The cervical spine

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Postural neck pain 34 Acute neck pain in the young adult 34

Cervical spondylosis (cervical osteoarthrosis: Osteoarthritis of the cervical spine 34

Thoracic outlet syndrome 35 Whiplash and extension injuries of the neck 35

Barre-Lieou syndrome 36 Rheumatoid arthritis in the cervical spine 37

Klippel-Feil syndrome 37 Neoplasms in the cervical region 37

Osteitis of the cervical spine 37

nspection and palpation of cervical spine 38

Examination of cervical spine movements 39

Diagnosis of thoracic outlet syndrome 40-41

Diagnosis of cord compression and cervical myelopathy 43-44

Examination of radiographs 42-45 Radiographs of cervical pathology 45-47

postural neck pain___

In this common condition, pain in the neck and shoulders occurs in association with some abnormality of neck posture. It is commonest in females under the age of 40, many of whom have sedentary jobs (such as computer operators) which entail the head being maintained for long periods in a position that may be short of ideal. In some cases there may be a history of minor trauma which exacerbates or precipitates the complaint. Clinically the head and neck may be held in a somewhat protracted position, with some loss of the normal cervical curvature, but there is usually a full range of neck movements with normal radiographs. Analgesics and physiotherapy are usually helpful in the acute case, but in the long term change of work practices and in the patient's working environment are likely to be of the greatest benefit.

acute neck pain in the young adult_

In the 20-35-year age group, and often before there is any radiological evidence of arthritic change in the spine, a sudden movement of the neck may produce severe neck and arm pain accompanied by striking protective muscle spasm and limitation of cervical movements. In some cases these symptoms are produced by an acute disc prolapse similar to those occurring more familiarly in the lumbar region. In others, with identical symptoms, investigations including MRI scans may be quite negative; some disturbance of the facet joints or related structures is often thought responsible. Most cases respond to a period of rest in a cervical collar, or physiotherapy in the form of traction. In a few resistant cases gentle manipulation of the cervical spine may be helpful.

cervical spondylosis (cervical osteoarthrosis: osteoarthritis of the cervical spine)

Cervical spondylosis is easily the most common condition affecting the neck. Degenerative changes appear early in life in the cervical spine, often during the third decade. The disc space between the fifth and sixth cervical vertebrae is most frequently involved. The earliest changes are confined to the disc, but the facet joints and the uncovertebral joints (joints of Luschka) may soon become involved. There is inevitable restriction of movements at the affected level, but this is often impossible to detect clinically as it is masked by persisting mobility in the joints above and below. The condition may in fact never attract attention, but unfortunately in many cases symptoms do occur, sometimes being triggered by minor trauma. Pain may be felt centrally in the neck and may radiate to the occiput, giving rise to severe occipital headache which may be confused with migraine; pain may also radiate distally, often and inexplicably further than might be expected on anatomical grounds, to the region of the lower scapulae. Often there is pain at the side of the neck, quite sharply localized, or in the supraclavicular region. With nerve root involvement from arthritic changes in the facet or uncovertebral joints, there may be radiation of pain into the shoulders, arms and hands, with paraesthesia and, on rare occasions, demonstrable neurological involvement; this may include absent arm reflexes, muscle weakness, and sensory impairment.

In cervical spondylosis the cervical canal may be narrowed by osteophytic lipping of the facet or uncovertebral joints, by central disc herniations, by thickening of the ligamentum flava, or even from local cervical vertebral subluxations associated with ligamentous laxity. Developmental narrowing of the canal may be an additional factor. The reduction in the size of the canal may lead to cord compression (cerx'ical spondylotic myelopathy). The disturbance of cord function that results may cause neck pain, difficulty in walking and unsteadiness on the feet, numbness, paraesthesia, weakness, and loss of upper limb dexterity. There is often coexisting compression of cervical nerve roots, leading to radicular symptoms which may complicate the clinical picture. Bladder dysfunction may occur, but is not common, and extensor plantar responses may appear late. Severe progressive myelopathy from spinal stenosis often requires operative treatment by decompression and stabilization.

Vertebral artery involvement by osteophytic outgrowths or local spinal instability may cause drop attacks precipitated by extension of the neck. Osteophytes arising from the anterior vertebral margins may sometimes, because of their size, give rise to dysphagia.

