezius ridge (C4), tips of the shoulder (C5), anterior part of the arm (C6), radial
forearm (C6), and often the thumb (C8) or all the fingers (C6, C7, C8).
The pain worsens with movement of the neck, coughing or sneezing or straining.
The clinical signs are motor weakness and wasting of proximal muscles or small
muscles of the hand depending on the roots compressed. In addition, there is also
areflexia and redicular sensory impairment. Sometimes L’hermitt’s sign or
‘barber’s chair sign’ can be elicited; this consists of tingling in all four limbs or
electric shock – like feelings down the back on flexing the neck. The roots most
often affected are, in order, C6, C7, and C5, C6, C8 and D1 are infrequently
affected. Occasionally, the shoulderhand syndrome or the so – called frozen
shoulder ensues if symptoms are unattended for some time.

(c) Compressive cervical myelopathy – This condition occurs less frequently than
root syndromes. There is some evidence that the patient has to be predisposed to
compression by a congenitally narrow canal (Cervical canal stenosis) and usually
presents with a progressive spastic paraparesis; later, bladder and bowel
involvement is added to sensory inpairment with a level.

(d) Combined root and cord compression – In a few cases, clinical features of both
radiculopathy and myelopathy are combined. In such a combined lesion occurring
at C5 level, the C5 root is compressed by lateral protrusion and the cord below
this level is compressed by medial lesion. The reflexes are asymmetrical, with
classically abscent or decreased supinator and exaggerated triceps jerks;
occasionally an inverted supinator jerk is elecited when on testing for supinator
response, there is finger flexion in the absence of the normal supinator response,
indicating a lesion of C5 with myelopathy below.

(e) Vascular insufficiency – Some times a completely different category of symptoms
may occur, viz. evidence of vertebro basilar insufficiency, this may be due to
permanent narrowing or kinking of the vertebral artery due to inter-vertebral
foraminal encroachment by ingrowing osteophytes from the bony wall of the
vertebral canal; it may produce intermittent or perpetual vertigo. Neck movement
may initiate or exacerbate vertigo by temporary compression of the vertebral
artery leading to further insufficiency.
The other symptoms like tinnitus, visual blurring, etc. have already been
referred too. As discussed earlier, there may be a non compressive myelopathy
due to compromised vasculature. In such cases, pain is usually absent and
myelography fails to reveal any spinal block; this is sometimes referred to as
cervical myelopathy (or cervical spondylotic myelopathy).
Nystagmus, though rare, is sometimes seen and is probably due to
involvement of the posterior longitudinal bundle in a high cervical lesion.
INVESTIGATION:
A plain X-ray of the cervical spine is helpful. There is impairment of natural
cervical lordosis, reduction of intervertebral spaces, osteophytic projection leading to
distortion and encroachment of intervertebral foramina (in appropriate obligue view), and
shortening of AP diameter of the cervical canal in few cases.
For demonstration of compressive myelopathy, a contrast myelogram is
necessary. It shows the presence of multiple disc protrusions as a negative indentation of
the contrast column or total extradural obstruction. CT scan with or without contrast is
preferred if available. MRI is another useful mode of invetigation.
Ayurvedic texts, there are many other ailments, which are related to neck and
demonstrate the similar symptoms. So it is worthy to have a look on these manifestations.
This will help in differential doagnosis and also in justification to the paralance with
Griva Hundanam.

Those diseases are:
1. Manya Stambha
2. Manya Graha
3. Griva Stambha
4. Asthi Majja Gatavata
5. Sandhigata Vata
6. Visvaci
7. Sirograha

Manya Stambha: As noted earlier in the description of Manya Stambha, its aetiopathogenesis
has been dealt in almost all the texts. Manya – Stambha, entity cannot be
considered as cervical spondylosis because of its acute onset, and having no mention of
pain and is described along with Antarayama and Bahirayama. It is also considered as
main symptom of Apatanaka. In addition, at the last in this condition Jatru Vakrata
happens. Whereas in cervical spondylosis is a slow process with pain and restriction of
the movements are the main symptoms. Moreover, the Manya Stambha occurs due to the
involvement of muscles whereas in cervical spondylosis, actual pathology lies in the
cervical intervertebral discs. So, it cannot be correlated with cervical spondylosis.

Manyagraha & Griva Stambha: These two disorders have been described as symptoms
of other disease as well as separate entities. The meaning itself suggest that the stiffness
of Griva muscles may cause this entity whereas in cervical spondylosis other symptoms
are also accompanied.

