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Clinical Anatomy and Management of Cervical Spine Pain
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CLINICAL ANATOMY AND .MANAGEME
T OF
CERVICAL SPINE PAIN
L. G. F. Giles MSc, DC(C), PhD Department of Public James
University
and Tropical Jledlcine,
Queenslond, 1i!1L'nsville
Director National Centre for Multidisciplinary Studies of Back Pain, Townsville General Hospital
Honorary Clinical Scientist Townsville General Hospitai, TOIl'lIsville, Queensill/ui, Australia
K. P. Singer MSc, PT, PhD Associate Professor School ofPh),siotberapy, Curtin Universil), of Technology, Shenton ParA?, I¥i'stern Australia
Honorary Research Fellow Departments of Radiology, Ne u ropathology and Bioe ngi neering , Royal Perth Hospital, Perth, Western Australia, Australia
With
Professor
Foreword by
Dvorak
Head of Departmen t of Neurology,
Sp ine Unit, Schultbess Clinic, Zu rich, Switzerland
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Contributor."}
P. G. Ba ker Associate Professor. Rural Health, University
Cummunity and
of Neurosurgery, Royal
\1ersey
South Australia, Australia
Hospital, Latrobe.
G. J. H.
Associate Prolessor Physiotherapy Department,
Bland
University of Queensland, St Lucia, Australia;
Professor of Medicine - Rheumatology, Emeritus,
Honorary Research Fellow, Department of
Rheumatology and Clinical Immunology Unit,
Physiotherapy, University of Melbourne, Victoria,
University of Vermont, Burlington, USA J. J. W.
Australia
Boyle
T. McClune
School of Physiotherapy, Curtin University, Perth,
Spinal Research Unit, University of Hucldersfield,
Western Australia, Australia
R.Burtt Spinal Research Linie
Hlldderstleld,
and Human Biology
Hudderstleld, UK
Australia, Perth, Wester n
R. Cailliet Professor Emeritus,
L.
of Physical
]'v[edicine, University of Southe r n California, School
Emeritus Professor of Medical Imaging, Department
of Medicine, Los Angeles, California, USA
of Neuroradiology, University Hospital, Groningen, The Netherlands
R. Clarke
L.J. Rowe
Spinal Research Unit, University of Hudclerstteld,
Departm e nt of Medical Imaging, Joh n Hunter
Hucldersttelcl, UK
Hospital, Newcastle, New South Wales, Australia
M. I. Gatterman Dean of Chiropractic States Chiropractic
Snences, Western
A. PSYchological Services, Univ(T,;iry
Oregon, USA
Olltario, Canada
L. G. F. Giles Reader, Departmen[ Medicine, James
and Tropical
School of Pl1ysiotherapy.
North
Shenton Park, Wesrern
Queensland; Director, National Centre for
Australia; Honorary Research Fellow, Departments
Multidisciplinary Studies of Back Pain, Townsville
of Radiology, Neuropathology and Bioengineering,
General Hospital; Honorary Clinical SCientist,
Royal Perth Hospital, Perth, Western Australia,
TownsviJIe General Hospital, Queensland, Australia
Australia
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Foreword
remarkably
The prevalence amounting to benNcen
J mongst
of
the eqU ilibrium can
on the age
called normal
trauma and sometimes
a hig her inci-
group. The aging dence
quite an unstable part
high,
the so
neck
1,-y[[hout
procedures The most .
radicular
symptoms and signs, prcscmi ng with a decreased range of motion. One of the reasons for this might be
tissue injuries of the spinc
rcsult of car collisions.
3S 3
The management of neck problems, due either to
the ongoing transformation of the bony structures, as
dege nerative changes or trauma, is not an easy task,
observed
Herbert von
and requires a profound knowledge of the functional
Luschka (1858) and scientifically studied by t h e Swiss Gian Tondury (1947). Such a devel
anatomy, the clinical biomechanics as we U as th e
by the German
anatomist,
anatomist,
radiology and neurology of the cervical spine. This impre s sively documents our current under
opmental transformation might be due to the upright
book
position of the human body as well as the use and
standing of the above. The editors have invited world
spille dur i ng daily
sometimes abuse of
contribute to this book well balanced, reviewing
activities, leading to
working, leisure degenerative changes
body and plates
our knowled ge combined
and the intervertcbr'll
sial joints.
a dvan ces
An understand ing
developmental ch anges,
his own clinical life,
this 'ongoing
spine disorders, ranging
or - as pointed
interpretation of
transformation', is
patient symp-
altered motion toms, clinical signs and diagnosis will
,
finally
.
radiological findings. The
de te rmi n e
the
appropriate
therapeutic approach, m ain ly in deciding whether
to the more difficult such
the spinal canal
severe cervical myelopathies which req ui re extensive surgery. Based upon my
OWll
clinical experience and
research work in the t1eld of the cervical spine, I
conservative or surgical treatment is indicated. Fur
would highly recommend t h is book,
thermore. an understanding of the underlying pathol
general practitioners, but also to specialists or to
not only to
ogy will help the clinician to recognize the limits of
anybody
the therapeutic procedure, especially when aggres-
cervical spine pro blems, bearing in mind that our
sive
be counterproductive
treatments
simple 'wait a nd
and
most beneficial
who
major task nocere
of
Much too often
n eedlessly prolonged
treatments of neck
disord ers
to
deal
competently
harm the patient
with
(primum
This is defi nitely importallt
recoglliLc
for the patient in
wishes
management
of cervical
.
medical practi
tioners, chiropractors.
and other pro
fessional groups
spine disorders
Zurich, September
who clo not always
and sometimes
Professor Jiri Dvorak,
delude
themselves
concerning
their
therapeutic
Head of Department of Neurology, Spine Unit, Schulthess Clinic, Zurich, Switzerland
omnipotence.
Copyrighted Material
Preface
Our intention in
text series is to
communication between
on the ration al
illtcn.,,[cd in this i mportant
spinal pain. We
hope to contribute to
and an alysis of
c ervi c al spine care.
basic sc iences
clin ica U y releva m
le ading to diagnosis allu treatmen t of mecha ni c al
a
organized so that it can p r oa ch ed
111
scvcral ways, according to the needs of
neck disorders, wi th a ch apter dedicated to con t ra
the reader. The clinician w h o wishes a quick over
indications to sp ina l manipulation.
view of clinical assessment c oncepts and techniques
This tex t h ighlights the value of a te am approach in
s ho u l d consult Part 3: Diag n osis a nd man agement .
apprecia ting the complexity of neck pain a nd a range
This includes : imagi.ng procedur es f()r mechanical
of treatment approaches .
Contempor ary contribu
n eck comp l a ints , medical and su rgi cal approaches to
c l in ica l medicine,
neck pain and separate ch ap te rs on the assessmen t
neurosurgery, c h irop ractic , osteopathy and physio-
and management s trategies provided by c hiroprac
tions from anatomy, pathology, therapy are p resent ed
volume. Each part,
written by experienced
cliniCia n s , provides
a s u mm a ry of pertinclH
which will lea d to an
improved undersundll1g
physiotherapists. rhe reas onin g behind clinical a n a tomy, pathology
cervical spin e .
of mechanical
neck pain . M anag em ent
to both the clLnicli using clinical
assessment teclmiqun,
re a son in g sequences.
mechanical neck
not at temp t to to highlight
endorse a single
pllin
review of the liter:l[urc
the
examples of clinical
co mm on appro ach to mechanical treatment which
three
dis cipli n es
of
therapy.
mechanical
may be provided by chiroprdctic, os teop a t hy and
Despite the need to va ti d a te theories behind mechan
physiotherapy practition ers .
ical intervention and to s h ow the long - te rm efficacy
Our goal is to p res ent this information in a manner which
ben efi t
bot h
the
un d ergra duate
of
t h ese
therapies,
this
text
also
sets
out
our
and
cha l lenge , as cl inic i an - scientists, to promote com
postgrad uate student of mechanical therapy, as well
muni cati on between all interested pa r tie s . Neck p a in
will
as all clinicians who seek a comp reh e nsive review of
is multifaceted and it demands the shar ing of ideas
mechanical ned
belief that qua li ty
and
illustrations facilillllC
careful selection of
to
material and detadnl
heen prepared to
complement
thc
objective
is
to
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improve the managemelll
Ie K.
Section
Introduction
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4 Clinical Anatomy and Management oj Cervical Spine Pain
Fig. 1.1 The motion (mobile) segment of ]unghanns. A and P Anterior and posterior longituelinal ligament respec tively; H hyaline articular cartilage; I interspinous ligaments; IVD intervertebral elise with anulus tibrosus, nucleus pulposus anel cartilage end-plates; C joiO[ capsule with associateel synovial folds at the superior anel inferior recesses; L li g a men tum flavum; N neural structures. In aelelition, the space between the transverse processes and all =
=
=
=
=
=
A
=
corresponding muscular parts must be included. (Compare with histological section shown
in
Figure
1.10.)
B
Fig. 1.2 A Good posture clue to proper mus cle tone. B Bad posture which develops when poor muscle tone is present. Nare the hyperiordotic cervical and lumbar spines with the kyphotic thoracic spine. The line of weigllt in the neck, and the rest of the body, is no longer normal. From =
=
of this line lies in its rel at i ons hip to th e transve rse axes of rotation of the j oi nts of the vertebral column and the lo wer limbs sinc e the bod y tends to fall forward s or backward s due to gravity a cc o rding to whether the line of weight passes in f ro nt of, or b e h i nd , these axes, res p ectively O o seph ,
The i mpo r t anc e
GiJes (1991) with permission.
Al t h o ugh motion of the s p ine is uneler the control of act ive sp i na l musculature, further prote c tive support is achieved from the
comp lex l i ga m ent ous system
1960).
(Farfan 1978; Putz, 1992). Some ligaments have a dual
Posture and m o vem e nt are related to t he muscu la tu re of the back which has two fu n c tions : first, to hold the c entral su ppor ting organ of the body (the sp i nal col u mn) in its pr op er shape and p ositio n, and second, t o su pp ly the force for its m ovement The muscles situated near the body's s urfa ce and far from
ro le
,
.
the
midline
are
highly
effective
motor
agents,
whereas the muscles situ a ted adj acent to the spinal
column are mainly concerned with maint enance of posture (Rickenbacher et al., 1985).
Poor posture, in which the head is t luust forward with excessive spinal curves in the sag ittal plane, sl oping
or hunche d sh o ulder s, pr o t rud ing abdomen
an d hyperextendeel kne es (Garlick, 1990; Fig. 1.2B) may be ha bitual
or o ccu pation al (MennelJ, 1960), and to poor muscle tone. This can cause chronic p ostura l strain which, in turn, can cause myo fasci a l pain (Keim anel Kirkalely-Willis, 1987). Thus it is imp ort an t that goo d erect posture be maintained because poor posture can great ly increase the biomechanic�l stresses on the cervical spine (C h a pter 7, Fig. 7.18). The hu m an spine as a wh o l e is � very complicated stru cture anel it is considered by s o m e to be a mas terp i ece of en g i n eer ing (Keith, 1923; Farfan, 1978; Giles, 1991). can be re l ated
,
for example the liga ment a f1ava are not only
involved ill reS i sti ng e xcess sep a rati o n o f ad j acent
al so p rotect the neural elements structures, such as the laminae anel zygapophysial j o ints , in parts of the s pin al anel inrervertebral (foraminal) canals. Furthermore, lU1der n o r mal circumstances, the epidural anel epir ad icu l ar a d ipo se tissue afforels an adequate reserve cushion for protecti on of n eu ral anel vascular struc tures wit lli n the sp ina l and intervertebral c anals . Three main factors make the cervical s pine incl ud ing some of its neurovascular struct ure s, vul nerable t o abnormal mechanical stresses: first, appar ent d i sreg ard for mai nt ai n ing good posture; seconel, c ongenita l or acq ui red anomalies of osse o us and so ft tissues; anel thirel our frequent inability to pro tect the spine fro m injuries, which may leael to joint dysfunc ti on anel degeneration. vertebral laminae but
from
ass o ci ated
osseous
,
,
Anomalies Anomalies are varied and include first, osseous spi nal
anomalies such as unilaterally or bilaterally enJarged
Copyrighted Material
Introduction F. Giles and
Although many
segment and
Lewi s et at"
1993; Lahad et
1994) w i l l suffer
from low back pam at some tune d u ring t heir lives, and onlv 35-40% will suffer f rom neck a n d arm p a i n (Bovim
�t at"
1994; D a y et at" 1994), the l a t t e r can be
a major sou rce of mecharucal spinal pain, and 30% of such patients wil l develop c h ronic symptoms (Shelo kov, 1991). In add ition, i t has been known for many years that neck pain can be associ ated with refe rred pain to the h ead, the shou l d e rs, u p p e r extremities and anterior o r
of t h e chest,
The cervical spine h a s typ ical cervical vertebrae b elow the secon d s p i na l level (C2) 'where as the vertebrae a bove the C3 vertebra a re atypical (Chap ter Ollt
that the b asic anatomical a n d functional urut of
the vertebral column i s the artic u l a r t r i a d consisting of the fibrocartilaginous i ntervert e b ra l joint and rhe zvgapophys i a l
a nd lower back
between shoulders, Oackson, 1977),
e l e me n ts (Andersson,
h a ve addressed
space
the validi ty of zygapophys i a l
j o i n ts
h a ve
been
stud ied
(Bog d u k, 1995), Many individ uals suffer from cervicogeruc head a ches due to neck i nj u ries and this is a major hea l th problem in view of the increasing n u m ber of motor veh i cle accidents w h ich can cause a varied consteUa l i on of symptoms d e p e nding on w h i c h structures are
in f lexion-extension-type i njur i e s of t h e cervical spine 1 5). injured
In ord e r to
Inagnilude of suffe r i ng
changes, it is
Ul1ClcrsLlnd the anatomy
and and pathology of I the cervicothoracic
1995), as b rietly
3.
In a d d ition,
between two
occu rs: the intervertebra l
associated with painful
The
conve n i ently s u b divided
vol u me o f med ical
servi c es and yet
j o i n ts.
]unghanns (Schmor!
without cervico-
gerlic headache
2).
Lewin et al. (1961) and Hirsch et at. (1963) pointed
its
t heir fibrous joint capsu les and the l i gamenta flava, the contents of the spinal canal and the left a n d right intervertebral can als, a n d t h e ljgamen tum n u chae (Fig, 1.1). The j oints in the neck are respon si ble for first, f leXibility, allowing a variety of movemen ts such as flexion. extension , lateral bendi ng and axial rotation. tra nsm ission a n d shock strai ns primarily as a
dege nerative
properties of t h e i ntervertebral. Fu r t h ermore,
i n cl uding tha t of
lumbosacral spines,
Chapters 2 a n d
arise as a result of c e rvical spine injuries must also be
pos t u re
cervical spine as it d ocs
j u nction (Bailey et at., Issues which can
p lates, the anterior a nd
longit u d i na l l igaments , t h e zygapophysia l joints with
Posture
considered (Merskey, 1993), as well as fibromyalg i a syndrome (Mc C a i n , 1993) a n d myofascial pain syn
In norma l posture , the l i ne of weig h t is the p e rpen
drome (Fricton, 1993).
d icular t h rough the centre of gra v i ty Ooseph, 1960).
Copyrighted Material
Introduction 5
Fig. 1.3
Two congenital anomalies
C7 rudimentary cervical
ribs;
B
=
of the
spine are shown as an example:
A
=
bilaterally
en.larged transverse
processes, i.e.
blocked vertebrae.
C7 tra ns verse processes or rudimentary cervical ribs 1.3A), bl oc ke d vertebrae (Fig. 1.3B), w hi c h oc cur most common ly at C2-3 then at C5-6 (Brown et at., 1964); a nd second, soft·tissue anomalies such as conjo i ne d nerve roots, or fibrous bands in con· tinuation with rudimentary ce r vica l ribs (Adams and Hamblen, 1990). E nlarged transverse processes can affect the subcl av i a n artery and the lowest trunk of the brachial plexu s as t he y arch over thi s process due to mechanical pressure again st it ( S u n de rland 1968; Adams and Hamblen, 1990). In the case of con geni tally block e d vertebrae, the freely movable articula· tions above and below the blocked segment are p laced under additional mechanical stress, and t his usu all y results in premature d egene ra t ive di scogeni c spondylosis ancl arthrosis at the fully articulated levels ( G ueberr et aI., 1996). (Fig.
spinal ergonom ics and cor rect posture. The latter issue is b eyond the scope of this volume but trauma is a s e rious problem in view of the eve r·increas ing number of motor vehicle accidents. This im portan t issue will briefly be mentioned in t h is chapter but considered in detail in Chapter 5.
Innervation
,
·
A summary of the innervat i on of structures which may be injUl"ed in cervical sp in e trauma is briefly discussed here. In order to lay a foun dat i on for understanding the possible clinical synd romes which may result from trauma to the cervical spine, reference s hould be made to original p ublications (Jackson, 1977) for a complete anatomical description The ce rvical zyg a p ophysial jo ints are innervated by art icu l a r branches derived from the medial branches of the cervical dorsal rami; an ascending branch innervates t he zyga pophys ial j oin t above and a descendin g branch innervates the jOint below, result· ing in a dual inn erva tion for each zygapophysial join t (Lord et at., 1993). Beyond the zygapophysial joint the media l branches of the cervi ca l dorsal rami sup ply th e .
Spinal injuries Our apparent inabiliry to protect t he neck fro m injury in many c i rcumsta n ces is an e normously co mp lex issue whi ch can be summarised as bei n g due to unexpected trauma, or a poor under s ta nd in g of
Copyrighted Material
6 Clinical Anatomy and Management of Cervical Spine Pain
PPR
A
\
B
Fig. 1.4 A
=
Schematic drawing showing a mid cervical vertebra. Some of the adjacent peripheral nerve structures arising
from the spinal cord are shown on the left side. On dIe right, the neural structures passing over the pedicle Ilave not illustrated but the spinal artery is shown arising from the vertebral artery. Note the anterior and veins, respectively
B
=
A 100,.un
and
posterior
been and
spinal arteries
the small epidural vessels supplied by tIle recurrent meningeal nerve.
thick histological section cut in the horizontal plane through the right Side of a ce rv i ca l spine is
(enlarged) for comparison with the overall view shown
in A.
Note the proximity
of
the
vertehral
shown the
artery to both
uncovertebral and zygapophysial joints. The sympathetic vertebral plexus located on the vertebral artery is not illustrated but is shown schematically A
E
=
=
in
Figure 1.7.
Articular process (superior); APR
epidural space;
EP
=
=
anterior primary ramus;
end·plate on vertebral body; G
=
C
=
capsule (fibrous) ofzygapophysial joint;
ganglion (spinal) on posterior nerve root;
H
=
D
=
dural I1lbe;
hyaline articular
the zygapophysial joint facets; L Ugamentum flav\lm; M muscle; P posterior longitudinal ligament; PPR posterior primal)' ramus; R recurrent meningeal nerve; S spinal artery branch arising from the vertebral artel),; U uncinate process (raised lip) of the vertebral body showing part of tile synOVial joint of von Luschka with its (I) capsule, (2) synOVial fold and (3) hyaline articular cartilage; V vertebral a r ter y and its adjacent thin·walled vein (v) within (he foramen cartilage on =
=
=
=
=
=
=
transversarium.
Copyrighted Material
=
Introduction 7 sem i sp i nal i s ami mu lt ifi dus muscles (Lord eta/., 1993). An o u tl i ne of the anterior and posterior nerve roots, the spinal ganglion, the spinal nerve dividing into anterior and posterior plimary rami, and the reClU"rent meningeal ne rv e is shown in Figure 1.4A. In Fig ure
I.4B
a
histological se ct ion, cut in the horizontal plane
th ro ugh a mid cervical vertebra, is shown to illustrate some of the hi stol ogi c al anatomy.
It sho uld be remembered that Slmderland (1975) showed that two anatomical fea t ure s in particular protect nerve roots from being overstretched: the a r rJ nge m e nt of
the
dura at the entrance to the
intervertebral canal (foramen), and the secure attach ment of the
C4-7 cervical spi nal nerves to the gutter
of the transverse processes (Fig. l. 5). As each of the
C4-7 spi nal nerves lea ves
the inter
vertebral canal, it is immediately lodged in the gutter of the transverse process to w hich it is secu rel y bound by
Fig_ 1.6 D ia gra m to illuslrate the manner in which the is forced agai ns t the posterior bony bar of the transverse process by the vertebral a rte ry (A). From
spinal n e rve
SlU1derland (1975) with permission.
its epineurial s hea th , by reflections of the preve rtebral
fascia,
by slips from the musculotendinous att a ch
ments to the transverse processes and by fibrous slips
that descend from the transverse process above to blend with the ep in eurium of the nerve below (Su n derlancl,
1975). The nerve is also held backwards
against the p oste r ior bony bar of the transverse process by the vertebra.! a rte ry whose adventitial coat blends
Fig_ 1.5 Diagram showing the manner in which nerve roots are pro te c ted from being overstretched during lateral traction on the spinal nerve under normal circumstances. A Attachment of rhe spinal nerve LO the transverse process; B plugging action of the dura.! slee v e as it is drawn into the foramen. La te ral displacement of the nerve complex is limited because of the attachments of the spinal nerve to the cervical transverse p rocess and subsequenrly, and wh ere no such art;lChmenrs exist, by the plugging acti on of the dural funnel as it is drawn into the foramen. Fo r simplifica tion on l ) one d o rs al rootlet is shown. Abnormal fo rc es may rupture the protective attachment at A and B. From Sunderland (1975) with permission.
with the sheath of th e nerve (Sunderland, 1975). The artery usually lies within th e foramen transversarium
from C6 cephalad (Oh et al., 1996; Fig. 1 6)
=
=
'
The autonomic nervous system The autonomic nervo us system i n c l ud es parts of the central and peripheral nervous systems, the latter
being con cerned with the i nne r vat ion of viscera, glands , blood vessels and non-striated muscle; it is the
Copyrighted Material
8 Clinical Anatomy and Management of Cervical Spine Pain visceral
(splanchnic)
component
of
the
nervous
the superior, middle and inferior sympathetic ganglia
system (Williams and Warwick, 1980; Chusid, 1985).
