DEFINITION:• Discomfort or more intense forms of pain thatare localized to the cervical region.• This term generally refers to pain in theposterior or lateral regions of the neck.
The spine has three majorcomponents:1. The spinal column(i.e., bones and discs).2. Supporting structures(e.g., muscles and ligaments).3. Neural elements(i.e., the spinal cord and nerveroots).
The spinal column:• It is composed of vertebrae that begin in the uppertorso and end at the base of the skull. Sevenvertebrae make up the cervical spine.• They are smaller in size when compared to otherspinal vertebrae.
A typical vertebra consists of:•Large vertebral body in the front.•2 strong bony areas (pedicles) connecting the vertebral body &the posterior arch.•A posterior arch of bony structures in the back (the spinous process, lamina & thetransverse process).•The vertebral bodies support 80% of all of the loads applied to the spine.•Its main purpose is to protect the spinal.
Intervertebral discs:The vertebrae are connected in the front of the spine by IVD. IVDmake up ¼ of the spinal columns length. Discs are not vascular & depend on the end plates to diffusenutrients. Discs help to support the spine & allow some vertebral motion(ext & flex). Individual disc movement is very limited – howeverconsiderable motion is possible when several discs combineforces. There are no discs between the Atlas (C1), Axis (C2), andCoccyx.
IVD are strong tissues, filled with gel. Composed of anannulus fibrosus & a nucleus pulposus. The cartilaginous layers of the end plates anchor thediscs in place. The intervertebral discs are fibrocartilaginous cushionsserving as the spines shock absorbing system, whichprotect the vertebrae & other structures (i.e. nerves).
Supporting structures:A complex system of ligaments, tendons, and muscleshelp to support and stabilize the cervical spine.
Ligaments:Ligaments (which arecomparable to thickrubber bands) workto prevent excessivemovement thatcould result inserious injury(they providestability to thespine).
Atlas and Axis Ligament SystemsThe Atlas (C1) & Axis (C2) are different from theother spinal vertebrae. The upper cervicalligament system is especially important instabilizing the UCS from the skull to C2.1. Occipitoatlantal Ligament Complex.(4)2. Occipitoaxial Ligament Complex.(4)3. Altantoaxial Ligament Complex.(4)4. Cruciate Ligament Complex.
Muscles:• They help to provide spinal balance andstability, and enable movement.• There are different types of muscle:forward flexors, lateral flexors, rotators,and extensors.Types of Vertebral Muscles: General Location:Forward flexors AnteriorLateral flexors LateralRotators LateralExtensors Posterior
Muscles of the Posterior Cervical andUpper Thoracic SpineSemispinalis Capitus(head rotation/pulls backward)Iliocostalis Cervicis(extends Cv)Longissimus Cervicus(extends Cv)Longissimus Capitus(head rotation/pulls backward)Longissimus Thoracis(ext./lat. Flex. vert column, rib rotation)Iliocostalis Thoracis(ext./lat. flexion vert column, rib rotation)Semispinalis Thoracis(ext/rotates vert column)
Spinal Cord and Cervical Nerve Roots :There are 8 pairs of cervical nerves.The PNS is the complex system of nerves thatbranch off from the spinal nerve roots.The cervical nerves control many bodilyfunctions and sensory activities.C1: Head and neck C5: Wrist extensorsC2: Head and neck C6: Wrist extensorsC3: Diaphragm C7: TricepsC4: Upper body muscles C8: Hands(e.g. Deltoids, Biceps)
• The spinal cord is surroundedby spinal fluid (CSF) and byseveral layers of protectivestructures, including the duramater, the strongest,outermost layer.
Vascular System of the SpineArteries Supplying SpinalColumn: Vertebral Basilar CarotidVeins Supplying SpinalColumn: Internal Jugular External Jugular Superior Vena Cava
How the Spinal Column Should Look? Posterior aspect-> should be perfectlystraight, with no lateralcurves. Sagittal view-> should be inward curves(lordosis) at the cervical &lumbar levels outwardcurve (kyphosis) at thethoracic level. These curves allow the headto position over the pelvis ina sitting & standingposition, while allowing forload bearing and shockabsorption in the spine.20 to 40˚
Facet Joints:(Zygapophyseal or Apophyseal Joints) Are located at the back of thespine (posterior). Each vertebra has 2 sets of facetjoints. One pair faces upward (superiorarticular facet) & one downward(inferior articular facet). There is one joint on each side (rt <). They are synovial hinge–likejoints (surrounded by a capsuleof connective tissue, produces afluid to nourish & lubricate thejoint & there surfaces are coatedwith cartilage allowing joints tomove or glide smoothly[articulate] against each other).