Siro or Sira Graha has also the different aetio-pathogenesis. In which severe headache
may be found. But due to absence of other symptoms, it cannot be considered as cervical
spondylosis.

Asthimajjagata Vata: The symptoms of Asthimajjagata Vata explained in the texts can
be found in this condition and these symptoms are similar to some extent in comparison
to cervical spondylosis. But, no justification can be given to the neurological symptoms
exhibited. Even though these symptoms can be taken in to consideration up to the stage;
when nerve root are not compressed. It can be considered as the later stage of

Asthimajjagata Vata.


Cervical region
Cervical spine due to its position, complex structure and great mobility is vulnerable to injuries. It is a complex and vital region. Vital knowledge of cervical region is essential for physician, while dealing with the patients having the problems of cervical region.
Components of the structure of cervical spine:

1.      Bony Structure
The cervical spine is composed of first seven vertebrae of the vertebral column. The seven cervical vertebrae are the smallest movable vertebrae and identifiable by their transverse processes, which are perforated by a foramen
a.       Typical cervical vertebrae- 2nd to 6th cervical vertebrae:
b.      The atlas – first cervical vertebra (C1)
c.       The axis – Second Cervical Vertebra (C2)
d.      The seventh Cervical Vertebra (C7)
e.        
2.      Musculature
The muscles of the neck are grouped according to their position. These groups are
as follows

a. Superficial and Lateral cervical muscles
b. Anterior Vertebral muscles
c. Lateral Vertebral muscles
d. Deep muscles of the back of the neck
e. Sub – occipital muscles
3. Articulations
(A) Intervertebral articulations – It is divided into two parts.
a. Articulations of vertebral bodies
b. Articulations of vertebral arches.
(B) Articulation of vertebral column with cranium:
The articulation of vertebral column with cranium involves the paired atlanto-occipital joints and ligaments connecting the axis and occipital bone.
4. Neural and Vascular contents.

Cervical Spondylosis
Definition:
Cervical spondylosis is a degenerative condition of the cervical spine. There is degeneration of inter-vertebral disc, with its protrusion and bony overgrowth of adjacent vertebrae causing compression of roots, cord or both. Occasionally it is associated with non-compressive myelopathy consequent to vascular degeneration.

Pathogenesis:
This is compound effect of the following processes:
a. The initial change is a decrease in the water content of the nucleus pulposus, the
central portion of the disc. As the disc dehydrates, it decreases in height and has
less ability to resist loading and stress,
Disc degeneration leading to its thinning and protrusion of the nucleus
pulposus posteriorly or herniation through fear in the fibrous annuloses laterally;
posterior herniation tends to produce compression of the spinal cord and lateral
bulging produces compression of roots.

b. Osteophytic spur formation on the posterior aspect of the vertebral body leading
to the ‘spondylotic bar’, which is the core pathology resulting in a horizontal
compression of the anterior aspect of the cord. Osteophytic extension of the bar,
laterally associated with articulatory hypertrophic changes or encroachment of the
intervertebral neural foramina by osteophytes developing from the rim of the
foramina, often cause additional entrapment radiculopathy. Anterior ostephytic
spur formation is usually symptom less but occasionally produces dysphagia.
c. Partical sublaxation of vertebrae causing impinging of osteophytes on the nerve
roots during movement of the neck.
d. Hypertrophy of the dorsal spinal ligament and dorsilateral facet articulation or
bucking of the dorsal spinal ligament particularly during extension of the neck.
All these may cause further narrowing of the sagittal diameter of a spinal canal,
which might have been congenitally narrow.
e. Encroachment of the vertebral foramina where the vertebral artery is lodged
producing compromise of the arterial lumen and significant vetebro – basilar
ischaemia, leading to brainstem signs like vertigo, tinnitus, intermittent blurring
of vision and occasionally episodes of retroocular pain. This apart, the
architectural pattern of the vasculature of the cervical cord may further affect the
cord lesion significantly.
f. Presence of congenital spinal canal stenosis; although the radiographic findings of
spondylosis are fairly common in the elderly, patients develop myelopathy or
radiculopathy only if spondylotic changes are associated with congenitally narrow
canal or foramina. If the shortest AP diameter is 13mm or greater, it is unlikely
that spondylotic changes are the cause of cord compression.
CLINICAL FEATURES:
The symptoms are related to

(a) Spinal symptoms – Neckpain, medial scapular pain and shoulder pain probably
originate in the disc and spine.