(Fig. 1.7); the inferior cervical ganglion (located on the
The autonomic nervous system is intimately respon
anterior aspect of the first rib head) is frequently fused
sive to changes in the somatic activities of the body,
with the first thoracic ganglion to form the stellate, or
and while its connections with somatic elements are
cervicothoracic, ganglion and it is jolned by the white
not always clear in anatomical terms, the physiological
communicating ramus of the first thoracic nerve and is
evidence of visceral reflex activities stimulated by
sometimes connected with the C6, C7, C8 and TI
somatic events is abundant (Williams and Walwick,
nerves by sympathetic roots (Kuntz, 1964). Figure 1.7
1980). The anatomy and physiology of the autonomic
has been Simplified fro m Jackson's (1977) text boo k
nervous system have been described over the years by
and gives an overview of the extent of the cervical
several authors, such as Sheehan (1936), White et al.
sympathetics.
(1952), Kuntz (1953), Mitchell 0953,
(1970), and illustrated in detail by Netter (1962). Anatomically,
Jackson (1977) has documented possible sympa
1956), Pick
thetic responses to injury of the cervical sympathetics
the autonomic nen'ous system is
and other authors have written on this topic (von Tor
divided into two complementary divisions - the
klus and Gehle, 1972; C hap ters 2 and 5). A ccordi n g to
sympathetic and parasympathetic nervous systems.
Shelokov (1991), bizarre vasomotor symptoms can be
The preganglionic efferent fibres of the parasympa
explained when one considers that spondylosis (spe
thetic nervous system emerge through certain cranial
Cifically involving the joints of Luschka) can irritate the
and sacral spinal nerves and constitute the craniosa
vertebral artery sympathetic nerves.
cral outflow. The cell bodies of the postganglionic
With respect to the sympathetic supply of struc
neurons in the parasympathetic system are situated
tures in the head and thorax, the preganglionic fibres
peripherally, either as discrete collections forming
terminate in ganglia of the sympathetic trunk: for
ganglia nearer to the structures innervated than to
smooth muscles and glands in the head, the synapses
the central nervous system, or sometimes dispersed
between pre- and postganglionic neurons are mainly
in the walls of the viscera themselves (Williams and
in the superior cervical ganglion of the sympathetic
Warwick, 1980). The cell bodies of the postganglionic
trunk (Barr and Kiernan, 1983); for thoracic viscera,
neurons in the sympathetic system are generally
the synapses are in the three cervical sympathetiC gan
situated in ganglia of the sympathetic trunk or as
glia (superior, middle and inferior) and in the upper
ganglia in more peripheral plexuses, almost always
t1ve ganglia of the thoracic portion of the sympathetic
nearer to the spinal cord than to the effectors which
trunk (Barr and Kiernan, 1983)
.
Autonomic innervation includes the muscles of the
they innervate. The sympathetic nervous system (thoracolumbar
iris and ciliary body in tbe eye, smooth muscles in the
outflow), which is the larger division of the auto
orbit, the lacrimal, salivary glands and �weat glands,
nomic nervous system, includes the two ganglionated
and all blood vesse l s (Barr and Kiernan, 1983; Fig.
sympathetic trunks,
l.7).
their branches,
plexuses and
subsidiary ganglia, and innervates sweat g l an d s and
The
superior
cervical
sympathetic
ganglion
is
arrector pili muscles of the skin, the muscular walls of
located
blood
processes of the C2-4 vertebrae and receives pregan
vessels
everywhere,
abdominopelvic
viscera
the
heart,
(Williams
lungs
and
and
on
the
ventral aspect of the transverse
Warwick,
glioniC fibres through the sympathetic trunk from the
1980; Barr and Kiernan, 1983). The pregangliOniC
first four or more thoracic nerves; sympathetic roots
fibres, which are myelinated, are th e axons of nerve
arising from this ganglion join the Cl and C2 (and
cells in the lateral column of the grey matter of all the
sometimes C3 and C4) nerves and fibres derived from
thoracic and upper two to three lumbar segments of
this ganglion make up the major portion of the
the spinal cord; they emerge from the spinal cord
internal
through the ventral roots of the corresponding spinal
1964). The laner branches of the superior cervical
nerves and pass into the spinal nerve tnUlks and the
ganglion consist of grey rami communicantes to the
and
external
carotid plexu.ses
(Kuntz,
commencement of their ventral rami, which they
Cl-4
leave in the white rami communicantes, to join either
(Williams and Walwick, 1980). The vertebral artery
the corresponding ganglia on the sympathetic trunks
plexus arises from the
or their interganglionic parts (Williams and Warwick,
inferior sympathetic trunk ganglia ( Ku ntz, 1964) but
nen'es and to some of the cranial nerves middle,
intermediate and
1980). The possibility of a Limited outflow of pregan
is
glionic fibres in other spinal nerves has been sug
cervicothoracic
gested and it is certain that nerve celJs of the same
1980). From the vertebral artery plexus, deep rami
type as those in the lateral grey column also exist at
communicantes pass to the anterior rami of the C1 to
derived
mainly
from
gangli on
a
thick
branch
of
the
(Williams and Warwick
,
levels above and below the thoracolumbar outflow
C5 -6 spinal nerves and the plexus continues into the
(Mitchell, 1953) and that small numbers of their
skull via the basilar arteries and their branches as far
fibres issue in corresponding ventral roots. The cervical portion of the sympathetic trunk lies in the posterior wall of the carotid sheath and includes
as the posterior cerebral artery where it meets with the pleXllS derived from th a t on the internal carotid artery
Copyrighted Material
(Williams
and Warwick,
1980).
Lazorthes
SF to smooth muscle via
Ophthalmic N.
oculomotor N
NasocIliary N
)
III
Introduction 9
Postganglionic connections with cranial nerves
IV /
SF to
V
vestibular
/ portion of
/// VI
, I
to
inner ear
�
dilator pupilae orb i tal i s
M.
� Internal
muscle via th e
auditory
long ciliary N.
]
Ca rot i d artery plexuses
A. plexus
Internal External Plexus on .---- vertebral A.
carotid A.
Cardiac
bra nc hes
___
\ SF to recurrent laryngeal branch N
of
Fig. and
"ympathetic nerves. The preganglionic by solid lines. C I Fir.'t ( pri m ary ramus of the
rdmth
lrrir:uion of postganglioni c fibres Interruption of pregangliorttt Postganglionic connec t i on, cervical sy mpa t heti c
=
are
posterior primary stimulation of the give paralysi s of the
Ul- VI, LX, X and XII cervical sym p a t hetic
ganglion; 3 inferior cervical sympathetiC ganglion (stellate ganglion). SF Simplified from Jackson (1977). =
.
,
sympathetic fibres.
,
con s ider that the verteb
vertebrae is 0.7 (Brown et al., 1964); the percen tage of
ral artery plexlis represe n ts the main intracrani a l extension o f the sym p at he t ic sys tem
r u d imentar y c ervical ribs in t h e pop u la tion is 0.5-1.00
(1949) a n d Mitc h e l l
(1952)
=
(H a ve n 1939; S te i n e r 1943;Jones et al., J 98/1) a n d ca n be clinically sig n ific a n t or asymptomatic It appears t h at
Lt c turs such as injury, faulty l a bour are a few o f t he
Pain
l a t e n t c o ndition in t o one
1968). Neck pain may be
al1omalous cervical
results
vertebrae such a�
anterior a nd /or pos
result
terior arches of
from in
m o tor
well-docmne ntecl
i llustrated in Figure 1.8.
h emivertebra(e),
congenita l block
j oints
of the
poorly
c ervical
p lain film
rib(s) (Sunderland, 1968; Jackson, 1977; Adams and
verte bral
Hamblen, 1990). Agenesis of the anterior or
arches of the atlas, and hemivertebra(e), are rare (Gue
radiographs, computed tomograp hy (Cn a n d mag netic reso n a nce imaging (MRl). Nevert heles s , j oin t
bert et ai., 1996). The percentage of c o ngen i t a l b lock
c apsule tears have been s hown a t s urgery Oeffreys,
p o ste r ior
Copyrighted Material
are
seen
with
10 Clinical Anatomy and Management of Cervical SjJine Pain will warn of incorrect spinal movements and strains. T hi s pain is a main cause of disability and expense fro m work-related in j uries a ccounti ng for a pprox imately 4% of workers' compensation injuries, an d is the eighth most common cause of in j uries (Workers' Compensation Board of Queensland Annual Report, 1995). In spite of thjs, cervical spine bas i c science studies received very little attention until re latively recently with t he studies of Giles (986), Jonsson et al. (1991), Taylor and Kakulas (1991) and the clinical studies by Jackson (1977), Barns\ey et al. (1993) and Lord et al. (1993), in spite of the possibly serious
8
implications of cervical spine injury. Central cord
9
syndrome is n o w a well-established en tity in spinal
injury which is m os t often see n in hyper extension in j ur ies in patients with cervical spondy losis or n ar ro w spinal canals (Chang, 1995). The syndrome is characterized by greater in vo l ve men t of cord
Fig. 1.8 The more common lesions which may affect rl1e cervical spine following whiplash. I Vertebral body fracture; 2 articular pillar fracture; 3 fractures involving the articular facet subchondral bone plate; 4 tears of the zygapophysial joint capsule; 5 haemarthrosis in the zygapophysial joint; 6 synovial folel traLlI11
=
=
=
=
=
=
=
=
=
1980) and other injuries have been found dur ing postmortem examination such as inte rvertebral disc
and soft-tissue i njuries of the zygapophysial joints (Taylor and Kakulas, 1991; Tay lo r and Twomey, 1993). Other
injuries from postmortem material have shown
injuries of the ligamentum flavum,
uncovertebral
joints and cartilaginous end -plate avulsions (Jo n sson et aI., 1991).
Cervical spine joint dysfunction due to injury can be shown by cervical spine flexion an d extension stress (fu nc tional) views. An example of a cervical spine extension stress view in a 29-year-old female who sustained a neck injury in a rear-end mot o r vehicle accident 16 months prior to radio graphy, highJights t hi s issue (Fig. 1.9). There is joint hypermobility and instability between vertebrae at the C3-4 and C4 -5 leve l s as indicated by backward displacement of the vertebral bodies upon each other and 'gapping' between some paired zygapo physial joint facet surfaces. Because soft tissues which could be injured are not visible on plain X-ray in1ages such as shown in Figure 1.9, nor in any detail on CT or MRl, Figures 1.10 and 1.11 s ho w some of the soft tissues which could be injured and which should be borne in mind when examining a pa t ien t Most soft-tissue structures of the cervical spine often
,
,
.
have a good nociceptive nerve
suppJy
so that pain
Fig. 1.9 A well·positioned laterdl cervical spine extension (stress) view. Note: (I) backward displacement of C3 vertebral body on C4 (as shown by the uoned line on the posterior aspect of the vertebral bodies); (2) backwaru displacement of C4 vertebral body on C5; 0) the facet joint planes are parallel, except at the C.)-4 anu C4-'5 levels where the joints 'gap' anteriorly (arrows). A Anterior; P posterior. =
=
Copyrighted Material
Introduction 1 1
Fig. 1 . 1 0 Parasa g i t t a l s ec t i o n from a cervical sp ine s h o w i.og part o f th e a nterolate ra l as p ect o f the vertebra l body (V) a n d t h e superior (5) a n d i nfe rior ( I ) a rticular processes of t h e zyga pophysial jOin t . N o t e the s u p e r i o r (a) a n d i nfe r i o r (b) h ig h l y vasc u l a r s y n ovi a l folds which can be nipped between j o i n t s u r faces d u r i n g inj u ry. H Hya l i n e articu.la r cartilage =
on
the
lowe r j o int's fa cet s u rfaces.
which
is essentia l ly
n o r m a l . Note that t h e cart ilage on the upper jOint facets o n e l e v e l a bove has al most w o r n away o n the su p e r i o r a rticular p rocess (5) . N N e u ra l structures in t h e i n te rvertebral fora men w h i c h a re s u rro u nded by fa try t is s u e a n d many blood ve s s e ls . P Ped i c l e j o i n ing the v e r t e b l,l l body and the poste r i o r spinal e l e me n t s , i . e . su p e r i or a ncl inferior a r t i c ular processes, etc. The da rkly sta i ned m uscle groups a n t e r i o rly and posteriorly a re i l l u s t rated . From G ile s ( 1 986) with =
=
permissi o n .
upper-ex tre m i ty motor fu nc t ion compared with t h a t of the l o we r extre m i ti e s . a n d s e n so ry s y m p t o m s m o s t ty p i ca lly c o n si s ti ng of a bu rning s e n sa t i o n o r hyper p a thia in the u p p e r extre m i t i e s (H o p ki n s a n d R u dge , 1 97 3 ; Maroo n , 1 97 7 ; WU b e rger et at. , 1 986) . The pathophysiol ogy of thi s syndrome i s be l ieve d to be an oe d e m a to u s ty p e of process in the c e nt ra l part of the spi n a l cord (Chang, 1 995). Refrac to ry neck and h e a d pain is a serio u s p rob l em which is d i ffi c u l t to t r e a t (Ca rpe nter a n d Ra uck , 1 996) . New su rgic a l techniques h a ve been estab li shed in o rel e r to co mbat t he p ro b le m of cervica l d isc herniation w i t h rad i c u l o pa t hy Oho, 1 996) as wel l as fo r c ra n ioverte b ra l j u n c t io n su rgery (A1-Mefty et aI. , 1 996) a n d s o m e cases req u i ri n g c e rvical spin e s u rg i c a l i n terve n t i o n a re ill ustra ted in Ch a p t e r 8 . The c l i n i c a l e ntity of cervical s po n d y lo tic m ye l o pa thy bec a m e well-recogni zed in the 1 95 05 through the work of Brain an d a ss oc ia tes (B rain et at., 1 9 5 2 ; B ra i n a n d Wi l k inso n , 1 967) as w e l l a s that o f C l a r k e and Robinson ( 1 9 5 6), w h o i d e n t ifi ed c e rvi cal spo n d y lotic myelopathy as re s u l ti n g fro m t h e s po n cly lo t ic p roc es s , a l tho u g h the p at hop hysio l o g y of cervic a l myelop a t hy i s p ro b a b l y mu l tifacto r i a l (B o hlm a n , 1 99 5 ) . L a w et al. ( 1 995) sch e m a t i ca l l y ill u s t rated t h e various structures that can co n tri b u t e to the p a t h o-
Fig. 1 . 1 1 Fu rther soft tissues wh ich c o u l d be inj u red in th e m i d cerv i c a l s p i n e by trau m a . Panial h o r i zontal section cut throu g h t h e m i d c e rvi c a l spine showing part of t he vertebral body (V) a n cl the s uperior (SAP) a n d inferior articular processes with their zygapophysial jo in t facet and a syn ov i a l fold (S) which c a n be n ipped b e tween jo i n t surt'aces d u rin g injury. A Verteb ra l artery wi t h in the fo rame n transvers a r i u m with its a d j a c e n t ve in (V arrow); C sp i na l c o rd ; 0 dural t u be ; H hyaline articu l a r ca rt il a ge on th e facet su rfaces, wh i c h i s esse n ti a l ly norm a l ; L l ig ame n tu m flavlIm; N n e u ra l s t ru c tu re s in t h e i n terverte bra l fora men , including the g a ng l i o n w h i c h are s u r ro u n ded by fa try tissue and blood vessel s . The d a rkly s t a i n e d muscle grou p s (M) a n t e r io rly and poste riorly are ill ustrated. =
=
=
=
=
=
l ogic a l a n a tomy o f cervical spon d y l o t i c mye l o p a t h y a n d these ca n be s u m ma ri se d as protru d i ng inter ve rtebral d is c , ossifi c at i o n of the p os t eri o r lo n g i t ud i
nal liga ment , h ype rtrop hy of t h e li g a m e n tu m fiavu m ,
zyg a p o p hys i al o r uncovertebral j oints, o r a n y c om bin a t ion of t h ese . An example of some osseous d e g e n era ti ve c ha n g e s which can occur in the c e rv ical s p in e is given in Figure 1 . 1 2 w hic h shows the s u p e r i o r anel inferior osteoarthrosis o f the
a s p e cts of the sixth vertebra . The
med i a l
m a rg in
of a
n o r m al
unc ove rtebral
j o i n t to the med i a l margin of the foramen trans ve rsa r i u m
which
conta i n s
the
ve rt e b ral
ra nges fr o m a p p roximately 4 .0 to 6 . 3 nun
ai.,
artery
(Oh
et
1 996) . Th e refo re , re l a tively mi n o r o s te op hyt i c
Copyrighted Material
12 Clinical Anatomy and Management of Cervical Spine Pain
Fig. 1 . 1 2 S u perior (A) and inferior (B) views of th e C6 vertebra showing s pondylotic l i pping of the vertebral body a n teriorly ( I ) , posteriorly into t he s p i n a l c a n a l (2), and at the l a teral m a rgin s of the ull cove r t e b ra l join t (3) . Osteop h y t i c e n c roach m e n t by the c6 - 7 u n c overtebra l j o i n t ( 4 ) of particularly t h e left tran sve rse foramen (5) t h rough wh ich t h e vertebral artery passes indicates how v u l n e ra b l e the verteb ra l artery can b e . The l e ft superior a r ti c u l a r facet s l i g h tly encroaches upon the adjacent transverse foramen in t hi s speci men .
development a t the l a tera l margin s of the u ncoverte bral j o i n t c an encroach
upon
the
fora m e n trans
versarium and its contents.
Magnitude of the problem of neck pain
Despite the sp i ne s excellent d e sign (Keith, 1 92 3 ; '
s p in e
presents the
Fa rfa n , 1 97 8 ; Giles, 1 99 1 ) , with its normal cervic a l
Ac u te
an d l u m b a r lordoses and i t s thoracic kyph os i s be i ng
treating
well a d ap ted to the fu nction of the ve rte b ra l col
ma n agem e nt issues, and successhll long-term treat
-
u mn ,
any ma j or a b e rrati o n s in these s p i n a l c u rves u n so u n d
inj u ry
of
the
c lin i c ian
c e rvical
num ero us
with
d iagnostic
and
ment is c o n ti nge n t on early rec o gn i tio n of the i n j u ry
al.,
(Sl ucky and E ismo n t , 1 994). Acute a n d c h ronic neck
1 98 5 ) . It is w e l l k n own t h a t rad io l o g i c a lly normal
p a i n , a l th o u g h sometimes due to frank p a t h ological
a re
mech a nically
(Rickenbacher
et
-
but p a in fu l spines (Benson , Renfrew,
1 99 1 )
may be
h ave
1 98 3 ;
EI-Kho u ry and
patho logica l
demonstrated
cha n ges
whi c h
cannot
rad i o logically
(Dixon ,
1 980). It is s u ggeste d that pain in t h ese
causes, c an res u l t from al terations from the n orm a l in t h e verteb ral col u m n and const i t u tes a
p ro bl e m
(National
H ea lth
and
major hea lth
M ed i ca l
Research
Council , 1 988; Spitzer et a/. , 1 995).
cases may be d u e to mechanical irri tation of various
Two i mp o rt a n t fac tors co m poun d the problem of
pa i n-s e nsitiv e soft-tissue stru ctures which c a nn o t b e
spin a l p a in mech ani sm s (Ha l d e m a n , 1 977) : p a i n may
visualized by imaging p roced u re s b u t can be fo u n d a s shown by ma c roscopic s tud i e s (fo n sson et al., 1 99 1 ; Taylor a n d K a k ul a s , 1 99 1 ; Ta yl o r and Twom e y 1 993), a l thou gh i t is no t pos sible to co rrelate p a tho logi c al findings in c a d a v e rs with pain. Many spinal s t ru c t u res p ro b a bly pl ay a rol e in pain p rod u c tio n as all inne rva te d structures i n the motion segm e n t a re po ss ible sources of p a in a t p o s tm ortem
,
,
,
(Haldeman, 1 977 ; Nache mson , 1 985).
have a m u l t ifactorial ae t i olo gy
,
and there may be
several types of p a in whic h c lo s e ly m i mic each oth er. Pa rt of the p roblem relates to the fac t that the neck regi o n is ex t re mely complex , both a nat o mi ca lly a n d
fu rther e l u c i d ati o n pain since t h e varieties of s pinal p ai n
fu nctiona lly (Cha pter 2). We a wait of the
p a t h o p hysiology
p a t h o l ogic aet i ol o gy
of
of sp in al
ma ny
rem ains und iscovered (Pea rcy et ai. , 1 98 5 ; Tajima an d Kawa n o , 1 986) .
Copyrighted Material
introductio n 13
In
s p i te of many a t t em p t s
t o p rov i d e a rationale for
clinicians to ord e r d i agn o s t ic exa mina t i o n s properly and prescri b e treatments that maximi ze the qu ali ty
a n d effic iency of pa t ie n t care (Spitzer et at. , 1 995), t he c o m p l e x probl e m of neck p a in con tinues u n
a b a ted Many p sy c holo g i cal factors a re believed to .
cont ri b u te to the devel o p ment, exacerba t i o n and/or m a intena nce of chronic spin a l pain ( Ki n n ey et at. ,
example , the innervated j o in t capsule s , o r pin c h ing and tractio n i n g of the h i g hly vascular and innerva ted i n tra-a rticu l a r synovial fo lds within the zygap o p hysial j o i n ts ( G i l e s 1 989; Fig . 1 . 1 0). Because d i a gn o s tic i m a ging p roce d u re s m ay well not p rovide a d i ag n OSi s in cases wh e re pai n is d u e to mechanical dysfunction o f j o ints, some au thors stress psyc h o logic a l fa ctors (HoehJer a n d To b i s , 1 98 3 ) . ,
1 99 1 ) and , when eval u a tin g p a tie n ts with chronic neck pa i n (Chapters 5 - 1 2) , i t i s necessary t o u n d e r s t and clinic a l fi n d in gs in re l a t i o n to issues
of eve ryd ay
fu ncti o n i ng , such as em p loym e n t , socia l a d j us t m e n t
Diagnostic problems
and activities of daily liv ing (M illard a n d J o n es , 1 99 1 ;
J a me s and
McD o n a l d , 1 996; Chapter 7) .