They allow flexion (bendforward), extension(bend backward) andtwisting motion. Certain types ofmovement are restricted. The spine is made morestable due to theinterlocking nature toadjacent vertebrae.
ROM of the neck: The neck has a significant amount of motion (e.g., rotateside to side, bend forward and backward). Flexion & extension mainly at occipito-atlantoid j.may extends throughout cervical spine. Lateral flexion throughout cervical spine. Rotation mainly at atlanto-axial j.may extends throughout cervical spine.EXTENSION:55 degree.ROTATION:30 degree rotationLATERALFLEXION:40 degree.FLEXION:Able to touchchest with chin.
Neck Pain Neck pain may result from abnormalities in the softtissues—the muscles, ligaments, and nerves—as wellas in bones and joints of the spine. The most common causes of neck pain are soft-tissueabnormalities due to injury or prolonged wear andtear. In rare instances, infection or tumors may cause neckpain. In some people, neck problems may be the source ofpain in the upper back, shoulders, or arms.
Cause:Intrinsic causes: Deformities: Infantile torticilis. Infections of bone: TB of cervical spine. Pyogenic infection of cervicalspine. Tumours: Benign & malignant tumoursin relation to cervical spine &nerve roots. Psychogenic. Arthritis of spinal joints: RA. AS. OA of cervical spine( cervicalspondylosis). Mechanical derangement: Prolapsed cervical disc. Cervical spondylolithesis. Whiplash injury. Cervical spine fracture. Neck muscle strain. Neck sprain.
Cervical Disc Disease:• Most common site C5-6 & C6-7.• Cause:– Trauma is a predisposing factor.• Pathology:– Disc bulge: generalized symmetric extension of the disc margin.– Disc protrusion: herniation of nuclear material through a defect in annulus.– Extrusion: herniation of nuclear materialresulting in an anterior extradural massattached to the nucleus of origin(pedicle).– Disc sequestration:separation of material from the disc.ProtrusionExtrusion Sequestration
• Clinical features:– Radicular pain with decreased cervical range of motion(ROM).– Discogenic pain without nerve root involvement:decreased cervical ROM, normal neurologic examination &possible pain exacerbation with axial compression.– Myofascial tender or trigger points commonly arepalpable.– Tenderness with posteroanterior mobilization may suggestdisc pathology.
Investigations: PXR -> narrowing of disc space. MRI -> modality of choice. Electrodiagnostic studies .TREATMENT:1. Physical Therapy2. Surgical Intervention3. MEDICATION○ NSAIDs are 1st line of R for most cervical conditions.○ Muscle relaxants to potentiate the NSAID analgesiceffect & not necessarily to control muscle spasm.○ Oral corticosteroids treat inflammatory cervicalradiculopathy.Sagittal MRIdemonstrating cervicalintervertebral discprotrusions at C3-C4 andC7-T1.
Cervical Spondylosis: Chronic degeneration of the cervical spine that affects thevertebral bodies, IVD (disk herniation and spur formation), facetjoints, longitudinal ligaments, ligamentum flavum & spinal canalcontents(nerve roots and/or spinal cord). Pathology: IVD lose hydration & elasticity with age -> cracks and fissures. Ligaments lose their elastic properties -> develop traction spurs. Disk collapses (biomechanical incompetence) -> annulus bulgeoutward. Disk space narrows, annulus bulges & facets override-> increases motion at that spinal segment & hastens the damage to thedisk.-> cross-sectional area of the canal is narrowed. Acute disk herniation may complicate chronic spondylotic changes.
Clinical features: 40-60 years of age. Examination: Spurling sign - Radicular pain exacerbated by extension andlateral bending of the neck toward the side of the lesion. Lhermitte sign - This generalized electrical shock sensationwith neck extension. Cervical pain with decreased ROM in the cervical spine. Radiculopathy . Distal weakness. Increased reflexes in the lower extremities & upperextremities below the level of the lesion. Extensor planter reflex & Hoffman sign in severemyelopathy.