(b) Root compression (Radiculopahty) – The range of movement is reduced
particularly during rotation and lateral movement of the head. Pain starts from the
trapezius ridge (C4), tips of the shoulder (C5), anterior part of the arm (C6), radial
forearm (C6), and often the thumb (C8) or all the fingers (C6, C7, C8).
The pain worsens with movement of the neck, coughing or sneezing or straining.
The clinical signs are motor weakness and wasting of proximal muscles or small
muscles of the hand depending on the roots compressed. In addition, there is also
areflexia and redicular sensory impairment. Sometimes L’hermitt’s sign or
‘barber’s chair sign’ can be elicited; this consists of tingling in all four limbs or
electric shock – like feelings down the back on flexing the neck. The roots most
often affected are, in order, C6, C7, and C5, C6, C8 and D1 are infrequently
affected. Occasionally, the shoulderhand syndrome or the so – called frozen
shoulder ensues if symptoms are unattended for some time.

(c) Compressive cervical myelopathy – This condition occurs less frequently than
root syndromes. There is some evidence that the patient has to be predisposed to
compression by a congenitally narrow canal (Cervical canal stenosis) and usually
presents with a progressive spastic paraparesis; later, bladder and bowel
involvement is added to sensory inpairment with a level.

(d) Combined root and cord compression – In a few cases, clinical features of both
radiculopathy and myelopathy are combined. In such a combined lesion occurring
at C5 level, the C5 root is compressed by lateral protrusion and the cord below
this level is compressed by medial lesion. The reflexes are asymmetrical, with
classically abscent or decreased supinator and exaggerated triceps jerks;
occasionally an inverted supinator jerk is elecited when on testing for supinator
response, there is finger flexion in the absence of the normal supinator response,
indicating a lesion of C5 with myelopathy below.

(e) Vascular insufficiency – Some times a completely different category of symptoms
may occur, viz. evidence of vertebro basilar insufficiency, this may be due to
permanent narrowing or kinking of the vertebral artery due to inter-vertebral
foraminal encroachment by ingrowing osteophytes from the bony wall of the
vertebral canal; it may produce intermittent or perpetual vertigo. Neck movement
may initiate or exacerbate vertigo by temporary compression of the vertebral
artery leading to further insufficiency.
The other symptoms like tinnitus, visual blurring, etc. have already been
referred too. As discussed earlier, there may be a non compressive myelopathy
due to compromised vasculature. In such cases, pain is usually absent and
myelography fails to reveal any spinal block; this is sometimes referred to as
cervical myelopathy (or cervical spondylotic myelopathy).
Nystagmus, though rare, is sometimes seen and is probably due to
involvement of the posterior longitudinal bundle in a high cervical lesion.
INVESTIGATION:
A plain X-ray of the cervical spine is helpful. There is impairment of natural
cervical lordosis, reduction of intervertebral spaces, osteophytic projection leading to
distortion and encroachment of intervertebral foramina (in appropriate obligue view), and
shortening of AP diameter of the cervical canal in few cases.
For demonstration of compressive myelopathy, a contrast myelogram is
necessary. It shows the presence of multiple disc protrusions as a negative indentation of
the contrast column or total extradural obstruction. CT scan with or without contrast is
preferred if available. MRI is another useful mode of invetigation.
Ayurvedic texts, there are many other ailments, which are related to neck and
demonstrate the similar symptoms. So it is worthy to have a look on these manifestations.
This will help in differential doagnosis and also in justification to the paralance with
Griva Hundanam.

Those diseases are:
1. Manya Stambha
2. Manya Graha
3. Griva Stambha
4. Asthi Majja Gatavata
5. Sandhigata Vata
6. Visvaci
7. Sirograha

Manya Stambha: As noted earlier in the description of Manya Stambha, its aetiopathogenesis
has been dealt in almost all the texts. Manya – Stambha, entity cannot be
considered as cervical spondylosis because of its acute onset, and having no mention of
pain and is described along with Antarayama and Bahirayama. It is also considered as
main symptom of Apatanaka. In addition, at the last in this condition Jatru Vakrata
happens. Whereas in cervical spondylosis is a slow process with pain and restriction of
the movements are the main symptoms. Moreover, the Manya Stambha occurs due to the
involvement of muscles whereas in cervical spondylosis, actual pathology lies in the
cervical intervertebral discs. So, it cannot be correlated with cervical spondylosis.

Manyagraha & Griva Stambha: These two disorders have been described as symptoms
of other disease as well as separate entities. The meaning itself suggest that the stiffness
of Griva muscles may cause this entity whereas in cervical spondylosis other symptoms
are also accompanied.