Neck pa in
may orig ina te from many d iffere n t inne r
In genera l , the answer to the c o m p lex issue of
vated sp inal tissues m a k i ng it d iffi cult to eva luate a
sp i n al p a i n may well d ep e nd u pon m u l tid iscip l i n a ry
mechanical o rig in , with o r p a inful stru c t u re o r s t ructu res are n ot amenable to d irec t scru tiny, s o a tentative d ia gn osis is us u a lly arrived at for an ind ivid ual by tak i n g a case history and e m p loying a fo rmat s i mil a r to t h e ex a mi n a t i on p rocedure s in d ica t ed i n C hapt e rs 7 - 1 2 . However, in spi te of fo l lowing ro u t i n e exam in a t i o n proced u re s , o n e often merely e l imi na te s demon strable p a t hologie s and the c a u s e of spi n a l p a i n o f mechanic a l origin ofte n re m a in s o bscure (Margo , 1 994) , esp eci a lly w h e n dysfu n c tio n a n d dege n e ra t ive pa tho logy of s p i n a l j oints occur. In severe cases of nec k pain , i n j e c t i o n s of anaestheti c , w i th o r w i t hou t s tero id su sp en s io n , are sometimes used to a u gm e n t the c l i n i c a l eval u a t i o n ( Lord et ai., 1 993), fo r exa m p l e t o determ ine wh ethe r p a i n o riginates i n t h e zygapo p hy s i a l j o in t(s) . Imaging proced ures such as p l a in mm ra d i ograp h y, CT, M Rl , m ye l ogra p hy, a nd bone scans (Chapter 6) have d i ag n ostic limitations, and e v e n three-dimensional M Rl t echniques (Ross, 1 995) h ave limi t a t i o n s . Specific a l ly, d i ag n o st i c pro b l e m s relate first to, ina d e qu a c i e s in the p recise knowledge of the anatomy of the cervica.l s p ine and its re l ated soft-tissue s tru c t u re s ; second , t h e re are mul tifacto r i a l c a u s e s of pa in a t a g i v e n l e v e l of the spine i n some cases , a n d third , m a ny d iagnostic p roced u res have l i mitati o n s . Als o , there is often d i s a gree men t o n w h ich i m a g i ng proc ed u res h a ve d i a gn os t i c validity for neck p ai n of m e c h an i c a l orig i n Ce r t ai n ly, the use of flexion and ex te n si o n plain ftlm rad i o gra p hy with m e a s u rement of s egm e n t a l motion in the sagitta l plane, is a valuable method for dete r m ining p a tho l o g ic a l cond itions such as hypo- a n d h y p e rmo b i li ty (Dvo rak et at. , 1 988) and c a n de m o n s tra te insta bility sec o n dary to l i g a m entou s lax ity (Gibs o n , 1 99 1 ) . As s h own in Figu re 1 . 9 , stress views of the cervical s p in e can d e mo n stra te regions of anatomical h ype r m o bili ty and i nsta b il ity. Such vi e ws can also demonstra te hypo m ob il i ty Fu r t hermore, so m e d i a gn os tic and t h e rapeut i c c h e m i c a l agents m ay be h a r mfu l , fo r ex a m p le when s u c h a g e n t s in j ec t ed i n t o i ntervertebra l discs ext rava s a t e into the epid u ra l space (We i t z , 1 984; Ad a m s et
coope ra t i o n and ,
as Frymoyer e t a t. ( 1 9 9 1 ) state , ce n tre s for spinal c a re will emerge as p a rt of la rger health care syste m s . T h i s pri nci ple is as importa n t i n cervi c a l spine pa i n syn d ro m e s a s i t i s i n t h o ra cic a n d lumbosacral spin e sy n d ro m es .
Degenerative processes the i nterve rtebra l disc and associ o f the sy novial zygap o ph y si al j o i n ts and j oi n t s of von Lu schka ( u n coverte b ra l joints; Com p e re et at. , 1 9 59; Williams and Wa rwic k, 1 980) can cause neck pa in resul t i ng from a s yn ov i tis , in aU p ro b a b i lity due to a n i n c rease of s y n ovi a l fl u i d causing p ressure on the rich ly i n n erva ted c a psu l a r structu res and adj a ce n t n e rve roo t Oack so n , 1 977). Acc ord ing to Butler et at. ( 1 990) , disc d ege ne rati o n occurs before zyga pophysi a l j Oint osreoarrhrosis w h i c h may be secondary to mechan ica l c h a nges in the l o a di n g of the zygapophysial j o in t s . It has a lso been su gge sted t h a t i n tervertebra l d i sc h e rn i a tion is assoc i at e d with vertebrogenic p a in a nd the a u tonomic syndrome Oinkins et at. , 1 989; G i les, 1 992) . Jackson (1 977) c l early i llustrated t h e poss i b l e ro l e of the cervical sympathetics in the cervica l sy n d rom e i n the presence o f i rritation of the ve rtebra l a rteries and the i.nternal and external ca rotid a rteries and their sym pa the t i c p l exuses (Fig . l . 7), as well as injuries t o t h e cervical ne rve roots Dege n e ra t i o n o f
ated
osteoa rthrosis
and the s p i n a l cord . I n addition, pa i n o f vascu lar o rigi n , d u e t o deforma tion of blood vesse l s
and ve n o us stasis withi n blood
vessels of the l u mbar spi n a l and in tervertebral canals,
has been s ugge s te d by Giles ( 1 97 3 ) , H oyl a nd et al. ( 1 989) , Gil e s and Kaveri ( 1 990) and Jayson ( 1 997) . Degenerative j oi n t cha nges i n the c e rvica l spine wou l d m o s t l ik e l y resu l t i n similar c h an ges to cerv ical spi n e blood vesse l s . Pai n may be expe rienced in the absence of rad iol o g i c al ly obViOUS dege n e rat ive j o i n t disease , or o t he r pathological changes, as a result of trac t i o n o n normal pain se n s i tive stnlCtures, fo r -
p a tie n t with neck p a in of
wit h o u t
referred
Copyrighted Material
pain ;
the
.
,
.
14 Clinical A na tomy and Managem ent of Cervical Spine Pain al. , 1 986; Mac Millan et aI., 1 9 9 1 ) d u ring discograp hy, cau s i n g complications d u e to contact between these c hemical agents and neural structu res (Eg uro, 1 98 3 ;
Dyck, 1 9 8 5 ; Merz , 1 986; Wa t ts a n d D i c kh au s , 1 986) . Th e re fo re
sll c h
,
diagnostic
tests
shou l d
only
be
performed t o p rov ide relia ble information a b o u t a patie n t ' s
condition
influ ence
the
if the
and
patient's
resu l t
manage ment
l.ikely to
is
(M o d i c
and
Herzog, 1 994) . In m a ny cases of neck pain with ra d i culopa thy, interve rtebra l d isc prolapse has b e e n d e scribed as being the p a t h o l ogical c a u se (M ix ter and AyeI', 1 9 3 5) , a l t hough rad i c u l a r a r m p a in c a n b e d u e t o irritation or compression o f a cervical n e rve root d u e to oth e r causes (C h a p t e r 8). Hern iated nucleus p u lposus does not n e cessarily produce radiculopathy and may only cause vague refe rred pai n The refore, cau tion must .
a lways be ex e rcised prior to m a n i p u l a t i o n of the cervical spine a s rad ic u lopathy may n o t necessa rily be the first symptom of c e rvical d isc p rolapse . An exa m p le to highlight such a case is th at of a 5 2-yea r o l d m a n who only experienced mild p a raesthesiae in t h e l a teral b o rder of the l eft l i ttle finger, even t h o ugh h e had signifi cant right-sided C 5 -6 inte l-ve rrebra l d is c p rolapse o n CT (Fi g . 1 . 1 3 ). Based o n l u m b a r sp i n e s t u d i e s , m a n y a u thorities
A
b e l i eve t h a t d i s c h e r niation h a s b e e n overemphasized as
the
p ri n cipal
advocating appropri a t e
e a r ly
source of spinal s u rgery,
p a tho l ogy
even
such
as
for
pain
and
patients
hern i a te d
that with
n u cleus
p ulposus, is not recommended given the favo urable history of n a tural recovery for t h e majo rity of t h ese p a t i e n ts (Le h m a nn et al., 1 99 3) . S p o n taneous recov e ry from p a i n thought to b e asso c i a te d with l u m b a r i n tet-ve rtebral d i s c herniation is welJ-known a n d i t i s reaso n a b l e to suspect t h a t such n e c k pain may also h ave a favou ra b l e history of natural recove ry. It is l i kely that cervical zygapop hysial j oint pa in is a c o m mon c o n d i t i o n which is frequen tly overlooked (We d e l a n d Wil son, 1 98 5 ; Lord et al. , 1 99 3 ) and the a l leviation of th e pain by inj ection of local a naes t h e t i c , wi th or w i thout s te roid s u s p e n s i o n , into t h e joints,
u nd e r
fluoroscop i c
contro l ,
supports
this
d iagnosis (Lo rd et ai. , 1 993).
Limitations of investigative methods
B
Ali im aging p roc e d u res only provide a shadow of the t r ut h (Giles and Crawfo rd , 1 997) as d e t ailed anatomy and e a r l y his t opat ho l ogy c a nnot be perc e ived (Fig.
Fig. 1 . 1 3 (A) The C5 - 6 inrervertebrJ I disc has thi nned by approxima rely 40% a s s e e n on rhe cervical spine flexion view. (B) TIle c o m p uted tomogra p h i c scan view shows rhe righ t sided C5 - 6 i n te rverte b ra l d isc h e r n i a t i o n , b u t rhe left interve rte b ra l c a n a l i s stenotic.
1 . 1 0) . CT, MRI and bone scans, a l though able to give that signifi c a n t cervical d i sc anular tears
additional and d ifferent typ es of i nformation to t h a t
showed
provided by p la in fi.Lm rad iogra p h s , stiU h a v e lim i ta
oft e n escape M RI d e tection when compared w i th
t i o n s . For examp l e , a l though MRI has pro v ed to be a va luable d i agnostic tool in t h e initial eva l u a tion of t h e
disc ography. It should be n o ted t h a t , although MRl is useful for n u c l e a r anatom y, it is not h e l p fu l for
p a t i e n t w i t h d i scoge nic pain , S c h e U h a s et at. ( 1 996)
symp tomatology (Bu irs ki a nd S Li berste in , 1 993). T h e
Copyrighted Material
Introductio n J 5
an atomical basis of p rimary cervic a l d i scogenic p a i n
prov oked w i th disco g ra p hy h a s been described by Bogd u k et al. ( 1 988) . M RJ is useful for a s sessing spina l cord anatomy and p a tho l og y, l igamen tous i n tegrity (Brigh t m a n et at., 1 992), particula rly t h e in tegr i ty of the a n terior and posterior l o n gitudi n a l liga ments (M cArd le et at. ,
1 986) , epidura l fa t, cerebrospinal fluid a n d m a r row 1 973) a n d , lIsed i n c o n j u n c tion with CT and p lain fLlm rad iography, it can also aid in t h e eva l u a t i o n of bony inj u ries (Brightma n et at. , 1 992). Th e re fo re a l th o u gh sp i n a l im aging c a n b e info r m ative (C ha p te r 6 ) i t has l i mi ta t i o n s (Carroll , 1 987) , a n d there is often a d i sc repancy between the s p ace (la u t erb u r,
,
d egree
of pain
and
the
seve rity
of rad i ogra p h ic
cha nges (Stockwell ,
Table 1 . 1
Some pussible
causes of mecbanical neck pain
with or without arm jJain
1 985). For exa m p l e , disa bling zyga p ophysiaJ joint s yn d ro mes can be associated with normal o r nearly normal plain f l m ra d iographs (Eisenstein a n d Pa r ry, 1 987). i
Nerve root conditions
Adhesions between d u ra l sleeves a n d (a) the j o i n t capsule w i t h n e rve root fi brosis (WiJJ< i n s o n , 1 967; S u nderla n d , 1 968; jackso n , 1 977) a nd (b) inte rve rtebral d i s c herniation (WU kinson, 1 967) I n tervertebral disc degeneration and fragmentation
(Sc h iotz a n d Cyriax, 1 \)75), or nucleus p u l p osus extrusion (M ixter and Ayer, 1 93 5) C3USUlg n e rve root c o m p ression o r nerve root chemical ra d icu l i t i s ( M a rshall and Tre t h e wi e 1 973)
.
Possible causes of mechanical neck pain with or without upper limb p ain Ta ble 1 . 1 briefly summa rizes some possible causes of neck pain o f mechanica l o ri g i n with or without arm ,
ZygajJophysial joint conditions Joint d e ra ng e m e n t (subluxation) due [Q I iga men[Qus a n d c a p s u l a r i nstabil iry (Hadley. 1 964 ; Cailli e t , 1 968; Jackso n , 1 977; Macna b . 1 9 77; v a n Norel a n d Ve rhage n , 1 996) Joint capsule tension , e n c roach ment of the unervertebral fo ram e n lumen Oackso n . 1 97 7) J o i n t degener;o tive changes, e . g . meniscal i n c a rceration (Schillorl a n d jungh a n n s , 1 97 1 ), t r,l l I m a r i c synovitiS d u e to pinching of synovi a l fol d s (G iJes, 1 986) , synovia l fo ld
pain, a nd prov i d es a s ummary of some l i terature references
order
to
p rovide
of the neck a n d cervical sp in e
Deformities
,
with or without
.
Classification of diso rders of tbe n eck Clnd
cervica.l sjJine
Infa n t i l e torticollis Conge n ital short neck Conge n ital h igh sc a p u l a of the spinal jo in ts Rh eumatoid artbritis
A rthritis conditions
S i g n ifio n t disc herni a t i o n into t h e s p ina l and
An h.-y losing spondy l i tis Osteoarrhritis of the c e rvical spine (cerv i c a l spondylOSiS)
inte rve rtebra l can a l s Spondylosis (yo u n g . 1 %7; jackso n , 1 977)
Injections of bone
Miscellaneous conditions S p i n a l a n el i n terverte bra l canal (foramen) stenosis (Young, 1 967; Jackso n , 1 97 7 ; Epstein a n d Epste i n , 1 987 ; Ra uscilling, 1 992) Interve rtebra l canal (fo ramen) ve nous stasis (Su n d e rla n d ,
1 9 75)
Myofascial genesis of pain ( t rigger a reas); Travell a n d Rin zle r, 1 95 2 ; B o n i c a , 1 9 5 7 ; Simons and Travel!, 1 983)
Tu berculosis of the cervi c a l spine Pyo ge n i c infection of the cervical spine ivlechanical derangements
Prolapsed in terverteb ra l disc Cervical r i b Cerv i c a l spondylolistllesis Joint dysfu nction Tltmours
Baastrup's s y n d rome ( Bl a n d , 1 987)
Ben ign and malign a n t tu mours in rela tion to the c e rvical
Osseous spin:l l anomalies, e . g . bilat eral cervical ribs, bl ock
a
Ta bl e 1 . 2 summarize s s o m e wel l -esta b l i s hed d is o rd e rs
Joint effusion with capsular d i s tension which mal' (a) exert p ressure on a nerve root Oac kso n , 1 97 7) ; (b) cause caps u l a r pain Oackso n , 1 966) or (c) cause n e rve root pain
Intervertebral disc
in
M a ny other causes of neck p a in
Table 1 . 2
Joint capsule a d h e sions (Jackson , 1 977; Farfa n , 1 980; Giles, 1 989)
the years
p rogressive rad icu l opat hy, should be conSid ere d , and
trac tioning agai n s t the pain-sensit i ve j o in t c a p s u l e (Had ley, 1 964) a nd ostcoa rth rosis Oackson , 1 977)
by dire ct d iffUSion (Ha ldeman, 1 977)
over
historical background to th i s com plex iss u e .
spine, spinal c o rd a n d n e rve roots
vertebra (Jackson, 1 977) Modified from Ad>lms and Hamblen
Copyrighted Material
( l 990).
J 6 Clinical A natomy and Management of Cervical Spine Pain and Otber Disorders ()J the Cervical Spine.
Summary
WB Saunders. Bra i n , W. R . , Northfie l d . t h e possible c a u s e s o f
It is n o t o u r n e c k pain
s u m m a rising some anatomy
and p a t h o l ogy
a bearing on c e rv i c a l
s p i n e p a in
b u t ra ther to p rovid e
a n overvic\\
hSlI e as an in trodu ction
to fo llowing
to appre ciate a n e c k symptoms, it is n e cessary to
p a i n sufferer's
u n de rsta n d n o r m a l erect posture and the c o m p lex a na to m y and possi b l e s u b t l e o r overt p a t h o logy o f the c e rvical spine and the cervicothora c ic j u nc t i o n (see C h a p ters 2 and
3) . The
foll o w i n g chapters review t h e
b as ic a na t o my a n d p a t h ology o f the c e r v ic a l s p i n e , fo l lowed
by
w h i p l ash-type
k i n e m a ti c s , i n j u ries,
the
c l i n ic a l
rad i o logy
picture
and
of
c li n ic a l
manage m e n t .
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Philadelph i a :
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Copyrighted Material
Management of Cervical Spine
18 Clinical sil1atomy M a rgo,
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Bosto n :
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P" osp e c t i ve
:111 0
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d iscogenic
m agne t i c reselll ll n c e i m a g i ng
lR:l l m e n t
mya l g i a . I n : Cervical Flexio n - Extension/Whiplash Inju
M b: t e r,
1 099 - 1 1 02
subjects
( 1 993)
menl
K.P,
Cervi c a l
HH5 - 89 3 .
AJNR
20:
,pin e . Spine S c h e U has,
M i r fa k h ra e e , M . et al. ( 1 986)
MR of spi n a l t rau m a : p re l i m i n a ry expe r i e n c e .
.\ i c C a i n ,
M il l a r d ,
93,
c e rvical
cva l u a tulg
reso n a n c e techn i q u e s
M a rs h all, L . L . , Tre thewie, E . R . ( 1 9 7 3) C h e m i c a l irritation of
M e rz,
( 1 985) Applied
( 1 99 5 ) Illl a gi.ng c o m e r Th ree-e1 i m e tbi(>n a l mag·
Ross.
( 1 977)
i n j ur i e s . ]A.M.A.
M e nn e l l ,
K.
Lan d o l t , A . M . Theiler,
A na tomy oJ tbe Back . Be rl.i n : S p r i n ger-Ve rlag, pp 1 84 - 1 116 .
1 7 1 - 1 79 .
Reviews
].,
Rlc k e n b a c h e r,
C i ba Coll e c t i o n o f
M e d i c a l J llllsrra ti o n s , vo l . 1 . N e w Yo rk : C iba P h a r m a ce u t·
N. ,
spine.
1 40 .
I
K. ( l ')86) Cryo m i c ro t o my o f t h e Sp ine 1 1 , 376 - .� 79 Kawa n o ,
lu mbar
Tay l o r, J R. , K a k u l a s , B . A . ( 1 99 ] ) Neck i n j u ries. lancet
338:
i c a l C o m p a n y.
N. I . ,
O h , S-H . , d im e n S I O n al
Cooper.
a n a to m y
PRo
T:l y l o r. J R . , Twornev,
( l 9<)6) Qnamitat ive
of the
s u b ,vo a l
cervical
spm e :
imp li c a ti o n fo r amerior s p i n a l s urgery. Neu rosurge ry
38:
1 1 39 - 1 1 4 4 . Pearcy,
M,
J
( I ')8�') The effe c t o f
Pick,
].
( 1 9 70)
The A utono mic
1 50 -
Nervous
System.
R.
( 1 992) The d e t a i l e d fun c t i o n a l a n a tomy o f t h e
liga m e n t s
the
col umn
A nn.
A nal.
40-47 Ra uschn i n g ,
( 1 99 3 ) A e u te i n j u ries Spf<1 l l1
c e rv i c a l
Spine
18:
R i n z l e r, S . H ( 1 9 5 2) Myofa s c i a l genesis of pai n . 425-43 i
vall N o re ! , GJ , Verruge n ,
Surg.
78B:
W. LVl .
( J ')96) Drop Clnacks a m]
clfge n e ra t .c c e n i c a l spin ('
n o n e jo inl
495 - 496
von To rkl u s , D. , Gehle, W ( 1 9 7 2) The Upper Cer/Jical Sp ine.
a d e l p h i a : Lippincott. Pu tz,
]. ,
i n s r a h iJ i ty of Phil
LT.
a u topsy s t u d y of n eck
Pus/grad. Med
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An
1 1 1 5- 1 I22. Travel l ,
POlle k , I . , S h e p h c rd ,
back
Joints.
Ref(ional A natomv,
Pathol0R.V and Traumatology A
Sl',lematic Radiological
{mci Text/wok
London
B u ttc rwo r t h s
W.
( 1 99 2 ) Spin a l a n a t o m y . t h e relati o n s hi p o f
struc t u re s . I n : Principles a n d Practice oj Chiropractic (Ha l d e m an
S.,
ed ), 2nd edn
La n g e , pr 6 3 - 7 2
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Wa ns,
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01
c a u t i o n . SU/g. NeuroL. Wed e l ,
OJ,
Wilson , P R .
Reg. A naestb
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10:
;- 1 1 .
t:ICet arth rography.
Introduction 19
We i t z , E . M . ( 1 984) Parap legia fol l ow ing chymopapa i n inj ec tion. J Bone joint Surg.
White, ] , e . , Smi t h w i c K ,
66A: 1 1 3 1 .
Williams, P. L . , Warwick, R . ( 1 980) Gray 's A natomy, 36th edn. Edinburgh : C h u rc h i ll Livingsto n e . Wo rker,'
Board
syn d rome rev i s i ted
li n d other Disorders of the
M . ( 1 967)
\\ lfkmson M . , eds), London
1
and other Disonfel"s Wilkinson
M.,
Queenslanel
.\.llt tUtJi
ItJ d i o l og y a n d cervical spondylo, i s
W i l be rger, ] , E . , A b l a . Wi l ki nso n ,
of
Australi a .
nomic Nervous
ed,)
Copyrighted Material
1 96 .
