Current RMA Instruments
| Reasonable Hypothesis SOP | 11 of 2023 |
| Balance of Probabilities SOP | 12 of 2023 |
Changes from previous Instruments
ICD Coding
ICD-10-AM codes: M47.01, M47.02, M47.03, M47.11, M47.12, M47.13, M47.21, M47.22, M47.23, M47.81, M47.82, M47.83, M47.91, M47.92, M47.93 or M50.3
Brief description
Cervical spondylosis is a degenerative disease affecting the vertebrae, intervertebral discs and facet joints (zygapophyseal joints) of the cervical spine. The cervical spine includes all cervical vertebra from C1 to C7 as well as the cervico-thoracic junction (C7/T1).
Confirming the diagnosis
The diagnosis requires both clinical manifestations (symptoms and signs) and evidence of relevant bone/joint pathology (osteophytes, disc space narrowing, facet joint degeneration). A diagnosis that is based on imaging (X-ray, CT, MRI) evidence is required for the SOP to apply (see further comments below).
The relevant medical specialist is an orthopaedic surgeon, neuro/spinal surgeon, or rheumatologist.
Additional diagnoses covered by this SOP
- Osteoarthritis of the cervical spine
- Degenerative disc disease of the cervical spine
- Facet joint osteoarthritis of the cervical spine
Conditions which may be covered by this SOP
- Cervical disc prolapse or herniation – An isolated cervical disc prolapse is covered by the intervertebral disc prolapse SOP. However, if the cervical disc prolapse occurs in the presence of pre-existing cervical spondylosis, it is likely that the new cervical disc prolapse is an integral manifestation of the cervical spondylosis rather than a separate disease.
- Cervical spinal stenosis – The stenosis may be a separate additional pathology or may be an integral manifestation of the cervical spondylosis rather than a separate disease. Separate cervical spinal stenosis may be due to congenital/developmental anomaly; disc prolapse; or other space occupying lesions such as neoplasia.
- Cervical spine spondylolisthesis - If degenerative (that is, not due to spondylolysis (pars defects)).
Conditions excluded from this SOP
- Ankylosing spondylitis*
- Diffuse Idiopathic Skeletal Hyperostosis (DISH)#
- Facet joint dysfunction#
- Isolated bulging of a disc – A disc bulge without any other concomitant signs of disc pathology such as disc desiccation, annular tears, endplate changes, osteophytes, is likely to be a physiological change, and hence not currently a disease or injury.
- Musculoligamentous strain or sprain of the cervical spine*
- Rheumatoid arthritis*
* another SOP applies - the SOP has the same name unless otherwise specified
# non-SOP condition
Clinical onset
The cervical spondylosis SOP includes a condition-specific defintion of clinical onset (thoracolumbar spondylosis is the only other SOP with such a definition).
It is likely that clinical onset will predate the first imaging evidence of degenerative change. This will be a matter of medical judgement, based on the relevant associated symptoms. Neck pain is a non-specific symptom, with other possible causes. The nature and pattern of the symptoms (location, temporal connection, persistence etc.) needs to be consistent with a degenerative origin. Difficulties in assessing onset may arise where a prior acute neck injury, or surgery (e.g. for a disc prolapse) has occurred and symptoms have persisted subsequently. The time to develop clinically apparent spondylosis post injury is variable and dependent on factors such as the nature and extent of the injury and age. Most commonly, spondylosis onset following a joint injury occurs between ages 40 and 50. Onset may be as soon as 5 years post injury, particularly if of older age at the time of injury, but is more likely to be 10 years or more (and up to several decades later), particularly if the injury occurred at a young age (<25). The clinical onset will not be at the time of an initiating trauma/injury. The degeneration takes time to develop following a trauma.
Imaging evidence of joint degeneration does not establish a clinical onset, as clinical manifestations from the degeneration are also required. An attempt should be made to backdate onset to before the time of first imaging evidence, based on the clinical picture and medical advice. However, in the case of a prior injury or joint disorder, in the absence of a change in symptoms, and where a diagnosis of spondylosis has been made, date of first imaging showing degeneration may provide the only available marker for the time of clinical onset.
Clinical worsening
The natural history of cervical spondylosis is for the degenerative changes to slowly progress and worsen. The symptoms may fluctuate over time and may improve in some cases. Conventional medical therapy and operative treatment may alleviate symptoms but will not slow or reverse the condition.
Further comments on diagnosis
In exceptional circumstances the diagnosis may be made without imaging, in a person > 50 years, with typical clinical manifestations, and in whom imaging cannot reasonably be undertaken or obtained.