Siro or Sira Graha has also the different aetio-pathogenesis. In which severe headache
may be found. But due to absence of other symptoms, it cannot be considered as cervical
spondylosis.

Asthimajjagata Vata: The symptoms of Asthimajjagata Vata explained in the texts can
be found in this condition and these symptoms are similar to some extent in comparison
to cervical spondylosis. But, no justification can be given to the neurological symptoms
exhibited. Even though these symptoms can be taken in to consideration up to the stage;
when nerve root are not compressed. It can be considered as the later stage of
Asthimajjagata Vata.
Sandhigata Vata explained in the texts has quite resemblance with osteoarthritis
explained in the modern texts. According to Ayurvedic description, i.e. painful flexion
and extension are related to big joints and in this case no neurological symptom is found.
Hence, this cannot be taken as cervical spondylosis.

Visvaci is the disease in which vitiated Vayu affect the Kandara, originated from the
finger and palm of the hand and insert into the posterior side of Bahu, causes loss of
function of the arm. This symptom can be found in the later stage of the cervical
spondylosis but there is no mention of other symptoms. So, it cannot be considered as
cervical spondylosis.
Treatment Principle
Joints in the neck are the seat of kapha.
It is a vata kapha problem.
·         The treatment management differs in acute cervical prolapse and degeneration.


Treatment in acute phase
Lepam
·         Apply the warm paste of Kottamchuckadi or Kolakulatthadi churnam with tamarind juice and little vinegar.
·         Apply twice daily .Keep it until it gets dry and wipe it off with warm water.
·         Then do ruksha svedam with kulattham (economical) for 20 minutes or until sweat appears.
·         Oil should not be applied for first few days.
·         Rest position missing




Kashayam
·         Rasna sapthakam kashayam 20 ml before food with warm 60 ml water twice a day.
·         Varunadi kashayam 20 ml before food with warm 60 ml water twice a day.
                         
  Once the acute phase is over, thailam can be applied.
·         Kottamchuckadi tailam, prasaranyadi tailam, murivenna and prabanjana tailam (all ushna veerya) are used externally.
·         Gandha tailam 1tsp with milk at bed time.
·         Parinata kshiradi is used only when pittanubanda vata is there.
1.      It is useful in sensory neuropathies and muscle wasting conditions.
2.      It is not effective in muscular pain and it will aggravate the pain also.
·         After sneha one can do dhanyamla  sveda or kizhi. Then you can do nasya.
·         For nasyam karpasastiyadi tailam is useful in both marsha and prati marsha forms.
·         Siro virechana ganam can also be used in kapha related conditions. In Brmhana phase kshirabala is applied .Thalam is optional.
·         Based on Sutram “urdhwa jathru vikareshu nishi” gugguluthikthakam or mahasneham can be given 15 ml slightly melted in half glass of milk at bedtime.
·         Aba guggulu 2 tablets twice a day after food.
·         To strengthen the nerve roots Asvagandarishtam or Balarishtam 25 ml can be given twice a day after food.



 Cervical spondylosis with dominancy of pain:
·         Rasna saptakam 20ml BD before food with warm water
·         Kottamchukkadi oil  ext application
·         Chanda marutham 1 pinch with honey BD after food
·         Aba guggulu 2 – 0 – 2  after food
Cervical spondylosis with dizziness:
·         Vidaryadi kashayam 20ml BD before food with warm water
·         Ksheerabala 1 tsp with kashayam
·         Sidardrakam 15ml bd after food
·         Maha kalyanaka gritham 1 tsp BD after food
·         Kachoradi ksheera bala  (for thalam).
Cervical spondylosis with numbness:
          Varunadi kashayam 20 ml BD before food
          Rasonaadi vati 2 – 0 – 2 after food
          Prabhanjana kuzhambu for external application       





Management
Wholesome
·         In cervical spondylosis, when acute phase is over, patient can do exercise.
·         Patient is should be advised to sleep in supine position with small pillow.
·         Computer operators are should be taught by Ayurvedic people to do flexion, extension, and rotation once in every half an hour for two – three times.
·         Bed rest is advised for seven days.
·         A smooth massage is recommended.
·         Lumbar traction is more useful in clinical practice than cervical traction.
Unwholesome
·         While giving massage, pressure should not be given.
·         Cervical neck traction aggravates the problem.
·         All other physiotherapies are not much useful
·         Keeping hand as pillows must be avoided.
·         Riding two wheelers must be reduced.