Copyrighted Material
Copyrighted Material
24 Clinical A natomy and Management of Cervical Spin e Pain Too seldom perceived in medical research is that
4. T he neural traffic from the extremities requires an
morbid anatomy remains , and always will be, key to
increase in the diameter of the spinal cord and the
our understanding of clinical disease.
nerve roots, particularly the sensory roots, ar e
O nce something has been observed, what was previously invisible is ob vious. The discove ry of perspective in painting is an exampl e, and so seemingly simple n ow ! An atomical abnormality, or normality for that matter, once well-comprehended,
larger in the cervical s pine than in the thoracic and lumbar spines.
5. The nucleus pulposus, pre sent at birth and up until 9-14 years, is made up of remnants of the primitive notochord,
that
is,
collagen and proteoglycan
the
mater ial. However, in the cervical spine , in contrast
radiologist, the clinician, the surgical pathologist and
to events in the lumbar spine , t his n ucleus pulposus
at the autopsy table (Bullough, 1987).
gradually disappe ars. In 191 whole human cervical
becomes
a
di agnostic
tool in
the
hands
of
In the case of the cervical spine, relatively li{{le
spines we have found no evidence of a gel-lik e
morbid and microscopic anatomy has been done
nucleus pulposus in adults. The intervertebra l disc
compared to the lumbar spine, presumably because
in the cervical spine is dry and is very much more
of difficulty in obtaining whole specimens of human cervical spin es to study. Major works describing the
like a ligament than a disc . It was found to be fibrous and gradually breaking up in various-sized
pathology of the cervical spine have been reported
pieces, seemingly a universal,
by Payne and Spillane (1957), Schmorl and Junghanns
logical, development. This is consistent with the
(1971), Ten Have and Eulderink (1980), Penning (1988) and Bland (1994). This chapter reflects a deep enduring interest in cervical spine an atomy and pathology dating back to a s in gle clinical experience in 1955. During this period, a total of over 191 whole human cervical spines have been removed at post
early observations of Tondury (1959).
probably physio
Clinical surface anatomy
mortem or obtained from anatomical laboratories and
Familiarity with surface anatomy is important to the
the coroner's office (Bland, 1991, 1994).
clin ician since the main structures of the neck can be seen and felt eaSily in the thin patient; they are more difficult to see and feel in the obese, pyknic body
Phylogenetic anatomy of clinical importance
type with
a short neck. The sternocleidomastoid
muscle runs from one corner to the other of a quadrilateral area formed by the anterior mid line , the clavicle and the leading edge of the trapezius muscle;
I. The nerve supply to this area is from Cl, C2 and C3, and clinical disease is reflected in referral patterns of those roots;
the mastoid - mandibular line divides the siele of the neck into anterior anel posterior triangles (Fig. 2.1).
the myotomal and sclerotomal
There is little to be seen in the posterior triangle,
derived structures, when abnormal, are perceived
which is really a pyramid (Fig. 2.2). The first rib is
in the forehead and retro-orbital areas. 2. The intervertebral foramina carry the anterior and
by the subclavian artery and the lower trunks of the
posterior nerve roots, the respective posterior root
brachial plexus. A cervical rib (see Fig . 1.3), or its
ganglia and the recurrent meningeal nerve (see Fig.
fibrous
1.4). The nerves occupy about 25% of the available space. The remain der of the space is t a ken up by lymphatics, blood vessels, areolar and fatty tissue,
accesso r y nerve runs forward to the sternomastoid
which constitute a compressible safe ty cushion
trdnsverse processes of cervical verrebr;le can be felt,
palpable at the base of the triangle where it is crossed
extension,
may
be felt
here. The
spinal
muscle, dividing the triangle into an upper 'safe' and lower
' danger ous '
area.
T he
upper
area
of
the
space, allowing physiological encroachment with
thoug h they are deep. The external jugular vein and
out damage to nerve roots. The bony prominence,
the platysma muscle cross the sternomastoid muscle
in
the uncus or uncinate process on the lateral and
in the
posterolateral aspect of the cervical vertebrae from
breath-holding . T he pulsation of the carotid artery is
C3 througb C7 (see Fig.
easily seen.
1.4), constitutes the
anterior triangles;
both
are prominent
phylogenetiC remainder of the costovertebral joint.
The hyoid bone, a horseshoe -shaped structure, is
The clinical significance is that this bony elevation
felt at the level of C3 on a horizontal plane just above
enlarges from age 9 to 14 years such that, beyond the age of 40 years, it cons titu tes a bony bulwark
the thyroid cartilage (Fig. 2.3). The anterior body of the bone and its two stems are readily felt by a pincer
acting to prevent herniation laterally or postero
like action of the finger and thumb. With swallow ing,
l aterally (Bland, 1994).
the movement of the hyoid bone is easily palpable .
3. The free rotary movement of the head became
Moving down with the fingers, the upper edge of
possible with the eccentrically located axle of the
the thyroid cartilage is felt at the level of C4 - 5; th e
axis, the odontoid, allow ing relati vely enormous
lower border of the thyroid cartil age is at the level of
mobility at that level, particularly in rotation.
C5-6. The thyroid cartil age also moves with swalJ ow-
Copyrighted Material
Anatomy and pathology of the cervical �jJine 25
Fig.2.1
and right/left triangles are bounded by the the sternocleidomastoid muscle, the midline, the lower border of the mandible. Some anatomists describe a large upside-down triangle bounded by the two anterior borders of the sternocleidomastoid muscle and the two lower borders of the mandible, witb its apex at the sternal notch and its base at the mandible.
anterior
Anterior
edge
of
ing and is, of course, the Adam's apple. The fi rst bite of the forbidden apple was s a i d to have stuck in
Adam's th roat , hence the name. Progressing downward, the first tracheal ring is felt immediately below the sharp lower bo rder of the
Fig. 2.3
main landmarks to cervical th e upper (C4 -5) and lower (C5-6) margins of the thyroid cartilage (T), the cricoid ring (C6), the first of the tracheal rings (C6-7). The examiner's fmger is at the lower margin of the thyroid Lateral view of the four
spine level: the hyoid bone (C3-4),
cartilage.
thyroid cartilage and at the level of the C6 ver te bra. It is the only complete ring of the cricoid series and is an inte gra l part of the trachea. The first ring is immed iat e ly above the site for emergency trache ostomy. Applying gentle pressure upon palpation prevents initiating the gag reflex. With swallowing, the cricoid ring moves, but does so less o bv iously than the thyroid cartilage. Moving laterally 2.5 em from the first cricoid ring, one
palpa t e s
the
carotid
tubercle,
the
anterior
tubercle of the C6 transverse process. Although the carotid tubercle is small, l ocated about 2.5 cm from
the mi d line and d eep beneath overlying muscles, it is still clearly palpable. It is especially well -detected by pressing posteri o rly from the lateral pOSit ion .
Fig. 2.2 The posterior triangle bounded by the posterior border of the sternocleidomastoid muscle, the clavicle, and the leading edge of the trapezius muscle.
Carotid tubercles should be pa lpated separately because simultaneous pa l pation of these tubercles and other str u ct u res of the neck may occlude flow in both carot i d arteries, res u lt ing in the carotid reflex, a drop in blood pressure and faint ing . The caro tid tubercle is the anatomical l an dm ark for an anterior surgi ca l approach to C5 -6 and the site for injection of the cervical stellate ganglion (se e Fig. 1.7). The neurovascular bundle can be compressed agai ns t the carotid tubercle (level of C6 vertebra). At the apex of the trian gle, the transverse process of the atlas can be felt as a small hard lump, just posterior to the internal carotid artery. It lies between the angl e of the j aw and the mastoid process of the skull just behind the ear. The ex a mi n ing fingertip rolls over the tip of the
Copyrighted Material
26 Clinical Anatomy and Management oj Cervical Spine Pain styloid process and the stylohyoid ligament. The
transverse
processes
of
the
atlas
the superior nuchal line is found the rounded mastoid are
the
process of the skull (Fig. 2.4).
broadest in the cervical spine and are readily palpable
The spinous processes of the cervical vertebrae are
- an easily identifiable anatomical point of orienta
in the posterior midline of the cervical spine. No
tion. The anterior arch of the hyoid bone, the notch of
muscle crosses the midline, so there is an indentation
the thyroid cartilage, the cricoid and the upper rings
there. The lateral soft tissue bulges oLltlining the
of the trachea are readily felt in the anterior mid
indentation are made up of the deep paraspinal
line.
muscles and the supertlcial trapezius.
The vertebra prominens, the spinous process of
The C1 posterior arch of the atlas lies deep and has
the seventh cervical vertebra, just above the first
a small tubercle. The C2 spinous process, the axis, is
thoracic vertebra, marks the lower end of the midline
large and
sulcus formed by the ligamentum nuchae, which
lordosis, but each spinous process can be felt. The
extends from the spinous process to the occiput.
cervical spinous processes are often bifid, having two
The splenius capitis muscle forms a rounded ridge
easy to feel. The neck normally is in
smaU excrescences of bone. The C7 and 1'1 spinous
on either side of the sulcus; the trapezius muscle
processes are larger than those above them.
origin is tendinous without muscle and extends from
maUy, the spinous processes are in line with each
the inion to the T12 spinous process (Fig. 2.4). The
other unless they have developed asymmetrically.
Nor
'dowager hump' is the upper part of the vertebra
Misalignment can result from unilateral dislocation of
prominens, always more obvious in obese people or
a zygapophysial jOint or fracture of a spinous process
in those with cervical osteoarthritis.
due to trauma (Fig. 2.5).
the cervical spine
The zygapophysial joints are palpable about 25 mm
include the occiput, the inion, the superior nuchal
lateral to the respective spinous processes (Fig. 2.6).
The posterior
landmarks of
line and the mastoid process. The occiput is the
They are often tender if abnormal and they feel like
posterior portion of the skull including the floor. The
little domes lying deep below the trapezius muscle.
inion (bump of knowledge) is a dome-shaped bump
The patient should be completely relaxed for palpa
in the middle of the occipital region and is the centre
ble perception of these joints. The vertebral 1e\'e1 of
of the nuchal line. The superior nuchal line is felt by
any one of the posterior joints can be ascertained by
moving
laterally
from
the
inion
and
is
a
small
lining up the joint level with the anterior structures of
transverse bony ridge extending out on both sides of
the neck: hyoid bone, thyroid cartilage and the first
the inion. Palpating laterally from the lateral edge of
cricoid ring at C6 (Fig. 2.3). The cervical spine is a superb example of the biological
principle of adaptation of structure to
function. It supplies support for the head, a flexible and buffered tube for the transmission and protection
Fig, 2_4 Post eri or aspect of the head and neck with landmarks drawn in. The trapezius muscle originates from the i nion extends through all the thoracic vertebral processes to T J 2, is inserted into the clavicle and scapula, and overlies aU superficial structures in the posterior
Fig, 2,5
cervical spine.
sial j o i n ts
,
A drawing of a whole cervical spine sp ec i men
i llustr atin g the large
C2 spinous
process,
the
vertebrd
prominens (C7), the atlas-axis relationship, the zyga pophy ·
Copyrighted Material
and
the ex.iting intervertebral
t'ol�mina.
Anatomy and pathology of the cervical spine 27
of the upper sp in al cord, prov ision for the entry and
exit of spinal nerves, and extremely serviceable front it ap p ears as a truncated pyramid, w idening from the axis down
mobili ty. Viewed from the
wards; laterally in the neutral position, there is a mild lordosis with an anterior convexi ty (Fig. 2.7). Sligh t scoliosis to the left is normal at the cervicothoracic
j unctio n in 80%
of p eople and to the ri ght in 20%.
Head and neck mobility Erect posture,
binocular vision and cervical sp in e
mobility allow human be in gs to l o ok quickly behind themselves, over their shoulders, to gaze up at the stars or pe e r down at the ir feet, far more efficiently
than most animals. Many head and neck movements are social signals ; non-verbal communication is indic ative of mood, attitude of the moment and emotion. We are not even aware of many of these signals. The cervical sp ine moves in flexion, extension, lateral
flexion and rotation (penn.ing and Wilmink, 1987; Dvorak, 1988; Dvorak et aI., 1991). The lat te r two movemen ts are always combined to some extent. Noddin g occurs prima rily at the atlanto-occipital joint with the atlantoaxial joints participating to some de gree . Rotation mainly occurs at the atlantoaxial joints, particularly the atlanto-odontoid rotation. The
atlanto-occipital joints allow movement only in flex
Fig. 2.6 Poster io r view
of the whole
cervical
the bilateral zygapophysial joints and the
Note
ion and extension , not in ro ta t i on. Thus, the atlas and
spinous
skull move in rotation as a unit and the position of the
spine.
bifid
processes. Pons
Anterior longitudinal ligament
Vertebra prominens
Fig. 2.7 Drawing of a sagittal view of th e cervical spine showing the relationships of the brainstem, the medulla oblongata, magnum and the s p i n a l canal. The lower portion of the medulla is real.ly outside and below the foramen. Thus, with subluxation of the atlas on the axis, compression of the brainstem can occur by pressure of the odontoid against the upper spinal cord and the Inedul.la. Note that the a n te rio r arch of the atlas is only millimetres from the pharynx. the foramen
Copyrighted Material
28 Clinical Anatomy ana Management of Cervical Spine Pain skull is a clear indication of the position of the atlas in
anteriorly eccentric, odontoid process. The odontoid
rotation. The
process is tightly bound to the OCCiput by the apical
limiting
factor
in
extension
is
the
trapping of the posterior arch of the atlas between
and alar l.igaments
the occiput and the spinous process of the axis;
of the atlantoaxial zygapophysial joints, limit rotation
lateral flexion is likewise limited. Further extension is
each way to 450 (Figs 2.8 and 2.9).
allowed by participation of the lower elements. Bony
Figure 2.10 illustrates a lateral view of the cervical
impingement limits further extension at the atlanto
spine's atlas and axis. In rotation, the wall of the
occipital joint. Flexion is arrested when the posterior
spinal canal at the atlas level swings laterally across
l.igaments are taut and when the tip of the odontoid
the spinal canal at the axis level, narrowing the area
process abuts against the bony anterior lip of the
of the canal at this level by about one-third. For-
foramen magnum (the atlas is tightly bound to it by
tunatel)', the canal is at its most capacious here and
the transverse li gam ent). In these movements the
accommodates such rotation. The diameter of the
atlas does not move appreciably on the axis. With
canal at C 1 level is equally occupieci by the odontoid
fusion of the atlas and axis, flexion and extension are
process, free space and the cord (Figs 2.11 and 2.12).
unchanged. All three atlantoaxial joints constitute the
The
most
complex
joints
in the body.
Four
distinct
free
space
accommodation
allows to
the
for
safe
spinal
rotation
cord.
and
an
Ligamentolls
movements occur here: rotation, flexion, extension
structures, remarkably enough, are sufficiently lax to
and vertical approximation/lateral glicie of the atlas
allow this wide range, but are inelastic with high
on the axis.
tensile strength and can limit further motion without
The normal cervical sp ine can rotate as much as
impingement on vital structures. Lateral flexion of
1600 and, rarely, up t o 1800• Approximately 50% of
the head produces as much, or more, associated
the rotation occurs at the atlantoaxial articulation;
rotation of the axis than does simple rotation of the
the remainder occurs in joints below that level, with
head. With head tilt, the spinous process of the axis,
joints rotating in decreasing magnitude from above
and of those vertebrae below, rotates to the opposite
down. The atlas, like a wheel with an eccentrically
side to a greater d egree in the upper than in the lower
placed axle, pivots around the laterally central, but
portion of the cervical spine. blteral gl.ide occurs in
Tectorial
Apical lig. of
membrane
odontoid process
Alar lig. Occipital
----=:::::==3ijJ�
bone
Atlas
-------'.,r"":ll-_ri!f--::� \o.=�_ Transverse lig. of atlas
Tectorial membrane
AXic--------y? Inferior band of cruciate lig. Posterior longitudinal lig.
Fig. 2.8 and alar
Coronal view of
the upper cervical
spine showing
the critical
(checkrein) Ugaments of the odontoid.
Copyrighted Material
transverse/cl'uciare
ligaments and the
apical
.
Anatomy and patbology of tbe cervical spine 29
Tectorial membrane
Superior band of cruciate ligament Anterior atianloPosterior atlanto occipital membrane
Anlerior arc h of atlas
Vertebral artery and Synovial joint cavities
1 st cervical n.
_""",:::::=-tmmr-:?];-"fl
Ligamentum flavum Synovial bursa
2nd Cervical ganglion
Transverse
li gam e nt of atlas
cruciate ligament
Anterior longitudinal
Posterior longitudinal
ligament
ligament Dura
fig. 2.9 Sagittal view of the upper cervical spine showing the atlanto-odontoid joint with synovial joint cavities located anteriorly and posteriorly to the odontoid process. The cervical spinal canal is at its widest at the level of [he foramen magnllm.
normal people, with the atlas shifting to the side of the til t. It is observable on radiographic film as narrowing
of
the
space
between
the
a
odontoid
process and the lateral mass of the atlas on the side of the tilt, and a widening of the o ther siele. The �ertebral artery normaUy enters the verse foramen
at
trans
the transverse process of the sixth
cervical vertebra and ascends through the foramina transversaria to enter the skull (see Figs 1.4, and
1.12).
It is
1.11
protected in th e foramen except
between the axis and the atlas, wh ere there is a bout 1.5-2.0cm
of artery
lying outside the
c ana l
.
In
addition, the artery is normally su b ject to the stress and
Fig. 2.10
and axis are shown as the vertebral artery winds its way tllwu gh the foramina transvcrsaria of the two vertebrae. The odontoid process and the anterior areh of the atlas are visible just below the two arteries. Note the sharp deviation outwards anel upwards that the artery must make from axis to atlas, followeel by a complete return about the posterior aspect of the lateral mass of the atlas before proceeding to the clivus to join the other vertebral anery as the basilar artery. This is a normal specimen; The atlas
consider the
implications of this situation with athero
sclerotic plaques, narrow jOint spaces, loss of intervertebral disc height
anel exte ns i v e osteophytosis.
stretch
bern'een
atlas
and
axis
,
since
it
is
situated at the periphery of the marked rotation
.
The artery is puUeci forward s and backwards by the rotary action. The clinical consequences must be co nsi de red in
any
rotary
dislocation,
fracture
or
maialignment of the atlas anel axis (Fig. 2.10; see Chapter 12). Below the axis,
rotation, flexion
-
exte nsion and
lateral flexion occu r in decreasing magnitude from the top clown. Normally, the cervical spine is in slight lordosis
but
a
linear
pattern
is
not
necessarily
abnormal. There is even reversal of the standarcl
Copyrighted Material
30 Clinical Anatomy and Management
of Cervical
Spine Pain
lordosis in a few normal people. Du ring flexion, the cervical spine appears to leng then This seems to be .
attributable to straightening of the lordosis rather
than to a ctual leng thening of the cervical spine (Fi neman , 1963; Ball and Meijers, 1964).
Specific structural anatomical characteristics correlated with age Nucleus pulposus The nucleus plllposus of the cervical intervertebral
discs
present at bi r t h
,
,
is less and l ess evident in
adolescence and above age 40 it mainly disappears. The adult disc is ligamentous, dry, composed of fibrocartilage islands of hy a l in e ca rtilage even some ,
,
tendon-like material, and cert a inly with very l ittle proteogJ ycan Thus, after age 40 years, it is .
generally
impossible to herniate the n uc le us pulposus clini
therel Figu re 2.] 3
caUy, since the re is none
is a
corona] section of the cervical spine of a 4-year-olel boy, which shows that the n ucleus pulposlIS is clearly present in the m i d dis c re gion -
By
.
ages 9 -14 years, the n ucle u s pulp os us is far less
ev i de nt anel bilateral clefts have devel oped in the
Fig. 2.11
of a whole human cervical spine, a nd viewed from the posterior aspect. The upper third of the pic t ure shows the spinal cord in the capacious spinal c a n al at the foramen magnum level ; the occipital condyles were cut off the skull with a sharp chisel (lateraUy situated) and the ed ges of the atlanto-occipital joint Specimen
vertically positioned
are visible; the anterior and posteri o r arches of the atlas can be identified.
poste rolateral aoulus fibrosus; med i al to the growing uncinate processes of the verte br a
,
and
postero
late rally situateel. This cleft is the site of the joints Qf Luschka (uncovertebral or ne uroce ntral joints; Fig.
2.14; Cave et at., 1955; B o re a dis and Gershon-Cohen, 1956; H a dley 1964; Hall, 1965; Tondury, 1974; Bl a n d and Boushey, 1987; Bland, 1994) At age 20-35, the clefts have graeluaLly enlargeel and are di s sect i ng tissue planes toward the midline, \vhere each fmall y meets its cou nte rp a rt from the opp o s i te side (Figs 2.15 and 2.16). This pheno m e non proved to be universal in ou r spine studieS, the re fore it is believed to be a p hysi olo gi ca l eve n t pecu liar to the human ,
,
cervical s pin e s biomechanics. Meanwhile, the disc is '
changi n g overall tissue characteristics with gradual disappearance of the nucleus pulposus and acquisi tion of ligamentous, fibrocartilage-like gross charac
teristics (Figs 2.15 and 2.16). An ex am pl e of the u ncinate processes is shown in Figure
2.17.
In cervical spines of p eople aged 60 and above, the anular dissection has reached the midline, suggesting a bise cted disc from u nc in ate process to uncinate process. The overall material in the disc has become dry with little p roteogl ycan
,
acquiring d e n s e lig a
mentous cha rac te r anel marked loss of volume of disc tissue.
It
is
physiological
for mul a ted
that
consequen c e
these
events
are
a
of shea rin g planes of
tissue - a biophysical, biomechanica[ consequence of the rela tively extreme rep etit i ons of motion that the
Fig. 2.12
A
close-up view of Figure
odontoid 'peeking' through.