Investigations: PXR ->facet joints, the foramen,intervertebral disk spaces, andosteophyte formation. Myelography + CT ->to assess spinal and foraminalstenosis. [INVASIVE] CT with or without intrathecaldye ->to estimate the diameter of thecanal, small lateral osteophytes& calcific opacities in the middleof the vertebral body. MRI -> modality of choice. Electrodiagnostic studies .
TREATMENT:1. Physical Therapy.2. Surgical Intervention.3. Injection: Cervical, zygapophyseal, intra-articular steroid injection4. MEDICATION:○ NSAIDs are 1st line of R for most cervicalconditions.○ Muscle relaxants to control muscle spasm.○ Oral corticosteroids treat inflammatorycervical radiculopathy.
Cervical Sprain and Strain:One cause of cervical strain is termedcervical acceleration-deceleration injury(whiplash injury).Causes: Motor vehicle accidents, lifting or pulling heavyobjects, awkward sleeping positions, unusualupper-extremity work & prolonged staticpositions. Repetitive or abnormal postures may contributeto cervical sprains and strains.
Pathology: Cervical strain is produced by an overload injury to the muscle-tendon unit because of excessive forces on the cervical spine.->Elongation & tearing of muscles or ligaments.->Secondary edema, hemorrhage, and inflammation may occur. Clinical features: C/O: Neck pain & headache. Difficulty sleeping, disturbed concentration & memory due topain. Neurologic symptoms: weakness or heaviness in thearms, numbness & paresthesia. Examination: stiffness of the neck with decreased active & passive ROM. spasm tightness, muscle hardness.
Treatment:1. Physical therapy.2. Traction, manipulation or acupuncture.3. Injection (chronic, persistent neck pain). Typesof injection include epidural, selective nerveroot, or facet block injections.4. Percutaneous radiofrequency neurotomy ofmedial branch nerve to facet joint is effectivefor chronic neck pain due to cervicalzygapophysial joint pain.5. MEDICATION:○ NSAIDs are 1st line of R for most cervical conditions.○ Muscle relaxants to control muscle spasm.○ Oral corticosteroids.Full recovery within weeks
Cervical sublaxation & dislocation:• Spontaneous or 2ry to injury.• Types:1. Cong. failure of fusion of odontoid body with axisvertebra.2. Inflammatory softening of trans lig of atlas.3. Instability dt previous injury or RA.Displacementof atlas withdensDisplacement of atlason axisSublaxationof v over 1below
Clinical features: Discomfort stiffness& muscle spasm. Radiology: Displacment.Treatment: According to cause:Traction or plaster collaror operative fusion.
Tumours in relation to Cx spine: Site:1. In the spinal Column.2. In the meninges or rarely spinal cord.3. In the fibrous components of PN (neurofibroma).4. In adjacent soft tissue. Type: Malignant > benign. Usually metastatic. Examples: Meningioma -> uncommon to compress the cord. Neurofibroma in IV foramen -> cord compression. Clinical features: Of compression on CORD, interference with BRACHIAL PLEXUS orlocal destruction & collapse.
Ankylosing spondylitis: It creeps up the spine from below. Cause: Unknown. Pathology: Begins with SIJ usually extends upwards to involve lumber, thoracic &cervical spine, in severe cases hip or shoulder involvement. Articular cart., synovium & lig. Show ch. Infl changes & thenossification. Clinical features: Men, 16-25 yrs. Aching pain in low back with increasing stiffness then extendsupwards to neck. Treatment: Patient education. Exercise. Support cervical spine by plastic collar.
Rheumatoid Artheritis: It is chronic infl of joints associated with mildconstitutional symptoms. Usually affected inrheumatoid polyartheritis, especially in sero –vedisease. Cause: Unknown. Maybe autoimmune or infection. Importance: IVD destruction leads to gradual forward sublaxation. Risk of atlanto-axial sublaxation dt softening in transverselig of atlas. Radiological:1-Errosions of IV joints. 2-Sublaxation. Treatment: Support cervical spine by plastic collar or in some caseslocal IV fusion.Diagnosis:1. Simultaneousinvolvment ofother joints.2. Raised ESR.3. RF +ve.