The mainstay of treatment in spondylosis is the judicious use of a cervical collar and the prescription of analgesics. If root symptoms are prominent, intermittent or continuous, cervical traction is often employed. Manipulation of the cervical spine, especially in the younger age groups with no neurological involvement, is sometimes advocated. Severe, protracted symptoms may be investigated further by MRI scans, or myelography followed by CT scanning. If a positive lesion is demonstrated, exploration may be carried out; if not, a local cervical fusion may sometimes be advised.

thoracic outlet syndrome_

The lower trunk of the brachial plexus and the subclavian artery pass between the anterior and middle scalene muscles and over the first rib. Compression of these structures may result from a cervical rib, a definite but rare occurrence. Slightly more commonly, the same structures may be kinked by fibrous bands or abnormalities in the scalene attachments at the root of the neck, or by a Pancoast tumour. Paraesthesia in the hand is usually severe, and there may be hypothenar and, less commonly, thenar wasting. There is sometimes sympathetic disturbance, with increased sweating of the hand. The radial pulse may be absent, and other signs of vascular impairment may be present. Complete vascular occlusion, sometimes accompanied by thrombosis and emboli, may lead to gangrene of the fingertips. In some cases symptoms may be precipitated by loss of tone in the shoulder girdle, with drooping of the shoulders; in such cases, physiotherapy is often successful in restoring tone to the affected muscles and relieving symptoms. When vascular involvement predominates, arteriography and exploration may be required.

whiplash and extension injuries of the neck_

Whiplash injuries are now a common cause of persistent cervical symptoms. A true whiplash injury occurs classically when, as a result of a rear impact, a stationary or slowly moving vehicle strikes another vehicle or object in front. Because of the inertial mass of the head of the car occupant, there is rapid extension of the cervical spine followed by flexion. In the partial whiplash injury the main element is extension of the neck; this also commonly occurs as a result of a rear impact, but in this case the vehicle in which the occupant is travelling comes to rest more gradually, without striking anything ahead. Unfortunately, the attractive nature of the term has led to its misuse, and some recommend that because of its present imprecision it should be avoided altogether. If, however, it is going to be used, then it should be reserved for soft tissue injuries of the neck where extension is the main element. In the majority of cases the radiographs show normal alignment of the cervical vertebrae, but occasionally small avulsion fractures of the anterior margins of the vertebral bodies give evidence of the forcible extension of the spine. In some cases there are minor fractures involving the uncovertebral joints. Where there are spondylotic changes that interfere with the dissipation of the forces involved (because of localized areas of rigidity in the spine), there may be avulsion of anterior osteophytes. The flexion element may sometimes produce wedge compression fractures of the vertebral bodies or avulsion fractures of the spinous processes. Nevertheless, the discovery of unequivocal pathology in the spine is uncommon, and it is now apparent that there is a significant non-organic element in many cases. Although malingering does occasionally occur, this is considered to be rare. It is thought that in many cases a significant component of late disability is psychological, even if this is not at a conscious level, and that psychological elements and sometimes illness-related behaviour are often established within 3 months of injury.

Symptoms of all degrees of severity may be encountered. There is always pain and stiffness in the neck, sometimes with neurological disturbance involving the upper, and occasionally the lower, limbs. Even minor symptoms may be most protracted, often lasting 18 months or longer. In some cases disability is permanent. Analgesics for short periods and an early return to work are generally advocated, and it is thought best to avoid the use of cervical collars.

Severe extension injuries may occur in falls (often downstairs), when the neck is forcibly extended as the head strikes the ground. There is often telltale bruising of the forehead. In a car accident an unbelted occupant may also suffer severe extension of the neck in the early phases of deceleration, when the forehead strikes the roof and ricochets backwards. In both sets of circumstances the head injury may attract prior attention, but the possibility of these injuries must not be overlooked. Cervical spondylosis again has a deleterious localizing effect on the forces involved, and the neurological disturbance may be profound. In some cases thrombosis extends from the area of local cord involvement, so that there may be a deteriorating and sometimes fatal neurological outcome.

barre-lieou syndrome

This may follow a whiplash incident. There is complaint of headache, vertigo, tinnitus, ocular problems and facial pain. It is thought that it may be due to a sympathetic nerve disturbance at the level, and in 75% of the cases there is impairment of sensation in the C4 dermatome, with weakness of shoulder and scapular movements. Myelography may show nerve root sleeve disturbances. Good results have been claimed for anterior discectomy combined with local cervical fusion.

rheumatoid arthritis in the cervical spine _

Rheumatoid arthritis frequently involves the neck, often in a patchy fashion so that additional stresses are thrown on the remaining mobile elements. With the ligamentous stretching that often accompanies rheumatoid arthritis there may be progressive subluxation of the cervical spine, particularly at the atlantoaxial and midcervical levels. As this progresses, pain and stiffness in the neck become accompanied by root and cord symptoms. In the case of atlantoaxial subluxations there may be severe occipital headache. The gait tends to become ataxic and there is progressive paralysis, often with bladder involvement. These lesions are usually treated by local cervical fusion if the patient's general condition permits.