2.11
showing the
ce rvical
] 991)
Copyrighted Material
spine e njoys
,
espe c i ally
rotation (Milne,
Anatomy and pathology of the cervical spine 31
2.13 This specimen is a c1ose·up of a coronal section of the cervical spine of a 4·year·old The nucleus pulposlIs is obviolls in the centre of the disc (arrow). The uncinate processes well·developed. From Hall (1965) with permission.
Fig. boy. are
Fig.
2.14
old
child.
Coronal section Note
VA
of
a c e rvic a l spine from a
(vertebral artery)
process). Arrows point to developing clefts
lateral
anllius fibrosus. From
Hall (1965)
3·year· U (uncinate in the postero
and
with permission.
Fig.
2.15
Whole cervical spine
spec imen (cut
coronally)
from an SO-year-old woman. Note the striking decrease in overall disc substance, marked narrowing of all discs and
completely
bisected disc surfaces facing one another.
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32 Clinical Anatomy and Management oj Cervical Spine Pain laterally and posterolaterally from C3 to C7 (Figs 2.16 and 2.17) With increasing age the uncin at e processes enJarge and often flatten, losing their sharp bony edge. This osteogenic phenomenon forms a bulwark of bone laterally, and to some degree po st erolat erally which, it is believed, prevents disc he rn i a ti on in this area. Figure 2.15 is an anterior view of an articulated cervical spine from an SO·year·old wo ma n which illustrates this princi pl e Figure 2.1S shows a coronal section of the uncinate process from a 2S-year-old man, while Figure 2. 19 is an illustration of the same uncinate process viewed from within the disc. The normal physiological sequence of events and anatomical structures here constitutes an accurate desc ript ion of normal ce rvica l intervertebral disc physiology and pathology. These findings are virtually
.
universal. At age 9 -14 ye a rs a cleft appears in t he lateral and anul us tlbrosus, a function of the unusual ab il i ty in obligate bipeds to rotate the cervic al spine. Th is cleft, or fissure, gradually dissects toward the midline to meet its counterpart coming posterolateral
Fig. 2.16 A corona l section of a lower cervical s p ine taken
fro m a 92-year-old
Note the spaces between all of the with most of the material gone, except in the lowest intel"VertehraJ disc. In life this is clearly only a potential space and has a pressure below that of th e atmosphere, the two surfaces are n ormally in close and well man.
intervertebral discs
moulded apposition.
Fig. 2.17
An
an terio r view of the C4
vertebra i.llustrating a
sharp remodelled uncinate process on th e viewer's left and
blun t remo delling unci.nate process on the right.
Pieces of disc tissue are frequently found as separate hard marginally elastic f ragme nts free within the disc which conceivably could he rn iat e .
Uncinate processes The uncinate pr ocess es (uncu.s
=
a small hook) are
normal bony developments of cervical vertebrae,
Fig. 2.18 Coronal sect ion of the uncinate p rocess from a 28-year-old man. The cleft or
fissure
medial to
process shows disc fibrocartilage fibrillation.
Copyrighted Material
the uncinate
A n a tomy and pathology of the cervical spine 33 later by ra p i d growth of the spi n e . With growth a n d extension o f t h e cervical spin e , phys i o l ogic a l trac tion is exerted on the cord and nerve roots and the d u ra l
root
sleeve
exit
s i tes
are
at
the
level
of
vertebral bodies ra ther than at the disc l e ve l ; the root exit zone is gen e ra l ly below the level of the disc (Bl a n d , 1 994; Fig.
2. 20) .
Incidentally, virtually
aU dural root sleeves become fibrotic , rigid and stiff after the a ge of 45 - 50 yea r s .
Anatomy of the anterior (motor) nerve root The a n terior nerve roo t is normally s ituated low in the
interve rtebral
fo ramen
and
u nlikely to be compressed (Fig.
hence
2.21).
is
very
The posterior
nerve root is we ll-pro tected from the point of any disc herniation. Howeve r, the zygapophysi a l j o ints could become e nlarged due to osteophytosis, and the posterior root c o u l d become c omp resse d , res u l t ing in radiculopa thy (though radicu lopa thy itself is u n u s ual in the author'S experience).
Fig. 2 . 1 9 On
right is a parasagittal section t h e u ncinate p rocess as seen from w i t h in the disc, looking from inside out . On the left is a parasagittal section of the same a n atom ical speci m e n showing C5 ve rtebra in t h e middle and the lower h alf of C4 a bove . N o t e the through-and-t h rough clefts above and below C 5 . From Ball (1 964) with p er
There is normally a considerable in divid u a l d i sparity
m i ssion .
betwe e n the spinal cord volume and space avail a b l e
the viewe r 's
seen on X-ray. Arrows point to
Spinal cord volume vs the measured transverse diameter of spinal cords and the bony spinal canal
i n t h e bony c a n a l . This s e e m s a constitution a l , or genetic , characteristi c . Thus, clinica l ly, if o n e inher i te d a wide s p i n al c o rd and a relatively sma ll bony from the other direc tion . In this space there are
canal , the d eve l opment of osteoa rthritis compromise
patches of synovi u m . With increasing age , the disc is
c o rd fu nctio n . The ideal i s clearly a na rrow cord and
fIna l ly b i sec ted in a transverse p l a ne and the two
a capacious spinal canal -
su rfaces are made up of a pecul i a r mix of connect ive
(Fig. 2 . 22)1
the luck of t h e d raw
tissues, anu l u s-like tiss u e , fibrocartilage , hyal i n e ca rti lage, even some tendon-l ike tissues as well as bony islands. Th u s , there a re cauclal and cephalad port ions of the normal transected c e rvical interve rtebral discs. The disc ove ral l becomes narrower with the passage of t im e , sometimes nea rly disap pearing. We d ubbed
Anatomy of anterior and posterior spinal canal
is
In people over a ge 45 - 5 0 , the anterior spin a l canal i s
complete , as per the smile of the Chesh ire cat (Fig.
characterized by b a r s of osteophytes a t t h e level o f
this ' th e
grin
of Luschk a '
when
the
process
2. 1 5).
the intervertebral d i s c s (F i g .
2 . 23). These
osteophytes
commo nly compress the cord to varying degrees
2 . 24),
(Fig.
n o t always resul ting in symptoms. The l iga
m e n tu m flavum
(Fi g .
2 . 2 5)
is
11ype r t rophied
and
Nerve root exit sites
hyperp lasti c , proj ec ting i n to the spinal c a n a l , a n d
At the C 3 - C4 level the an terior and poste rior n e rve
varying sym ptomatic consequences .
may root exit sites through t h e d u ra l root sleeves are below
the
level
of
the
interve rtebra l
approxima tely 4 m m . This is as
discs
by
compress
the
spinal
cord
posteriorly,
with
The posterior longitudinal Ligam e n t i n the cervical spine is three- to fi vefold thicke r and more devel
consequence of the
oped than in either the thoracic or l u mbar spines,
formation of the nervous system, being fol l owed
where i t tends stro ngly towards a tte n uation. Since
a
Copyrighted Material
34 Clinical Anato my and Management of Cervical Spine Pain
Fig. 2.20 A sag itt a l section o f a whole ce rvical s p in e showing n e rve exit
s i t es
(dural r o o t sleeves) and t h at t h e y
are a t the u pper level of the verte brae ra t her tha n at the level o f t h e d i sc s .
Fig. 2.21 C oron al section through the i n terverteb ra l fo ra nl e n a t C7 - T I . The upper
a rrow
and the
a r rowhead to the an terior (motor) roo t . The level i n the fo ra m e n is proxim a l to the posterior root ga nglio n . The mo t o r root' is a nat o mically
p o in ts to the posterior (sensory) roo t
s i tu ated low in the fora m e n , we l l · p rotected from
any
cou rse from t.he spin a l co rd.
Copyrighted Material
oste o p hytic c o m p ressio n t h roughout its
A natomy and pathology of tbe cervical spine 35
Fig. 2.22 A tran sverse view of C6 ve r t e b ra illu strati.ng the spaciolls spi nal can a l and th e re l a t ively s m aIl s p i n a l cord - there is a great tolera n c e f o r exte n s i ve osteoa rthritis without cord c o m p ression a n d myelopathy.
very
the poste r i o r l o n g i t u d i n a l ligament is in a to preveJll h e rn i a tion posterolatera l ly a n d orly, this may be a p a r t ia l ex p l a n a t i o n unusu a l occurrence of d isc herniation i n
pOS i t i o n p o ster i for
the
the cer
vic a l spin e .
Fig. 2.24
This specinlen i s a
gros s
m i d l in e
section
of a
cervical s p i n e . Note anterior arch of the a t l a s at t h e top ; the odontoid is e roded a n d the anterior atLanto-occipital jOi n t is
fLi l e d with granu l o m a tous tissu e ; the s p i n a l cord i s the sagittal p l a n e a n d compressed by intensive intervertebral d i sc gran u l o m a and osteophytes at the C5 - 6 leve l ; r h e C2 - 3 a n d C 3 - 4 d i sc s a re o f n o r m al heigh t . cut
in
The anteri o r longitudinal l igament i s a t t ac hed fU'mly to t h e vertebral bodies, b u t only l o osely a t the d i s c area . Co nverse ly, posterior l o n gi tud in a l lig a ment i s fir m ly a ttached to the disc but loosely to the vertebra l body surface . This anatomical fact may explain why osteophytes (foLlowing t h e p a t h of least resista nce) a re la rge r and m o re common anteriorly
Fig. 2 . 2 3 O n t h e Left t h e s p e c imen iUustrates t h e posterior s u rface o f ce rvical vertebrae seen from inside th e spinal canaL, showing massive posterior ve rtebra l body osteo p hytes a t the margi ns o f the i n t e rvertebra l discs, p rotrud ing i n to the anterior cervicaJ s p ine canal ( a rrow) . The p oster i or longitudi nal liga ment i s grea tly t h i c k e n e d . On the righ t i s a se c tio n iJi ust ra t in g the posterior surface of the spinal canal w i th i mm e nsely t h i c k e n e d a n d protruding Liga m e n ta f1ava (arrow).
than posteriorly. In the cervical reg i o n o n ly, the posterior
l o ngitudinal
Ligament
is
very
broad
throughout , whil e in the thoracic and lu m bar regions it narrows strikingly b e hind each vertebral body.
A stra n ge and poorly und erstood c ervical s p i n e characteristic i s t h a t of marked remodelling hyper trophy and hype rplasia of cervical verte brae w i th increaS ing chronological age .
Copyrighted Material
3 6 Clinical A natomy and Management of Cervical Spine Pain We a re t h r u s t into this world by smooth mu s c l e wh ich is u nd e r the con trol of the ,
autonomic nervou s syste m . From mome n t to mo men t we a re depe n d e n t for our conscious existe n c e
on
the
m o d e ra te
of
con tractio n
blood vesse l s , routinely kept in t h is state by
a u t o n o m i c im p u lses. Most of the co mp l i ca te d processes of digestion, from
the i n i tia l o u t
po u r ing to the fina l ridd a nce of waste, requ ire the
p a rtic i p a tion of a u to no mi c
n e rves . Any
vi g oro us exe rcise in which we m ay engage d epe n d s on c o o perat ion of autonomic g o ve rn
ment of approp riate effecto rs th us throughout e o n s of past t ime t h e physical s truggle fo r ,
existence
has
been
made
possible
by t h a t
' gove rn m e n t ' which p reserves the stable state s
Fig. 2 . 2 5 A
whole cervic a l spine c u t sagitta lly
down
the
m idline, dividing the spine and s p i n a l c o rd i n to two facing halves. The w h ite sp in a l cord is i n mid·sec tion . The l e ft and right bisected spec i m en s show a greatly hypertrophied and
hyperp l astic an te r i or l o n g i t u d i n a l liga m e n t (arrowhead) a
very
a nd
n a r row d i s c a n d an extre mely thjcke ned posterior
of t h e fl u i d matrix t h at are requ ired for s t e ady
response to every call to actio n .
O n c e the great importance o f t h e i nvol untary o r ne r vo us s y ste m was e sta b l is hed a n d p rove n to be a b so l u tely req u i s ite to effi c i e n t fu nc-
vege tat ive
longitud inal ligam e n t a n d l a rge osteophytes compress the s p i nal cord a n t e r i o r l y (wh i t e ligamentum
f1avum
arrow) . A seve rely tluckened poste riorly
compressing the sp i n a l cord
(cu rved a rrow).
Synovial folds (menisci) of zygapophysial joints All zyg ap o phy sial j oints have s y n ov i al fol d s (menisci) i n a circular arrang emen t a bout the periphery of the
j o i n t with varying degrees of projec t i on in to th e joint (Fig. 2 . 26 ; see Fig. 1 . 10). These have a prop e nsity to p rol ifera te in a fib ro u s-like p a nn us in d ise ase of t he zyg a po physial j o iJ1ts (B l a n d 1994). Th ere i s evi d e n c e t h a t if the hyal ine cartilage surface is d ama ge d fi bril.lation of the s u rface a nd c hond rocyte clone fo rm a tion o c c u r. The p ro Liferation may b e r el a ted to immobilization, re l a t i ve o r a b so l u t e . T h e re is n o sec u re know l edg e o f physiologi c a l fu nctio n of the m e n i s c i o t her than that of lubrication. ,
,
The autonomic nervous system and the cervical spine Perti n e n t to the cervical s p in e is t h e fact tha t a very
l arge p a rt o f our nervo u s system (and that of a U o the r a n imals) is c o n c e r ne d w i th ac tivities and vital func
tions of whi c h we a re total.ly u n aware a n d over which we have n o v ol u n t ary contro l . Claude Bern ard ( 1 9 5 7)
p r op o sed that a d iv ine p rovid e n c e considered these a u tonomic act ivi t ie s far too importa n t to e ntru st to a c a p r i c i o u s will.
Fig. 2.26 Sagittal sec t i o n th rough four
of [he zyga pophysial
j o i n t s . Note the m e n isci which a re reasonably n or ma l
(black
arrows). The m e n i s c i a re c a pa b l e o f prolifera rion a n d may re s u l t i n a fi b rou s·l i k e pannw; prolifera t i n g
c a r ti lage
Copyrighted Material
su rface.
over
[he
hya l i n e
Anatomy and pathology of the cervical spine 3 7 tioning of t h e h u m a n o rga n i sm , physio logi s t s t h e
mechanical
world ovcr, l e d b v Wa l t e r B
of Ie
(Rotes-Qlwr a l e t aI. , 1 94 9 ; Stewart, 1 980; B l a n d a nd 1 994) . In addition, i of t h e zy gapo p hysi a l
t h e c o ntin u a
t o t h e a e tio l ogy of n ,,·,, " ,Ir 'U"
long a n d
h a rd
autonomic
c' a n n o n , have worked
to
fu nctions
!
n ervo u s
milieu interne, tion
of the
of t h e
m a in t e n a nce
rac e ,
n a tural
d e ra ngemen t s
a l re a dy known
the
attention
c e rvical
spin e
manner
by
the
a n d p o s s i b l y t h e 30th
I
decades has res e a rch
the
reflex
s m o o t h m u s
mechanisms o f
of
c o rd inju ry involved mo re
in
1 9 30), we full grasp of the p hy s i c a l and
wh.ich the a u t o n omic n e rvous system pa rti c ipa t e s
j u s t motor a n d sensory loss (Breasted ,
i n n eu rolog ica l d i s e a s e s , o r h o w th e sy m p a thetic
s t i ll d o n ' t h a ve
parasympa t h e t i c n e rvous system may be selectively
p hy s iologi c a l c o m p lexi tie s of a ut o n o m i c fun c tio na l
a
d era nge d by p a th o log i ca l p rocesses. O n l y re c en tl y
a l t e ration
have cl in ical investigators m a d e sign ifica n t advances
erated c lini c a l syndromes in p a r t i c u l a r. Our u n de r
in
ge n e ra l ,
and
of c e rvic a l
sp ine
gen
in t he neurology of t h e a u to no m i c n e rvous system .
stan d i n g of the physiology a n d p a th o p hy s i o l ogy of
The p a t h o l ogy of the sym p a t h e t i c n e rvous syste m
a u to n omic
fo r
bee n ,
has
fi rs t
the
time ,
s u rveyed
in
m any
diseases. Neu-
i m portant m e d i c a l rop ath o l ogic a l
fun c tion
Nevertheless.
we
do
limi ted
is
h avc lor
logici l
(Stewa r t ,
1 980) .
clini c a l ,
physio-
valid
such
c o mm o n
w i t h t h e use
c ervi c a l dizziness a n el
of modern n e u ro i m m ll l1o logicai mClh o d s , d o n e o n
p u zzling syndro m e s such
the
the
autonomic
h ope
of
cla rifyi ng h u m a n Perti n e n t t o t h c clin i c a l
syn d romcs
sp i n e a nd
its
there
no
a re
fib res in t he n e ck, a l l
p rega n g l i o n i c sy m p a t h e t i c
co m i ng from T l , T2 a n d T3 l e v e l s , h a v i n g t h e i r first syna pse in o n e of the th ree c e rv i c a l sym p a t h e t i c ga n g l i a , s te l l a t e , m i d d l e a n d s u p e r i o r. Va riations o f
Table
signs
of dysfunction
arising
from pathophysiological
changes in the cervical spine
Symptoms
Sig ns
t h i s have b e e n demonstra ted i n p rega n g l i o n i c fi b res from t h e C7 a n d as l o w a s t h e L4 cord segme n ts
Pa i n
Fa U i n g
(Ap p e n z e l l e r, 1 994). The postganglio n i c fib res t h e n
Headache
Tend e r sca l p
D i z z iness
Ten d e r b o n e s
d i re c t i o n s : fi r s t , o u t i nt o the
g o i n t h ree
extre m i ties, pro v i d i llg :ll l
upper
f u n c t i o n s , c ir
c u l a to ry vasom o t i o ll . second ,
re-enterillg
in terverte bral fOr;lJllt'n t i o n s in the vest i b u l a r the
w n a p t i c c o n nec-
the cerebeJJ u m , t hi rd ,
thalamus
l a rge
segments of
the
vertebra l a n d c a rolid
aneric" follo w i n g t h e i r d is
tri b u t i o n in th e b ra i n (see Fig. 1 . 7). The e a r l i e s t descrip t i o n of sym p at h e t i c n e rvous system s y n d r o mes was by Barre i n 1 926 and fu r th e r
described by h i s student Lieou in 1 928. So d iverse , b i z a rre a nd sig ns
that
widespread some
a u thors
were
the
symptoms a nd
did
not
regard
it
as
a
d isorder associated w ith t h e cervical s p i n e (Lie o u ,
1 928; Rotes-Quel�lI
I
My c u r r e n t view
011
the basis of p a t h o p hysio-
a u to n om i c
d e J o ng a n d Bles,
logical events (Hincs
1 986; see C h a p ter i n te r p l ay
Fa tIgue
Dysaesthesia
Ins(Hn n i ;)
·\trophy
Resliess
Hypertrophy
CouglJ
Hyperp l a s i a
Sneezt"
Wea kness i n the u p p e r
DiuriH)c;(
Sweating, o r l ack o f
Syncupt:
Nystagmus
Visual d isturba n ces
Te n d e r m u s c l e
Aud itory d is t u rban c e
Fasciculation
Orop atrack
Pa t h o l ogi c a l ga i t
Ar m and leg a che/pa in
Tra n s i e n t hearing loss
Stiff n e c k
Fain t i n g
To rticoll i s
S p a s t i c ga i t
G a i t abnorma l i ty
Reflex C h anges (deep t e n d o n
B a l a n c e poor
superfi c i a l a n d a u t o n o mic Ca rotid sin us s e n s i tivity
a p p a re n t ly n e b ulous ,
i c a l experience a n d
the
Hyperaesthesia
reflexes)
w e l l-w i th in c l i n -
nizes
c\naesthesia
Pa LH:: s t hcsja
K()\ :Iks, 1 9 5 5) .
biza r re and atypical kno w n
Ve r t igo
Benign p aroxy s m a l p o s i t i o n :iI M ood
nystagmus
Tin n i t u s
Vertebrobasilar insuifi c i f" I1Cl
Diplopi:.
Sensory a taxia Physiological h e a d exten,;ion
app rec ia ti o n recogberween
rhe
c e rv i c a l
vertigo
sympa
Cervico c o llic reflex
the t i c system , t he ve rtebral ar te r ie s , the brain a n d spi n a l c o rd , muscle
Cervico-o c u l a r reflex
the zygapo physi a l j o i n t s , the scal e n e
system,
a
p re-existing
degree
Ves t i b u l o-oc u l a r re flex
of a rterio
sclerosis and col l a te ra l c i r c u l a t i o n - all rela ted to
Ada pted from B l a n d
Copyrighted Material
( 1 994).
38 Clin ical Anatomy and Man agement of Cervical Spine Pain of p roprioception , and repro d u c i b le reflexes such
Experimental
as the cervical ocul a r reflex, vest i b u l o-ocu l a r refl ex,
New York : Dover Press
pupillary d ila tion on f'xtf'nsion of the neck, p o s t u ra l and
induced
B l ake,
by cerv i c a l s p i n e
W. ( 1 925) 3
the Romberg test CHine s s i m p ly to call attention of t h e cervical s p i n e 's re la[ionship to the a u tonomic
n e rvous
l ists sym p t o m s a n d s i g n s
a r i s ing from pathop hysiological cha nges in the c e rvical spine . In s u mm a ry, from a postmortem exa mination of
1 9 1 cervical spines, the fol l ow in g observati o n s a re made:
Breaste d , J.H. cited in :
P c . ( 1 987)
Cave,
A .]. E"
5 . Norm ally, a n t erior nerve roots a re too l o w in the i n tervertebra.l fora men to be subject to comp res s i o n . Exc e p t fo r zvgap o p hysial j o i n t osteoarthri t i s , the
also n o r m a l ly well-p ro
" plll e ; f l exion/ex t e n s i o n . Spine f1cxlon/exte n s i o n
n o r m al l o rdotic pattern i n to a li n e a r pattern i n the n e u t ral
45A: 1 1 7 9 - 1 1 83 . L . ( 1 964) A natomico-roentgenographic Studies oj the Spine , Springfield , IL: C h a rles C. Tho m a s . H a l l , M , C . ( 1 965) Luschka's joint. S p r i n g fi e l d , ill i n ois H i n e s , S., H o u s ton, M" Robertson , D . ( 1 98 1 ) The clinical spectrum o f a u to n o m i c dysfu n ct i o n Am .I Mer!. "0, H a d le y,
( i ')77) Th e Trunk and Vertebral Chll('ci1ill, ')55) S u b l uxation a n d
E d i n b u rgh:
joints: a c o n t r i b u t i o n t o
bisec ting the disc .