TB of cervical spine• Less common than in thoracic spine &lumbar region.• Pathology:
Clinical features: Child, & young adults. Pain in neck and occiput, aggravated by motion. + 1 of following: diff ofswallowing, abcess, sinus, neurological sympt. from corddysfunction (UL before LL) On examination:○ Cervical muscle spasm. Prominent 1 or more spinal process.○ Local tenderness on deep palpation over spinal process. Limitedpainful neck ROM. Investigations: ESR -> raised. Mantoux test: +ve. Tb bacilli in pus. Radiological: 1-Dec disc space. 2-Bone destruction.3-Abscess shadow. Treatment: Principle R: Antibacterial therapy. Local R: support Cv spine (plaster of Paris or plastic collar. Operative R: drain abscess, decompress spinalDiagnosis:1. History(contact or septic focus).2. Muscle spasm with limited ROM.3. Radiological findings.
Pyogenic infection(Pyogenic cervical spondylosis): Uncommon in cervical vertebrae or IVD. Cause: staph., strept., pneumococci & less commonly salmonella orbrucella. Pathology: As TB. Clinical features: Acute or subacute with fever. As TB but more rapid course . Investigations: ESR -> raised. PNL-> raised Radiological: 1-Dec disc space. 2-Bone destruction.3-Abscess shadow. 4-osteoperosis. Treatment: Principle R: Proper a antibaiotic therapy. Local R: support Cv spine (plaster of Paris or plastic collar. Operative R: spontaneous fusion usually makes it unnecessary.
Infantile torticilis Tilting & rotation of head by contarctures ofsternomastoid muscle of 1 side. Causes: ?? Interference in blood supply of sternomastoid muscle, dtinjury during birth. Pathology: Muscle fibers replaced by fibrous tissue. Clinical features: Child, 6m-3yrs, head held to 1 side. On examination:○ Contracted sternomastoid muscle (cord like).○ In long standing cases: Retarded facial development on same side(facial asymmetry). Treatment: In sternomastoid pseudo-tumour stage: Stretching ofmuscle. In established stage: Surgical division with postoperativeDiagnosis:1. History.2. Cord like.3. Facial asymmetry.
ROM Fix the head with one hand while you examine neck Inspection Note the normal concavity of cervical spine Identify Transverse process of C7 Observe Trapezius and Sternomastoid muscles Palpation Feel each spinous process looking for focal areas of tenderness Joint○ Feel for crepitus during passive motion Para spinal muscles Range of motion Active○ Touch chin for flexion○ Throw head back for extension○ Touch each shoulder with ears for lateral flexion○ Touch each shoulder with chin for lateral rotation Passive○ Feel for crepitus during passive motion Normal: 30 degree rotation, able to touch chest with chin, 55 degree extensionand 40 degree lateral bend.
CERVICAL MUSCLES FUNCTION NERVESternocleidomastoidExtends & rotates head, flexes vertebralcolumnC2, C3Scalenus Flexes & rotates neck Lower cervicalSpinalis Cervicis Extends & rotates head Middle/lower cervicalSpinalis Capitus Extends & rotates head Middle/lower cervicalSemispinalis Cervicis Extends & rotates vertebral column Middle/lower cervicalSemispinalis Capitus Rotates head & pulls backward C1 – C5Splenius Cervicis Extends vertebral column Middle/lower cervicalLongus Colli Cervicis Flexes cervical vertebrae C2 – C7Longus Capitus Flexes head C1 – C3Rectus Capitus Anterior Flexes head C2, C3Rectus Capitus Lateralis Bends head laterally C2, C3Iliocostalis Cervicis Extends cervical vertebrae Middle/lower cervicalLongissimus Cervicis Extends cervical vertebrae Middle/lower cervicalLongissimus Capitus Rotates head & pulls backward Middle/lower cervicalRectus Capitus Posterior Major Extends & rotates head SuboccipitalRectus Capitus Posterior Minor Extends head SuboccipitalObliquus Capitus Inferior Rotates atlas SuboccipitalObliquus Capitus Superior Extends & bends head laterally SuboccipitalMuscles of the Spinal Column
• However, because it is less protected than therest of the spine, the neck can be vulnerableto injury and disorders that produce pain andrestrict motion.