klippel-feil syndrome_

In this condition there is restriction of movements in the cervical spine owing to a congenital abnormality characterized by a failure of the cervical vertebrae to differentiate. One or more groups of vertebrae are fused together, and the condition may be associated with congenital elevation of the shoulder (Sprengel's shoulder). The condition gives rise to an increased susceptibility to injury and often neurological compromise.

neoplasms in the cervical region ___

Tumours of the cervical spine are rare, secondary deposits being the most common. They may cause vertebral body erosion or collapse, affect issuing nerve roots, or give rise to cord involvement. Of the primary tumours in this region, sarcoma and multiple myeloma are the most common. Primary involvement of the cord may arise with meningiomas and intradural neurofibromata, which may also affect isolated nerve roots.

osteitis of the cervical spine_ _

Osteitis affecting the cervical vertebrae is a rare occurrence in the UK. Tuberculosis, when it occurs, is seen most frequently in children, and may produce widespread bone destruction, vertebral collapse and cord involvement.

Causes Cervical ErosionCervical Bone WithUntreated Congenital Torticollis

3.1. Inspection (1): Note any asyuiuuUry in the supraclavicular fossae: this will require separate investigation (e.g. Pancoast tumour). (2) Note the presence of torticollis, where the head is pulled to the affected side and the chin often tilted to the opposite. In congenital torticollis there may be in the infant a small tumour in the sternomastoid muscle, and in the untreated case some facial asymmetry. NB: in about a third of cases the abnormal head posture is due to ocular muscle weakness, and a specialist ocular assessment is mandatory in every case.

3.2. Inspection (2 ctd): Torticollis ctd: The head is tilted and rotated, the sternomastoid cord-like, and there is often facial asymmetry. In acquired torticollis protective muscle spasm may result from tonsillar or vertebral body infection. It is sometimes seen accompanying the Klippel-Feil syndrome. It may also be due to a vertebral malalignment (especially at the C1/C2 level), from trauma or upper respiratory infection. In advanced infections and tumours the head may be supported by the hands.

3.3. Palpation (1): Begin by looking for tenderness in the midline, working from the occiput distally. Tenderness localized to one space is common in cervical spondylosis, and much more rarely accompanies infections of the cervical spine.

Most Prominent Spinous ProcessMost Prominent Spinous ProcessThyroid Gland Palpation

3.4. Palpation (2): Now palpate the lateral aspects of the vertebrae, looking for masses and tenderness. Note that the most prominent spinous process is that of Tl. and not the vertebra prominens. CI.

3.5. Palpation (3): Continue palpation into the supraclavicular fossae, looking particularly for the prominence of a cervical rib with local tenderness; look also for tumour masses and enlarged cervical lymph nodes.

3.6. Palpation (4): Complete palpation of the neck by examining the anterior structures, including the thyroid gland.

Brought HeadPalpation Region ChestBrought Head

3.7. Movements (1): Flexion: Ask the patient to bend the head forward. Normally the chin can be brought down to touch the region of the sternoclavicular joints. The chin-chest distance may be measured for record purposes.

3.8. Movements (2): Extension: Ask the patient to tilt the head backward. The patient should be seated (preferably in a high-backed chair) and erect. The plane of the nose and forehead should normally be nearly horizontal, but guard against contributory thoracic and lumbar spine movements.

3.9. Movements (3): Recording motion in the cervical spine with any accuracy is difficult, but may be attempted using a spatula in the clenched teeth as a pointer. Stand back, and ask the patient to flex the head forward. Line up the legs of a goniometer with the spatula and the horizontal, respectively. Read off the included angle. Normal range = 80°.

Normal Range Knee Flexion AngleGoniometer Measurements Lumbar SpineLumbar Flexion Normal Range

3.10. Movements (4): Now ask the patient to extend the head to measure the range of extension from the neutral position. Normal range = 50°. The total range in the flexion and extension planes should be assessed, either by a single measurement or by the summation of flexion and extension. Normal range = 130°. Of this total, about a fifth occurs in the atlantoaxial and atlanto-occipital joints.

3.1 1. Movements (5): Lateral flexion: Ask the patient to tilt his head on to his right shoulder. In the normal case lateral flexion, with only slight shrugging of the shoulder, will allow the ear to touch the shoulder. Repeat on the other side and note any difference.

3.1 2. Movements (6): Lateral flexion: For greater accuracy, a spatula clenched in the teeth may again be used as a pointer. Normal range = 45°. About a fifth of this movement occurs at the atlantoaxial and atlanto-occipital joints. Loss is common in cervical spondylosis.

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