4 3 : 1 - 6. (28) Syndrome sympathique
a u tonomic fibres the
from T l - 3 l evels befo fe
syn a p s ing in t h e cervical ga n gl i a ,
arlbritie cervicace chroniqtte
Radiologique, S t rasbourg S c h u l e r & Minh . Milne, N. ( 1 99 1 ) The role of zygapophysi a l j o i n t
u nc i n a te p rocesses i n c o n t ro l l i n g motion
cervical s p i ne . ] A nat, 178:
References 0, ( 1 994)
in In: Disorders of the Cervical I II . (C d , ) . Phil a d e l ph i a : Sa u n d e l'.
The a u to n o mic n e rvo u s system
cervic a l s p i n e d isord e r s ,
Spine,
31 ].
techn i q u e)
special
L ( 988)
particular
reference
to
the
57 1 - 596.
Differences in a natomy.
aging of t h e u p p e r a n d patholog y
of
Clin. Bio mecl1Cl n ics 3 : 37W i lm ink, ) . ( 1 987) Rotation 0 1 1 2 : 7 3 2 -738. I , C resp i , P B " Par i ggros,
r h e u m a toJ(j
C e n t e r for Rhe u m a tic D I S· eases
Con gress
o l ogica]
]., Rheum B a rre , ].
61. 6 1 : 25 - 39.
Series
a rt h r i t i s
Rad i·
On c e rv i c al mobiUry. A n n
Bal l ,
B e r n ard ,
with
p r o b l e m o f c c rv i c a l s p o n d y losis, Brain 80:
pp.
Neurol.
o r i e n tation
in the 1 89 - 20 1 . Pay n e , E.E. , S p i JIa n e , J D , ( 1 957) The cervical s p in e : an a n a to m i c o-p a t h o l o g i c a l study o f 70 speci mens (using a a nd
et
nornui
posture. j Bone joint Surg.
progressively disects medially ! I II lIy
of the
9: 828 - 8YI .
F i n e ma n , S. ( l 963) The cel-v i c a l sp i n e : transformation of the
l a t e ral a n u l u s fi b rosus from
7.
oj Posture
P:lll p b i , M , M " Novotny, J E "
.
tected
6 . A cleft
the
( I ()H8) Func tional rad i o gra p h i c
Orthop. Res.
disc,
of
osteoarthr i t i s ,
Rheumatol. 1 4 : 1 89 - 1 90, Wh i t ley, M , M . ( 1 95 5) Os teo t h e Luschka j o i n ts r. anr·et 1:
Bles, \XI.
regio n s , probably preven ting
j o ints, these n erve roots a re p ro tected from the
ieur
G r iffi t h , J.D"
Disorders
poste r i o r disc herniatio n . the d i sc leve l . Together wit h t h e u n c overtebf'JI
Su./'gical Papyrus , SpondylOSiS, Phil·
I
ligam e n t i s fo ur to five
4 . From C3 t o C4 , t h e n e rve root exit sites a r e helow
U n d e rsta n d in g
v a l u e of a n a tomical s t u d i e s , j
c e rvical s p ine than in t h e
Bal l ,
(1 930) Tbe Edwin Smith ( 1 967) Cervical
the
a d e l p h i a : S a u n d e rs ,
the
thora C i C
( 1 956) Luschka joints of ReI. Res. 66: 1 8 1 - 1 86.
B ra i n . L . .
bone whi c h constra i n s
3 . The
( 1 987) Disorders
c e rvical s p ine �in Orth()p.
s u p e r i o rly, for m i n g a lateral and
poste ro!;Hn:1 1 h i
William
P h i l a d e l p h i a : S a ll l l ( i c l.'
Boread i s , A. , Gershon-Coh e n , .I :
presen t from early liIe ,
AppenzeUer,
82- 224,
J
a r t h r i t i s cl e form ,U1s
2 . The
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Saunders.
abse n t i n the a d u l t gra d u allv
(Ke y n e s ,
B o u s h e y, D.R.
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1 , Al though p resent a t birth , the n u c l e u s p u l p osus i s
Jerusalem,
by Greene, H , C.).
( 1 99 1 ) Cervical and t horac i ( 3: 2 1 8 - 22 5 . ')')4) Disorders of the Cerv iral
Bles, 1 986).
specific
Medicine (tra n s l ated
s y n d ro m es of poss i b l e n.,'vl'il()f'(' ni l l so·c:! lled Ba rre-Lie o u synd rome
S y n d rome s y m p a th i q u e cervicale poster· sa
cause
fre q uent
I ' Arthritie
33: 1 246 - 1 25 4 , C . ( 1 957) A n Introduction
C e rv i c a l e ,
Re v
.
Schmorl ,
G"
]ung h a nn s , H.
Health a n d Disease, to
t h e Study
oj
S t ra t t o n ,
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( 1 97 1 ) The Hu m a n
2nd cdn,
New York :
Spine in
GrLme
&
A natomy and pathology of the cervical spine 39 Stewart, D.Y. ( 1 980) Current
concepts of the Barre syn
d rome or the posterior cervical sym p a thetic syndrome . Clin. Orthop .
24: 4 0 4 8 .
Ten H a v e , H . A . M . j. a nd Eulderink , changes in the cervical spine and
Pathol 132: 1 3 3 - 1 5 9 . G. ( 1 974) Morphology o f the
cervical spine.
In:
1' , M atert F
et aI., e d s) .
G. ( 1 9 5 9) La coloMe cervi c aJ e , son d e ve l o ppe et ses modifi c a t ions durant l a vie . Acta Orthop. Belg. 2;: 602 - 6 2 7 . Vel ea n u , C. ( 1 975) Contri b u tions t o t h e anatomy of the cervical spine. A cta Anat. 92: 467- 480.
Tbn d u ry,
F ( 1 980) Degenerative the i r rela tionship to its
mobili ty. J Tbnd ury,
The Cervical Sp ine Oung A . , K a l l n Bern : H a n s Huber. ment
Copyrighted Material
Clinical anatomy of the cervicothoracic Boyle, K.
N. Milne
Introduction
of the articular facets
The head
the slender chain
seven cervical vertebrae, By means of their zygapophy·
cervicothoracic transition clear, In non-human mammals there is a distinct
sial and u ncovertebral joints , intervertebral discs and a
transition at the second thoracic vertebra from the
com plex
thoracic-type
system
of
ligaments
and
muscles ,
this
(or
tangentially
oriented
articular
configuration allows considerable motion in all planes,
facets) to the lumbar type (or radiall y oriented facets)
The mobile cervical spine in turn rests upon the
found in the cervical spine (Milne, 1990), Measure
rel a tively rigid dlOrax which consists of the thoracic
ments
vertebrae and ribcage , The intersection of these two
between the left and right superior articular facets) in
regions defines the human cervicothoracic transition,
humans show that the thoracic pattern (interfacet
This chapter
of
the
angle
angJes slightly less than 180'
remains one of the least h uman spine ,
described
(posterior
is a more subtle transition
tr;lllsitional region which"
accordin g
angles
than 180°) continues
anatomy, mechanics, injuries
and pati1ologl('s
interfacet
cervical motion segments reported a similar of the orientation observed this change
Normal
cervical
spine
and
the
rypical
between
In contrast to typica l cervical segments, the thoracic
attributed cervical
it
to
a
vertebrae
tranSitIon and
the
suboccipital segments (Overton and Grossman, 1952;
1976), Interfacet angles less than 1800
vertebrae are distinguished by the presence of the ribs
Mestdagh,
and their articulations. The rib tubercles articulate
provide a much more stable configUf'dtion and it is
with the transverse processes (costot ra nsverse joint) and
the
rib
heads
typically
articulate
with
the
vertebrae at the inte rve rteb ral disc and the adjacent demifacets joint). The
motion segments,
the disc (costovertebral
the orientation of the
rule in tbe upper tboracic
zygapophysial joints, as seen
freq u ently articulates wilh
spine is the
is
l ate ra l aspect of the fLfsr
a single
presence of the ribcage and
this plays
reg u lating thoracic spine
The transition from the thoracic to the cervical
un u sua l compared to other mammals (Milne, 1990; Bland 1 99 4 ) With respect to is
gradual
transiliOI1
regions to the obliquely ("('["leal
spine
(Milne ,
19')0,
occurs between about the � egments ,
motion (Stokes, 1997). hu m ans
a
vertically oriented facets
of the thoracic spine
thoracic increased
spine in
possible that this provides a more stable platform for the highly mobile atlantoaxial and atlanta-occipital
There are other morphological features which h el p to define this transitional zone (Fig , 3,0, Panjabi et at.
(1991a) sta ted that the transition from the cervical to
Copyrighted Material
Clinical
Fig. 3.1 l'arasagittal l ,)O!Jm thick histological section through the cervicothoracic juncti on , immediately medial to the uncovertebral joints. Note the bipl ana r pattern for the zygapophysi:1.1 joim of the TI - 2 leve l ; the tip of the infer ior articular process forming an articulation w ith the lamina of T2. l!ncovertebral joints are a ppa ren t at C7-Tl and TI-2. The b.rger se n sory branch of the spinal nerve is clearly shown compared to tbe motOr branch. The intervertebral discs show the greatest vertical height anteriorly.
the thoracic region is readily a pp arent from the vertebral body dimensions. In the cervical spine the upper end·plate dimensions at C6 and C7 are significantly greater than those of the more superior cervical vertebrae. There is a t re nd towards increasing values from C3 to T 1 for the transverse dimensions of both the vertebral body and the superior articular facets (Milne, 1991). Uncinate processes are best d eve loped at C3 -6, but they are still evident down to T2 or T3 (Fig. 3.1). Thi s would infer tha t the upper bou n dar y of the cervicothoracic transition p robably begins at the level of the sixth cervical vertebra. As for the lower boundary of this transi tional zone, Panjabi et al. (1991 b) state th a t the thoracic spine can be divided into three distinct regions. The upper region is characterized by a narrowing of the end· plate and spi n al c a na l width from Tl to T4, while the
anatomy of the cervicothoracic junction 41
depths remained relatively constant. As a result, the width to depth radio decreases from Tl to T4, suggesting that the fourth thoracic vertebra repre· sents the lower boundary of the cervi co th oracic transition. The transitional zones of the human spinal c olum n fre quently show variations in their morphology as the ve rtebrae and zygapophysial joints assume the fea· tures of the adjace nt region (Schmorl and Junghanns, 1971; Fig. 3.2). In the cervicothoracic region this was t hou ght to involve more commonly the vertebral arch. There are, however, additional variations in the anatomy of this transition which will be discusse d in this chapter. Of aU the spinal literature the thoracic region has not received the same attention as the other reg i ons. There are numerous studies describing the cervical morphology using cadaveric (Veleanu, 1971; Med, 1973; Panjabi et al., 1991a), dr y specimens (Fran cis , 1955a, 1995b, 1956, Milne, 1991; Stanescll et al., 1994) or radiological techniques (Gilad and Nissan, 1986; Liguoro et al., 1994) as a basis for measure ment. LogicaUy these studies include the cervical vertebrae to the level of th e seventh cervicaJ and on rare occasions have included the flfSt thoracic verte· bra. There is a s mall er body of literature describing the morphological characteristics of the th ora cic vertebrae (Med, 1972; Veleanu et al., 1972; Taylor and Twomey, 1984; Scol es et al., 1988; An et al., 1991; Panj abi et al., 1991b). However within these studies a strong bias exists towards describing the lower thoracic region and its inter relationship with the lumbar spine. In addition , recent literature on the upper t horacic region has focused predominantly on pedicular anatomy relative to surgical stabilization techniq ues (An et al., 1991; S ta ne scu et al., 1994). Both of these studies report very small mar gins for error in insertin g pedicle screws due to the high degree of variability in the angie of attachment of the pedicle to the vertebral body. Stanescu et at. (1994) re ported a 7° difference in pedicle angulation between C7 and Tl and a total of 38° var iat i on from C5 to T5. The angle between t he pedicle and the lamina in th e sagittal plane was more conSistent, with only a 10° c hange between C5 and T5. However, 7° of change occurred at the C7- T1 junction. There are very few data available on th e upper thoracic vertebra e , fo c using sp eCifically on vertebral body and zygapophysial joint morphology. Panjabi et al. (1991 b) provided a three·d imension a l anatomical descr iption of all thoracic segments, and lower cervical segments (panjabi et at., 1991a), from only 12 cases. T his metric analysis provides linear and angular measures on the anatomical morphology of this transition. In recent work, we have disclosed gender differences fro m analysing cervicothoracic vertebral morphology. Using mean data, female verte brae were consistently smalJer than in males for the C6- T4 vertebral levels based on all ve rteb ral body
Copyrighted Material
42 Clinical Anatomy and Management of Cervical Spine Pain
heights and end-plate surface area measures (Boyle et al., 1966) Taylor and Twomey (984), in their morphological study of the thoracolumbar spine, reported that gender differences in spinal growth produce a more slender thoracolumbar spine in females than in males, as seen in the coronal plane. They postulated that the relatively thinner and taller vertebrae of females were potentially more unstable and may be related to the greater prevalence of progressive scoliosis in adoles cent females. A vertebral index (the superior end plate surface area divided by the posterior vertebral body height) was calculated (Boyle et al., 1996) and indicated a non-significant trend for a smaller index in females. However, for both sexes, the upper thoracic vertebrae are narrower and more slender than their lower cervical counterparts. In the trJnsitional zone at the thoracolumbar junction, differences in tIle pattern of transition from coronal to sagittal joint orientation have been weIJ described. Singer et al. (1989), in a prospective study of 630 routine thoracolumbar CT scans (TlO-L2), confirmed previous reports of a higher incidence of asymmetry between zygapophysial joints at these transitional segments and indicated the variability in the level at which the transition occurred. The morphology of the cervicothoracic transition was examined by Boyle et al. (1996), with particular reference to the orientation of the zygapophysial joint pairs relative to the plane of the superior end plate (disc-facet angle) and the sagittal midline (facet angle; Fig. 3.3). Measures were recorded from 51 disarticulated skeletons, totalling 306 vertebrae. There was a marked change in the disc-facet angle from C6 to Tl with a Significantly larger disc-facet transition in females (160 variation) than in males (140 variation). The incidence of asymmetry (> 1 00) between the left and right disc-facet angles was highest at theTl level (8%). Similarly, there was a high freqency of right versus left facet angle asymmetry (> 100) through the lower cervical (24% at C6 and 18% at C7) and first thoracic (16%) vertebrae; however, no gender differences were evident.
Motion characteristics at the cervicothoracic junction
Fig. 3.2 Morphological changes through the cervicothor· acic transitional region (C6- T4 vertebrae). Note the change in width of the ve r te b ral body, widest at TI, and the progressive i ncre a se cJudaUy in depth of the tho ra ci c vertebral bo d ies . Tile transverse process is widest atTl with a progressive posterior change in direction from Tl to T4 as the rib angle increases.
There have been many studies on the motion characteristics of the cervical spine (LyseU, 1969; Penning and Wilmink, 1987), but motion in the thoracic region is less well-studied (White, 1969). Recent studies performed by Milne ( 1993a, b) exam ined the motion characteristics between the second cervical and the third thoracic vertebra. The cervical spine was highly mobile compared with the thoracic spine and this is reflected in the results where a
Copyrighted Material
Clinical anatomy of the ce-rvicothoracic junction 43
Disc - facet angle
130 -.. en Q) Q) "-
0> Q) 0 Q) 0> C
«
Facet angle
100 .-------.---,
125 90 120 115
80
110 70
...... F -O-M
105
B
100
60 C6
C7
T1
T2
T3
T4
C6
C7
T1
T2
T3
T4
Vertebral level Fig. 3.3 Changes in orientation of the superior articular processes (zygapophysial joints) through the cervicothorJcic junction (C6-T4) using mean data from 51 cases (Boyle et al., 1996). Data fOf the disc-facet angle is given for males (M) and females (F) separately, while both male and female c1 at a are combined for the mean facet an g le results. A schematic representation of the angles is included (d elisc-fAcet angle, i.ii right and left facet angles). =
=
steady decline from tile C5 -6 mot i on segment to the upper thoracic segments was fo u nd , as depicted in
motion has relatively more tilting and less sliding within the disc ( Lyse II , 1969; Penning, 1988; Milne,
Fig ure 3.4. Due to the oblique orientat i on of the cervical
1993b).
articular facets, motion in the sagittal plane incorpor
cervical articular facets, the movements of rotation
ates some sl i din g as well as tilting within the cervical
and lateral flexion are coupled wi th i n the cervical
discs during flexion and extension. The centre of
spine so that rotation is accompanied by ipsilateral
Again,
due
to
the
oblique
orientation
of
the
rotation in the cervical region is situated well below
lateral f l ex i on. This motion can be considered to
the disc, within the sub j acent vertebral body. As you
occur about a single axis which is perpendicular to
move into the lower cervical and the thoracic motion
the plane of the zygapophysial joints, as seen in rhe lateral projection (pe nn i ng and Wilmink, 1987; Milne, 1993b). As the lower c ervical and thoracic
segments the position of this centre of mo t ion moves close to the intervertebral disc, indicating that the
Segmental ranges of motion and trauma patterns
20
C5-6
cs
C6-7
C6
C7-T1
C7
Tl-2
T1
T2-3
T2
TJ-4
TJ
'0
'00
200
300
Cases
Degrees
Fig. 3.4 Comparison of se gm enta l composite rotation (Milne, 1993b) and combined flexion-extension range of m oti on (White and Panjabi, 1990) for the vertebral segments of the cervicothoracic transition. The reduction in mobility from C5 [0 T3 corresponds with representative data for c ervica l trawna Oefferson, 1 927).
Copyrighted Material
44 Clinical Anatomy and Management of Cervical Spine Pain articular facets become more vertical (Fig. 3.3), the axis
of coupled
become
m ot i on
could
horizontal
more
ex p ec t ed
be
(involving
more
to
l ateral
Spinal curvature and weight transmission
flexion). However, the interfacet angles have been shown to have
a
bearing on the axis of coupled
The th o ra cic kyp h osi s has been shown to be high ly
1980;
motion (Milne, 1993b; Fig. 3.5). At C3 and C4 the
variable in normal
i nterfacet angles a re less than 1800 an d the orienta
Be rnha rdt and Bridwell, 1 9 8 4 ; Singe r et at., 1990b).
individuals (Fon
et
al.,
tion of the axis of coupled motion is c o n strain ed to
Bernhardt a n d Bridwell (1984) s tate that the kyph os i s
n ar ro w band p e rpe n d ic u lar to the facets. in the
in the t h ora c ic spin e us u a l ly starts at T 1- 2 (averaging
a
lower cervic a l and thoracic reg i ons where the interfacet angles are greater than 1800 (F ig. 3.3) the
at each
orientation of the axis of c oup l ed motion can vary
kyp h osis centred around the T6-7 diSC, is reached.
gre a t ly depending o n w h ether t h e app lied force was
Fon et at. ( 1 98 0) rep or t ed that females have a sl igh t ly
a b ou t 10 at that s egmen t) and incremental l y increases segment
c au d al ly until the apex of the
,
greater kyphosis and t ha t the ky p h o si s in both sexes,
axial rotation or lateral flexion.
,
tended to increase s l iglltly with age, with the upper
limits of normal in e l d erly adults being as high as 5 6
°.
In ad d i tion to soft tiss ue ageing, Fo n et al. (1980)
Axes of motion in the cervicothoracic spine
-
speculated that the increased kyphos is i n fema les was d u e to relative physical inactivity, probably related to
occ up ati on and that d e pe n d ent brea sts lUay further ,
accentuate the kyp hotic c urv a ture
.
The articul a r s u rfaces of the c ervical vertebrae not only regu l a t e the dire cti on and type of movement
but,
bec au se
of
their
oblique
inclination,
in
a
ventrodorsal directio n they also transmit the weight ,
of t h e head (Med,
transmission in
the
1973). In i nve s tiga t i ng we ight ce rvi c al
and
up p er
thoracic
regions of t he ver t ebra l co lumn compressive forces ,
are tho ug ht to be tra nsmitted through three para l l e l columns
in t h e cervical spine a n d through two
columns in the thoracic spine (pal and Routal, 1986).
Their st u dy pr o pose d that the transfer of load from the cervical to the upp e r th o ra ci c s p ine occurs at the
tran sition of the cervical and thoracic cu rva tur es
.
Th e y postulate three reasons fo r this: first, that there is a sharp decline in the zygapophysial joint surface area in t he upper thoracic region as co mpare d to t he cervica l regi on ; second, that the p e d ic les at Tl and T2 are l arge co mp a re d to tho se above and are inclined downwards and forwards fr om the lamina to
the bod ies, and finally, that the posterior column becomes more c l o se ly placed to the anterior column. Thus, putatively t h e re is a transfer of we ight transmis sion from th e posterior column in the cervica l region
Fig. 3.5
The axes of coupled
rotation in the cervicothoracic
laterdl flexion spine ee2 T2). -
and axial The solid
lines in dica te the axes of coupled motion when the applied force was rotary,
and
the i nter r upted lines indicate the axes
The
when the applied force was l a t er a l bending.
shaded
sectors indicate the range of p ossibl e orientations that the axes can ta ke. TIle axes
in th e
upper two motion s egments
are constrain e d to a very na r row band. The axes in the lower three
segm ent s
shown
can
take
on
a
wide
range
of
orientation, bu t the range of motion here is qui te limited. However
in
the middle three motion segments
where
disc
degen e rat ion is most frequent there is the greatest rd nge of motion and
the
axes have an intermediate range of possible
ce ntres of cervicothoracic spine.
orientations. The small Circles rep r esen t the rotation for sagittal motion in the Adapted from
M i l ne
(l993b).
to the anterior column in the thoracic region. However, to facilitate weight transmission in this
region a p rop or tiona te increase in t h e surface are a of the ver teb ra l bodies in the u p pe r thoracic spine would b e ex pecte d yet this is not the c ase (B o yle et ,
al., 1996). T his may indicate why this c o uld be an
area
where stress is co n c en trate d
.
Similarly,
one
would po stu l at e that there should be an increase in bone mineral density at the cervicothoracic j unction
.
However, the b one mineral d e n s i ty of the seventh
2
cervical ver tebra (approximately 0.6 g/cm ) is sig nificantly l o wer than the levels above (Curylo et at.,
1996). The bone mineral density further d ecrea se s at l t h e first thoracic vertebra, approximately 0.45 g/cm , and a p p roxinlat e ly 0.35 g/cm2 w e re recorded for the
Copyrighted Material
Clinical anatomy Of the cervicothoracic junction 45
second and third thoracic verte brae (Singer et al.,
1995) Based on these find ings any added stress, due to the
population (Fon et al., 1980; Dalton, 1989; Singer et al., 1990b). G riegel-M orris et at. (1992) also studied altered head
pOS ition ,
su ggestin g that there
is a
rela tion ship between the presence of some postural
putat iv e transfer of weight to the a nterior thoracic column, would be applied to a narrower and more
va ri ations and the i nc i d en ce of pa in . They investi
slender thoracic vertebra with a lower bone mineral
gated 88 healthy subjects, aged 20-50 ye a rs, and
de nsity. It is proposed that, in co mbin ation , these
reported that subj ects with increased kyphosis and
in part, contrib ute to the higher
rounded s h oulders had an increased incidence of
findings
may,
inciden ce of d egen er ative ch anges
in
the zygapophy
interscapular pain. Ad ditional ly those s ubjects with a
sial joints reported at C7- Tl, and to the continui n g high incidence of d i scal degenerative changes repor
fo rward head posture hacl an in creased incidence of
ted in the u pp er thoracic region (Boyle et al., 1997).
cervic a l and int ras capular pains and head ache. There was no relationship, however, between the severity
of the post u ral ab nor mality and the s everi ty and frequency of pain. Oegema and Bradford (1991) posed the hypot hesis
Transitional anomalies
that a decrease in disc space may lead to al t ered mechanics of the zygapophysial j oints a n d that the
The incidence of cervic al ribs is thou ght to be about
1 % of the pop u lation O ones et al.,
1984),
changes in motion a n d/or pressure on th e se joints
with
ma y lead to degenerative change. However, Malmi
approximately one-half of these c ases being bilateral.
vaara et al. (1987), in investigating the thoracolumbar
Jones et at. (1984) repor t that these ribs vary from
region, repor ted that anular di srup tion of the disc
remnants emanating from the seventh cervica l verte
was not related to zy ga pophy si a l joint asymmetry, nor
bra to comp lete ribs a rticul at i ng with the manubrium or first rib. Gladstone and Wakeley (1932) described
was t her e an increas e in zyga pophysi al joi nt osteoar
10
cases
of
ce rvica l
ribs and
rudimenta r y
throsis , a l tho ugh,
at Tl1-12, facet
j oin t asymmetry
first
was associated with m ore OA on the side with the
thoracic ribs. Coup led with a review of the literature, indicated that these anomalies were d evel op m e nta l defects prob ably occurring in the ea rly
more s agit ally oriented facet. This fi nd in g was con
stage of embryonic life. Ano m ali es in the nervous and
joint d egene rat ion affect in g the m ore s a gitaLl y ori
they
vascular systems were frequently associated.
sistent with a re port by Giles (1987),
a necdotal
histo logical
evidence
of
who noted
zygapophysial
ented j o i nt as c o mpared to the joint oriented to the
Variations in the morphology of the first rib may
coronal pl a ne , from an ex aminat ion of the lumbo
have a causative role in thoracic o u tlet s y nd rome. A
sacral trans i tion . Similarly, Farfa n and S ulli van (1967)
thick or abnormally curved first rib m ay comprom is e
reported a high correlation between as ymmetrical
the neurova scular bundle in its passage about this
orientation of the zygapop hysia l joints and the level
region and is often associated with changes in the
of disc pathology,
muscul a r
scalenus
prola pse and the side of the more oblique oriented
anterior ancl meclius. Similarly, an anomaly of the
joint in patien ts with low back pain with sciatica. By
attachments
to
the first
rib ,
and
between the side of disc
clavicle can lead to a pincerlike action between it an d
comparison, Hagg and Walln er (1990), in a study of
tl1e first rib Oones et al., 1984).
47 ca ses of lumbar disc protrusion,
were of the
opinion that there was no relationship between facet a symmetry and intervertebral disc prot rusi o n . At the
thoracolumbar junction, the v ar iabi lity in zygapophy
Vertebral degenerative changes
sial joint orientation was not shown to influence the d egenerative
There is lim ited literature on clegene ra ti v e changes of the
vertebrae
of
the
cervicothora c i c
junctional
p a tter n s ,
on
of the zygapophys i al jOints of the ver tebral column
orientation
and reported an increased incidence of disease in the
remains inconclusive.
cervicothoracic junction - a flilding he termed t he peak.
Shore
s pecul ated
that
the
histologically,
of
recorded for the cervicothora cic junction the debate
region. Shore (I935) consiclered osteoa rthri t is (OA)
cervicodorsal
recorded
these joints (Sin ger et al., 1990a). With no da ta as yet the relationship between anel
vertebral
zygo p op h ysial
d egenerative
joi n t
p atter ns
In addition, the ana lysi s of assoc ia tion between zygapophysial joint degeneration a nd zygapophysial
ex p lanation for this flilding may lie in the al t era t i on of
jOint asymmetry must be a ppro a che d
the col umn in ord er to maintain the p O Sition of the
degree
head in the upright posture on a changing thoracic
normative dara on aged zyg a po ph ysi a l joint appear
of
caut ion .
There
appear
to
with some be
limited
kyphosis. The cha ng e in direction (infl exio n ) of curve
ance and in par tic ul a r what constitutes degenerated
coup led with different fu nct i onal demands might
j oint appearance. Fletcher et al. (1990), in a small
tend to localize stress on the cervicothoracic zygapo
series of 20 cadavers, demonstrated that the m ajority
ph ys ial joints . Certainly there h as been su p port for an
of
increasin g
normal appearance. They reported that, in cadaveric
thoracic
kyp hosis
in the aged female
cervical
Copyrighted Material
zygapophysiaJ
joints
do
not
have
a
46 Clinical Anatomy and Management of Cervical Spine Pain spe c im en s, 37 years of age or o ld er, ar ticu l a r carti la g e is redu ce d to a thin, d i sco l o ured or mi c ros cop i c lay er and that menisci are non-existent. In contrast, Bland (1994) showed synovial folds (menisci) with cervical facet j oin ts to be a comm o n occurrence across the a ge spa n. Fletcher et at. (1990) ind icated that about h alf of t h e ce rvical j o ints in adults have thickening of subchondral bone or osteophytes, as well as cartilage loss. In pa tic ul a r the lower and mid cervical l eve l s were u s u al ly more seve rely affected. T hese data are supported by Frieden berg and Miller (1963), who reported th a t 25% of th eir asymptomatic patients demonstrated degenerative cha ng es on radiographi c ex a m ination by their ftfth decade and by the se ven t h decade, 75% showed roentgenographic d eg en erativ e changes. S imil a r l y analysis of dege nera tive changes of the intervertebral dis c s must be a p p roache d with some caution. Ten Have and Eulderink (1980) rated cervical discs on the presence or absence of di scal splits. The r
limitation with the Ten H ave and Eulderink (1980) disc a na lys i s is that c lefts may be found in the middle of hea l rhy cervical dis c s on c o ron a l ins pec tio n (Tondury, 1959, 1972; Bland, 1994). These clefts may starr to appear in the uncovertebral j Oint regi on as ea r ly as 9 y ea rs of age. Tondury (1959) and EckJin (1960) both deny t h a t the formation of uncovertebral fissures in the cervical intervertebral d i scs should be regarded as a degenerative process. Of p art i cul a r interest, given the proposed ef fects of the uncovertebral joints in the development of discal clefts, is the influe nce of t h e ribs in theif articulation with the thordcic discs. luschka (1858) suggested that th e tUlci ll ate pro ce sses are hom ologou s with the rib h eads This postulation has gained some support in the literature (Bull , been specul ated t h at the contact of th e rib head with the fibroc art i lag e of the a n ulu s may prod uce the same kind of changes as seen in u nco v e rtebra l joints (Milne, 1993). F igu re 3.6 demonstrates the similarity between
,
.
,
Fig. 3.6
Coronal
sections through the
(A)
cervical
and
(B)
upper thoracic human spine
demonstrating carbon particles in the uncovertebral j oin t s ami the costovertebral joint of
the
second rib (arrows) foUowing injection of suspended carbon into the centre of the intervertebral discs.
The
migration of carbon within these joints demonstrates fissures within
communication with the costovertebral
and
ullcovertebral joints.
Copyrighted Material
the disc tissue and
Clinical anatomy of the cervicothoracic junction 4 7
the uncovertebral and costovertebral joints wi th leakage of radiopaque dye from upper thoracic discograms into the costovertebral joints. Given the scarcity of litel�lture on degenerative patterns of the intervertebral disc through the cervicothoracic transition, 96 vertebral columns from the sixth cervical to the fourth thoracic vertebra were studied (Boyle et at. , 1997). The disc-grading scale of Ten Have and Eulderink (1980) was used, com plemented by the categories of discal changes of Nachemson (1960) which has previously been used to rate lumbar discs. Comparison with other studies was limited to previous cervical investigations. How ever, data from this study compared favourably with the ftndings of Ten Have anet Eulderink (1980). Analysis of these cases revealed that there was a decline in the incidence of degenerative changes in the intervertebral discs from the C6-7 to the T1-2 segments. However, there was increased incidence recorded at the T2 -3 segment and comparable results at the segment below, which was more consistent with the lower cervical findings (Fig. 3.7). This increaSing incidence is surprising given the presumed stabilizing effect of the thoracic cage and increased stiffness of the thoracic spine (Panjabi et at. , 1976). The high frequency of degenerative findings in the mid cervical spine is well-documented (Fletcher et al. , 1990; Milne, 1991). This finding relates to the combination of disc-facet and interfacet angles seen in the mid cervical vertebrae which allows for larger anteroposterior translation during sagittal motion and a greater freedom in combined lateral flexion and axial rotation (Milne, 1991; Milne, 1993a,b; Fig. 3.5).
This pattern of movement is thought to result in greater shearing forces in the intervertebral discs (Tondury, 1959). The variations in orientation of the zygapophysial joints through the cervicothoracic transition may in part account for the discal degenera tion in the upper thoracic spine. Unfortunately a causal link between the angular asymmetries and the pattern of discal degeneration in the cervicothoracic junctional region could not be measured in our study (Boyle et al. , 1997) due to prior autopsy procedures rendering measurement of zygapophysial configura tion impossible. In inspecting degenerative changes in the cervico thoracic transition, significant trends with respect to age were identified (Boyle et aI. , 1997), consistent with the view that there is an increasing frequency of degenerative lesions with ageing of the human spine. In the youngest age group 0 1 - 29 years), 75% of a ll discs were graded normal, with the majority of the remainder demonstrating minor lesions. Ratings of normal declined steadily through the age categories, with the 30-49-year group recording 62% of all discs as havi.ng no degenerative lesions and the 50-69-year group scoring 57%. In the oldest age group (greater than 70 years), only 42% of all discs were graded normal anc!, of the remainder, over half were moder ately to severely degenerated. The frequency of osteophytic lipping decreased dramatically from the C6-7 vertebral segment and thereafter remained constant in frequency into the LIpper thoracic region (Boyle et at. , 1997). The lowest incidence of marginal vertebral osteophyte formation occurred at the C7 T 1 vertebral segment. The report -
Segmenta l patterns of degenerative chan ges C6-C7 C7-T1 T1 -T2 T2-T3 T3-T4 10
o
Disc degeneration (Ten Have) (Nachemson)
End-plate lesions
Osteophytes
Fig. 3.7 G ra ph i c a l s u m m ary o f til e incidence of degenera tive changes for tile vertebra l segments of the transition from sagittal m i d l ine inspectio n of 96 verte b ra l columns, b a s e d o n t w o rep orted scales of d i scal dege n e ra t i on (Nacll e m s o n , 1 960; Ten Have and Eulderi n k , 1 980) . Patterns of end-plate lesions and ourgi n al osteophyte formation are a l so presente d . In generdl, t h e last cervical (mobile) segme n t tends to be affected most. Modified from Boy l e et at. ( 1 997).
Copyrighted Material
48 Clinical A natomy and Management of Cervical Spine Pain by Natha n
( 1 962)
sh o wed a similar trend, suggesting
t ra n S I t i o n
f rom a very mobil e cel-vica l spine to th e
th a t Tl and T2 were least l i ke ly to d e velop an ter i o r
re l a ti vel y rigi d thoracic s p i n e . Ro g er s et at ( 1 980) ,
ve rte b ra l body os t eophytes in the w h o l e ve rtebra l
rev i e w ing 35 cases of upper thoracic s p inal trauma,
column. I n co ntrast, Nathan added t h a t
C 6 had
the
searched fo r pattern s of r e s ul tan t booy lesio n s . They
hi gh e st freq u e ncy of osteop h yt e fo rmation in the
report e d a b a s ic p a t tern of i n j u ry occu rri ng in 2 2
c e rv i c a l sp i n e . The com pa rison of d iscal degenera t i ve
c a ses
changes , as d e fin ed by N a che m so n ' s grading, with the
vertebra e
inc idence of os teop hyt e presen c e , i ndicates that if the
a n te riorl y. Ad d i tion a lly, associated s e c o n d a ry spin a l
with
a
fra c tu r e
wi th
i n vo lvi ng
s up e r i o r
the
two
verte b rae
con t iguo u s d islocated
not
inj u rie s w e r e conun o n ( 1 7% i n cid e n c e ) a nd lI s u a lly
c o mmo n . H owever, in t hi s series o f 96 cases, one-third
represented a hyperexte n s i o n in j u ry of the u pp e r
of the
cervi c a l sp in e .
d i sc
is
normal
then o steo ph yt e fo r m a ti o n
d ege n e ra ted
is
inte rvertebral d i scs were not
associated with evid e n c e of os teo p hyte formation on s a g i tt al mi dl i ne in sp ect i o n .
Dislocation or fra ct u r e d islocation at the C7- T l
l evel s i s a rare i n j ury. Eva n s ( 1 983) re p o rted 1 4 cases
The rel a tionship be tw ee n the presence of ce rvica l
fro m 27 yea rs of s p in al i nj u ry m a n a ge ment at his
of
centre, o u t of a s e r i es of 587 cel-vical t ra u m as. A s i m i l a r
symp toms was studied by Frie d e nberg a n d M iller
th e incidence o f cha nges a t t h e po sterola te ra l m argin s
inci dence rate is rep o r t e d by All en et al. ( 1 982), who record ed 1 0 ca se s from 1 6 5 lower ce rvi ca l inj u ries over 1 5 years. In a n o ngoing review o f spinal inj u r cases from the S ir Geo rge Bed b rook S p i n a l Unit at t h e Roy a l Perth R e h a b W t a t ion H o s p i tal , Western Aust ral ia (Bo y l e , u n p u blis h ed ) 6 ca ses have b e e n identifi e d .
of t h e vertebra l bodies, t h e in te rverte b ra l fo ramina o r
T h i s series rep rese n ts a n l l -yea r re view ( 1 98 5 - 1 995)
degenera tive
lesions
and
p a tie nts '
co m p la in ts
( 1 963) in 1 60 asymptomatic patients and compared 92 of them to age- a n d gender-ma tched p a t ients w i t h cel-vical pain . Us ing ra d iogra p hi c e x am i nat i o n t h ey reported no d iffe re n c e between these two groups i n
y
,
t h e zygap ophys i a l j o ints . T h e associati o n , by these
out of a to tal of 865 spinal i nj u r y cases. Five of the 6
authors, betwe e n postmortem observations and clin
cases reflect the basic pa t t e r n d escribed by Ro ge rs et
i c a l p ain syn d ro m e s w a s co n s ide re d te n uous .
al. ( 1 980) , and w o u l d be c l a s s ifi e d u n d e r the dis tractive-flexion category ( A ll e n et aI. , 1 98 2 ; Fig. 3 . 8) , a l though
a ro ta r y component a p pears to b e an
a dd i tio na l fe atures i n two cases. The final ca se is
Spinal trauma
co n sis t en t with the vertical compression category Ll s i ng th i s c l a ssifica tion (re p rese n ted in F i g . 3 . 9) .
Transiti o n a l regions of the h u man sp i n a l column a re
There a p pea rs t o be gen e ral
consensus i n t h e
considered to be vu lnera ble to inj u ry d ue to the
litera tu re t h a t , a l th o ugh these l e s i o n s are u ncommon,
a br u p t changes in vertebral morphol ogy wh ich alter
they are easily m i ssed and cl oser s cr u t i n y is re q u i red
sp inal mechan ics and load tr'd. nsmission (Kaza r ia n ,
when ex a m i n i n g tra u m a i n th is reg i o n , Eva ns ( 1 983)
1 98 1 ) . The biomecha n ics o f the cervicothoracic j u nc t ion a re co n s id ered so mewha t u ni qu e d u e to the
re p orted that nea rly two-third s o f all cases reviewed were not pro p e rl y d iag n o s ed Oll a d mi ss ion and that
Mecha n i s m s of cerv i c ot h o rac i c j u n ct i o n t ra u m a
Fig. 3.8 The
ty pical
mech a n i s m s o f i n j ury resulting i n
cervicothoracic j u n c t i o n i s extreme flexi on (A).
rotation, fractures .
without
frac ture - dislocations a t
B shows axial
the
c o m p ression with o r
Hyperexten s i o n (C) c a n res u l t i n posterior j o i n t complex compress i o n
Copyrighted Material
Clin ical anatomy of the cervicothoracic junction 49
e lements . In the l a rge p a t i e n t magne tic resonance ,
imaging of the cervicothorac ic ju n c ti o n p rov i d e s a
more detailed i nve stig at i on and is c ons i de red t he
examination of choice if fra ctu re or fracture - disloca tion is sus p ec te d (Ke rslake et at. , 1 9 9 1 ) . An added ad v an t age i s th a t magnetic resonance im a g i n g is also
c ap ab le of demonstrating oedema a nd h a e m o rr h age within the sp i n al c o r d .
C o m pli cat i o n s fo ll o w i ng
acic
region
a re
trauma
to the cervicothor
w i t h An
common,
et al.
( 1 994)
repo rti n g 28 out of 35 c a se s presenting wi t h ne u ro logic al deficits. In t h e 1 4 cases re p o r ted by Eva ns
( 1 983), 1 1 we re associa ted with the spinal cord ,
a
comp lete l e s ion of
all re m ain ed complete. These
a nd
findings m ay in p art , be reflective o f t he decrease in ,
canal size i n the thoracic s pine .
Fracture of the vertebral body of the first thoracic vertebra is very rare and usually involves grea t fo rce . This is though t to reflect the sta b i lizin g effe c t of th e first rib Oones et at. , 1 984). Fracture s of the spinous processes of either C7 o r T l , m o re commonly known shoveller'S fra c t u re s a re
as
t h ough t to
be
stress
fractures due to re pe t i t i ve muscular acti o n . F i r st rib frac t ures can be e i ther anterior or po ste rior with t h e ,
l a t t e r often i n vol v ing the costotldl1sverse a rtic u l a tion a n d the tran sverse p ro ce s ses o f C7 and Tl Oones et
al. , 1 984). The question a rises as to whether the m o rp ho
,
logical v a r i at i o n s evi dent in the transitional regions of
the
s pin e
influence
degenerative c h ange s
the .
patterns
of t raum a
and
In the thoracolu m b a r tra n s i
tional re gio n Singer et at. ( 1 989) compared a series of
630 normal pa t ien t co m pu t ed t om o gra ph i c sca ns scans of 44 p at i e n ts with thoraco l u m b a r
with
in j u ri es
.
Th e y concluded that individ uals with a n
a br up t transition
Fig. 3.9 Tra nsverse p l a n e c o m p u te d tomogra p hic sca n of the cervicoth o ra c i c jun c t i on from an 1 8·yea r,old male in vo l ved i n a rol l over motor veh icle accidem. Scan A demonstra tes a c o mm i n u t e d b u rst fra c t u re of C7 with a lmost c o m p lete ablation of the spin al canal and i n volve ment of the artic ular processes. Scan B demonstrates a cleaved fl�lcture of the body of T I with assoc iated frac tu res of tile left l a m ina and cemral s pinous p roc ess . The neu ro logical lesion resulted in an inc o m p l e t e q u a d r i plegia below C6 and c o m p l ete qua d r i p legia below T I . Th is case i l l ustra tes the vi ol e m n a t u re of cervicothora c i c j u n c tion in j ury.
of thoracol umbar j u n c tion mortice j o i n t s was d e mon·
strated in the inj ury gro u p . There has not been a sintiJar i n vestiga ti on of th e cervico thoracic j u nct i on re p o rt e d .
Clinical anatomy The
with dislocations at the ce rvi cot h o ra ci c j u nc tion re qu i r e
had a greater p re dis p os i t io n to
to r sio n a l inj u ries at t his j un c t i o n . A h i ghe r in cidence
cervico thoracic
the
other
transition
j u nctional
appears
regions
consistent
o f the
spin e .
Marked cha nges in verte b ral morpho logy o c c u r at
carefu l scrutiny. The d iffi c u l ty l i es in the i n a bil i ty of
the
routine l a tera l ra d i ogra phs to id e ntify I.esions unless a
fea t u res of the thoracic regi o n . Changes occur in
' swimmer's p ro j e c t i o n ' technique is us e d (Fig . 3 . 10) .
The
l at e ral X-ray is taken w i th
th e p a tient s a r m '
tran sition
as
the
cervical
sp ine
assumes
the
the o r i enta ti on of the zygap o p h y s i a l j oi n ts t h rough the transition an d the incidence of fac e t trop ism is
elevated above t h e h e a d w i th the oth e r arm pe rpen·
s u c h that care w h e n
dicu l a r to the body. D esp i t e better v i s u a li zation of the
te s t in g of individual segments is necessal-y. Add i t ion
upper thotdcic spi ne
ally, accessory gliding of these segments may test
with this
technique,
tomo
graphy i s con si d e red essen t i a l to reflect the true status
of
the
vertebral
body
and
the
po s terio r
int e rp re ting pas sive m a n u a l
with va riations in ra n ge and quality of movement
i r respect i ve of the presence o f pathology.
Copyrighted Material
G rieve
50 Clinical A natomy and Management oj Cervical Spine Pa in
A
B
Fig. 3. 1 0
Swimmer's view X·ray
(A) , with
associated o u tline
(B),
to il l u strate a b i l a teral d islocation a n d fracture of C7 on
Tl
i n a 26·year·old m a le following a motor vehicle a c c i d e n t .
( 1 994)
rec ommends cau tion, b o t h i n interpreting
apparent treatment
abnormal using
motio n ,
manual
and
in
the rapy
the
at
the
na t u re
References
of
thoraco
Alle n , B. L. , Ferg u s o n ,
D e sp i te
the transitional variations in verte bral morphology, it would be s purious to associate the vari atio ns described here with increased likelihood of changes
in
e i t h e r the
zygapophysial
j o ints or interve rte bral disc. Given the relatively h igh incidence of degenerative disc changes a nd zygapo
An ,
H . S . , G o rd i n ,
R.,
2 5 5 7 - 2564 . the
saginal
cause of p ati en ts ' sympto m s . Based on upper tho
7 1 7 - 72 1 .
racic vertebral body morphology, and the post u lated weight transmission, this region is potentially an area of localized s pinal stress . The upper thoracic s p ine wit h
this
increased
Bla n d , J , H . ( 1 994)
kyphosis could be loo ked upon as fur t h er accentuat
normal thoracic and
Spine 14:
j u n c ti o n .
Disorders of the Cervical Spine ,
2 n d ed n .
P h il ad e lp h i a : S a u n el e rs . Boyle,
HW., S inger, K . P ,
M ilne , N. ( 1 996) Morp holog i c a l
su rvey of the cervicothoracic j un c ti o n a l re g io n
loa d i ng .
Deterioration in posture with an increasing thoracic
of the thoracolumbar
p l a n e align ment
l umbar spines a n d
assist
Spine 7: 1 - 2 7 . K . ( 1 99 1 ) An atomic consid era fi x a t i o n of the cervi c a l spinc. Spine
Bernh ard t, M . , Bridwell, K . H . ( 1 984) Segmen tal a n a lysis of
ribs
A
16: 554 8 - 55 J An, H . S . , Vaccaro, A . , Co tl e r, ) . M . , Un, S. ( 1 994) Spina l disorders at the cervicoth oracic j u nctio n . Spin e 1 9 :
a cic j u nct i o n should not be overlooked as a possible
the
et al. (1 982)
Ren ner,
t i o n s for p l a te screw
p h ys i a l jo int d egenera tio n reported , the cervicotho r
and
Leh m ann , R . R .
dislocations of the lowe r c e rv i ca l spin e .
the cel-vicothoracic j u nctio n .
degenerative
R.L.,
mec h a n istic classi fication of c1osc d , i n d i rect fractures a n d
l u mb a r transi t i o n . The sam e advice is suggested for
5 4 4 - 54 8
Boyle , ] I W. ,
Singe r,
Copyrighted Material
M il n e ,
N.
Spine 21:
( 1 997) I ntervertebral
e1isc
degenera t i o n in the c e rvi c o t h o racic j u n ct i o n a l regio n .
Manual Therapy
ing the stress in this transitional region.
K.P,
.
( i n press) .
Clinical anatomy of the cervicothoracic junction 51
BuU, J , W D . ( 1 948) D isc u s s i o n on ru pture o f the i nter vertebra l d isc in the cervical regio n . Proc. R. Soc. Med. 4 1 : 5 1 3 5 1 6. C u ry lo L.J. , Lindsey, R. W , Doh erty, BJ et at (J 996) Segm e ntal va ri a t i o n s of bone m i neral de n sity in the cervical spine. Spine 2 1 : 3 1 9 - 3 2 2 . Dalton, M . B . ( 1 989) The effect of age on cervical posture in -
,
a normal female popula t i o n . I n : Manipulative Therapists H . M . , Jones , M . A . , Milde, M . R . , eds) 6: 34 - 4 4 , Adel a i d e , South Au s tralia : MTAA. Ec kl i n , U. ( 1 960) Die A ltersvercmderungen del' Halswirbel Association of A ustra lia Ganes,
saule. Berl i n : Sp ringer-Ve r l a g .
Liguoro, D., Van dermeersc h , B., Guerin , J ( 1 994) Dimen sions of cervical v e rte b ra l bodies acco rd i n g to age a n d s e x . Surg. Radiol. A nal. 1 6 : 1 49 - 1 5 5 . Luschka, H . ( 1 858) Die Halbgelenke des menschlichen Korpers. Berl i n : Rei m e r. LyseU, E. ( 1 969) Motion in t he cervical spine. An ex p e r i mental srudy on autopsy s peci m en s . A cta Or/hop. Scand. Stlppl. 1 23 : 1 - 6 1 . M a Lm ivaara, A . , Videman, T. , Kuosma, E. et al ( 1 987) Facet joint orientation , facet and costovertebral jOint osteoar tilrosis, disc d ege neration , vertebral body osteophytosis and S c h mo rl s nodes i n the thora c o l u m bar j u n c t i on a l region of cadaveric s pi n e s . Spine 1 2 : 4 5 8 - 4 6 3 . Me d , M . ( 1 972) Ar t i c u lations o f the thoracic ve r teb rae a n d t h ei r varia bi.l i ry. Folia Morph. 2 0 : 2 1 2 - 2 1 5 . Med , M . ( 1 973) Ar ti c u l a t ions o f the c e rvical verte b rae a n d the i r v a r i ab Ui ry. Folia Morph. 2 1 : 324 3 2 7 . Mestdagh, H . ( 1 976) Morphological aspects and biomechan ical properties of the vertebroaxia l joint (C 2 - C3). Acta Morph . Neerl·Scand. 1 4 : 1 9 - 3 0 . Milne, N. ( 1 990) ZygapophysiaJ j o i n t orientation reflects t h e r o l e of u ncin at e processes in the cervical spine. I n : Fourth '
Evans, O . K . ( 1 983) D i slocations at t he c e rvicothoracic j u nction. } Bone jo int Surg. 65-B: 1 24 - 1 2 7 . Farfan, I-I . E , Su l l iva n , J. D. ( 1 967) T h e re l a t ion o f facet orientation to interverte bral d isc fail u re . Ca n. } Surg. 1 0 : 1 79 - 1 8 5
-
F l e tch e r, G . , Haughto n , \1 M . , 1-1 0 , K C .
et at. ( 1 990) Age
related changes in the cervical facet joints: studies with cryomicrotomy, MR and C'T. A J R. 1 5 4 : 8 1 7 - 82 0 . Fon , G.T. , P i tt, M.) . , Thies, A . C ( 1 980) ThoraCic kyphosis: ran ge in normal subjects. A J R. 134: 979 - 98 3 . Francis, c . c . ( l 95 5a) Dim e n s ions of the cerv i c a l v e r tebra e . A naL Rec. 1 2 2 : 603 - 609. Francis, C c . ( 1 9 5 5 b) Va riations in the a rti c u l a r facets of t h e cervica l vertebra e . A nat. Rec. 1 22 : 589 - 60 2 . Fra n c is, C . C ( 1 956) Certain changes i n t h e a ge d m a l e wh i t e c e rvical spine. A nat. Ree. 1 2 5 : 783 -787. Friede n berg, Z . B . , Miller, WT ( 1 963) Degenera tive disc disease of t h e cervical spin e . } Bone joint Surg. 4 5 -A : 1 1 7 1 - 1 1 78 . Gilad, I., N issan , M . ( 1 986) A study of vertebra a n d disc geom e t ric re lations of th e h u m a n cervi c a l and l u mbar s p i ne. Spine 1 1 : 1 54 - 1 5 7 Giles, l.G E ( 1 987) Lu m bo-sacra l zygapophyseal j O in t tro pism a nd its effect on hyaline ca r til age . Clin. Bio mechanics 2: 2 - 6. G l adstone, R .). , Wa ke ley, c . P G. ( 1 9 3 2) C e r v i c a l ribs a n d rud im en tary fi r s t t h o racic r i bs considered fro m the clinical and etiological stand points . } Anal. 6 6 : 3 3 4 - 370 G riege l - M o r r i s , P, Larso n . K., M uell er-Kl a u s , K . et al. ( 1 992) Incidence of common postural abnormalities i n ' rhe cervica l , shoulder, a n d thoracic regions and thei r associa tion with pain in two age groups of healthy su b jec t s . Phys. Ther. 7 2 : 4 25 - 4 30 . G r i e v e , G. P. ( 1 994) Bony and s o ft tissue a n o m a lies of t h e ve rtebral c o l u mn . In : Grieve 's Modern Manual Therapy: The Vertebml Column, 2 n d edn ( B o yli ng, ] . D. , Pa las t an g a , N . , e d s) . C hu rchj ll LiVin gs t o n e , p p . 240 - 24 1 . Hagg, 0 . , Wa ll ne r A. ( 1 990) Facet join t asymmetry and protrusion of t h e i ntervertebral disc. Spine 1 5 : 3 5 6 - 359 Hall, M . C ( 1 965) Luscbka 's joint. Springfie l d , 1L: T h o m a s . Jefferso n , G . ( 1 927) Discussion o n s p in a l injuries. Proc. R. Soc. Med. 20: 62 5 - 63 7 . J on es , M.D., Edwards, K . C . , O n g , E. (I 984) T h e cervicothor acic j u nction on chest rad iogra p h . Radio/. Clin. North Am. 2 2 : 4 87 - 4 96. Kaza rian , L ( 1 98 1 ) Injuries to the human sp in a l colum n : biomechanics a n d i n j u ry classitlcation . Ex. Sp ts. Sci. Rev. ,
9: 297 - 3 5 2 .
Kersl ake, R . W , Jaspa n , T , Wort h in gto n , B . S . ( 1 99 1 ) M a gnetiC
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Human P , e d ) . Ned lands, Western Au s t ra l ia : Cen tre for Human Biology, UWA , p p . 1 7 1 - 1 85 . M il ne, N. ( 1 99 1 ) The role of zygapophyseal jo i n t o r i e n tation and uncin a te p rocesses in conrrolling m o ti o n in m e Conference of the A ustmlasian Society for
Biology (O ' H iggins.
.
cervical spine . } A nat. 17 8 : 1 89 - 20 1 M i l n e , N . ( 1 993a) Compamlive artCltomy and function of the uncinate processes of cervical vertehrae in humans and other mammals. Ph D thesis , Universiry of We st e r n Aus tralia .
Mil n e ,
N. ( 1 99 3 b) Composite motion in cervical Ctin. Biomechanics 8 : 1 93 - 20 2 .
disc
segmen t s .
Nachemson, A . ( 1 960) Lumbar intradiscal press ure. Acta Orthop. Scand. Suppl. 4 3 : 2 5 - 1 04 . Nath a n , H . ( \ 962) Osteophyte, o f the ve rt e bra l co lumn . An a n a to m i c al study of t h e i r development according to age, race and sex with c o n s ideratio n s as to thell' e t io logy a n d s i gnifi canc e . } Bone jo int Surg. 44·A: 2 4 3 - 268. Oegema, T. R . , Bradford, D.S. ( 1 99 1 ) Th e inter-relationship of facet j o in t osteoa rth ritis and degenerative disc di se as e . Br. ) Rheumatol. 30: 1 6 - 20 . Ove rto n , L. M . , G ro s s m a n , ].W ( 1 9 5 2 ) Anatomical variation in the a rti c u l a t i o ns between the second and third ce rvical ve r te bra e . } Bone joint Surg. 34-A: 1 5 5 - 1 6 1 . Pal, G. P , Routa l , R . V ( 1 986) A study of weight tra n smission through the cervical a nd u pp e r thoracic regions of the ve r te b ra l column in m a n. } A nat. 148: 245 - 26 1 . Panj a b i , M . M . , B ra n d , R . A . , White, A . A . ( 1 976) Mechani c a l p roperties of t h e h u m a n thoracic s p ine . } Bone JOin t Surg. 5 8 - A : 64 2 - 6 5 2 . Pa n j a b i , M . M . , Durancea u , ]. , Goel , V et Ci t. ( 1 99 1 a) Cervic a l human vertebra e . Quantitative three-d imensional ana tomy of the m i d d l e a n d l ower regions. Spine 1 6 : 86 1 - 869. Pa nja b i , M . M . , Ta kata, K., Goel, V et a l. ( 1 99 1 b) Thoracic h uman vertebra e . Q u a n ti tat ive three-dimensional ana tomy. Spine 1 6 : 888 - 90 1 . Penning, L. ( 1 988) Differences in a n a t o my, m otion, develop ment and ageing of the upper and l owe r cervical disc se gm en ts . Clin. Biomechanics 3: 3 7 - 4 7 . Penning, L . , Wilmink, ] . T ( 1 987) Rotation of t h e cerv i c a l sp ine . Spine 1 2 : 7 3 2 - 73 8 Rogers, L. E , Thayer, C , Wei n be rg , P E . et ai. ( 1 980) Acute
Copyrighted Material
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Clinical A natomy and Management oj Cervical Spine Pain
inj u r i e s o f the u p p e r thoracic
s p in e
1 3 4 : 67 - 7 3 . Jungha n n s , H . ( 1 97 1 ) The
asso c i a t e d wi t h
Sta nesc u ,
Sch mori, G . ,
Healt}]
S.,
Ebrahei m ,
N.A.,
Yeasting,
R.
et al.
( 1 994)
M o r p h o m etric e v a l u a t i o n of the c e rvico-t horacic j unc
p a raplegi a . A J R.
tio n . Practica I considera t i ons of poste rior fIXation of t h e
Human Spine in
1 9 : 208 2 - 2088.
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( 1. 997) B i o m e c h a nics of t h e
The
B. et al. ( 1 988) Vertebral morp h ol ogy: s p i ne
Shore,
the
normal
1 08 2 - 1 086.
L.R.
vertebral
Twomey,
I f.A. M.]. ,
8 3 3 - 849
K . P ( 1 996) C lin i c a l a na t o my of t h e t h oracol u m bar j u nc t i o n . In : Clin ical A n atomy and Management of Low Back Pai n (Gil e s , L. G. E . , Singer, K . P. . eds) . Oxfo rd : B u t terworth-H e i ne m an n ( in press) . Singer, K.l� , Will e n, ]., B re i d a hl , P o. el al. ( 1 989) R a d i ologic study of the infl uence of zygapophyse a l joint orientation
t h o ra c ol u m bar of radiograp il i c r h o ra c i c
KP,
Pric e ,
Pa th ot. 1 32 ] ) 3 - 1 '>9 (J 9 5 9) I..;, colollne cervicale: son deve l o p pe ses mod ifi c a ti o n s d u rant la v i e . A cta Orthop.
mobil i ty. ] ment e t
Belg. 2 5 : 602 - 6 27 Tbndu ry, G . ( 1 972) T h e
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c.,
Zotterma n ,
Y,
eds) . Pergamon Press, p p . 5 9 - 66 . R . E . ( I 990a) I nflu e n c e o f
Ve iea n ll .
C ( 1 97 1 )
o n h y a l i n e c a rtilage a t
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Day,
R.E.,
Breida lll , and
"f;n likance . A cta Anat. PD .
U1 nn n .
lumbar
v e r t e b ra l body compressive s t re n g t h : c o r re l a ti o n s w i t h b o n e min e ra l d e n s i ry a n d vertebral regio n . B o n e
D i a conesc u ,
82: 97( 1 969) Ana l ysis o f the m e c h a n ic s
c u rv a t u re .
of t h o ra c i c
U"
G rii n ,
pec u l iarities o f t h e thoracic
con' p Uf c r-assisred measu re m e n ts sagi t t a l
Ver t e b ra l stru c t u r a l pecu l a r i ti e s w i t h a
c e rvical spin e mech a n ic s
Radial. S inger,
F
Tond b u ry, G .
Radiol. A nal.
Singer, K P .
E u l d e ri n k ,
c h a n ges in t h e cervica l spine a n d t h e lr re l a tionsh i p to its
on spinal i njuries a t t h e t h o ra c o l u m b a r j u nctio n . Surg.
zygap o p l ly,r a l
L.T ( 1 98 4 ) SeXII111
, {' ncbral body s h a pe . ] A nal.
m orbid a n a t o my. Br.] Surg.
S i nger.
S i n ger,
K. P. ,
B l l t t e rw o r t h -H e i n e m a n n (in
O,[(o·"rthritis in rhe dorsal in te r
1 1 : 2 3 3 - 23 9 . K P . G il e s . L . G . F , D ay.
Clinical A natomy
Spine Pain (Singer,
An
experim e n ta l study
Samcl. Suppl. 1 2 7 M . M . ( 1 990) K i n e m a t ic s
01·thop. Wh i t e ,
17:
1 67 - 1 74 .
In:
A.A.,
Pa nja b i ,
Clinical
Biomechan ics
P h il a d el p h i a : Li p p i n c o t t
Copyrighted Material
of the
of the spi ne.
Spine,
2nd
edn.
Normal kinematics of the cervical spine 1. Penning
This ch apter deals with a radio l ogi ca l analysis of normal motion of the cervical spin e followed by a functional anatomical correlation.
Functional radiographic studies Kinematics is the study of motion without taking into accowH the influences of force and mass (as opposed to kinetics). Spinal kinema tics have been profoundly studied by radiological methods. This chapter deals with the radiological analysis of normal motion of the cervical spin e, followed by a comparative review which relates the anatomy with function. Motion takes place in the separate motion seg ments of the craniovertebral junction, oc ci put to C2 (occipitoatlantal segment occiput-Cl, atlantoaxial segment Cl-2), and of the cervical spine proper C2 -Tl, in cluding the cervicothoracic junction C7-T1. Only movements in the three main pl ane s are described: flexion -extension in the sagi tta l p lane; lateral bending to the right and left in the frontal plane; and rotation to the right and left in the transverse (or axial) plane. The head may also move parallel to itself, which is called translation (White and Panjabi, 1978; Penning 1992a). Such translatory head motion is virtuaUy limited to the sagittal plane. The range of flexion-extension motion is deter mined by superimposition of radiograp hs of the cervical spine in both end-positions (Penning, 1968, 1978). Details are gi ven in Figure 4.1. In super imposition both the outlines of the vertebral bodies and the spinous processes should match. Only these midLine structures may be used as landmarks, not, for
,
Fig. 4.1 Determination of vertebrae.
Flexion
mm
is
ranges taped
of motion (shaded
between
area)
to
the
viewing box (occipital and vertebral outlines OCCiput to in
solid
lines).
C7
Part of the outline of the mm edges is
shown. To determine flexion-extension range of motion of, e.g. C4 - 5, an extension view and
film
edges
shown
imposed on a flexion
film
in
ftlm
(vertebral outlines
interrupted
lines)
is
super
with the images of C5 matching.
Then a line is drawn along one edge of the extension film on the underlying flexion images of
c4
fi.lm
and
viewing
box.
Next,
are made to match and a new line is drawn
along the corresponding edge of the
extension mm.
The
angle between both lines is the range of flexion-extension motion at C4 - 5 .
Copyrighted Material
54 Clinical Anatomy and Management of Cervical Spine Pain Vortman (1992), the a verage difference in each segment is 1.5°. Ranges show wide variations (Buetti Bauml, 1954; D vora k et at., 1988; Penning, 1968). When only end-positions are taken into considera tion, sequence of contribution of different regions of the cervical spine to total flexion -extension motion remains unknown. Such sequence can be studied by cineradiography, but small size and poor definition of individual frames interfere with detailed analysis. Using larger frames (100 X 100 mm) and lower speed (4 images/s), Van M am eren et at. ( 1 990) were able to show that motion commences and ends' in the lower part of the cervical spine (and ne ver in the mid cervical part), and that sequences of c o n t rib ution in normal s u bj ec t s are rather constant. During motion of the c ervica l sp ine as a whole, individual segments may temporarily move in oppo site direction (so-called paradox motion, or inver-
example, the articular processes. Both images should have the same radiological enlargement factor. Differ ences in lateral projection (due to concomitant rotation and/or lateral bending) i nterfere with reliable superimposition and enhance measurement error. If radiographs are too dark to allow reliable super impO Sitio n the contours of vertebral bodies and SpinOliS processes on one ftlm are redrawn on a tra nspare nt paper, which is subsequently super imposed on the other ftlm; this likewise enhan ces measurement error. Ranges of flexion - extension motion are listed in Tab les 4.1-4.3. Range of motion in children is larger than in adults (Mar kusk e 1971). In adults ranges decrease with increasing age, except at C6- 7 (Vort man, 1992). Average range of motion is larger in passive motion (brought about by investigator) than in active motion (Dvorak et at., 1988). According to ,
,
Table 4.1
Ranges offlexion - exte ns ion
A
motion
(in degrees) according to several authors
D
C
B
Occiput-C1 12 (5-20) 10 (5-15)
15 (8-22) 12 (6-[7)
IS (7-2» [9 (13 -26) 2003-28)
17 (10-24) 2[ (14-28) 23 (16-31)
19 (11-26)
21 (13-29)
Cl-2
C2-3
5-18 13-2) 16-28
C3-4 C4-5 C5-6
5 16 13-26 15-29 16-29 6-25 -
18-28 1 3 25
C6-7
-
=
13-42 years, spread of ranges. 15 3 0 years, spr� ad of ranges. Dvorak el al. (1988): n = 28; 22-47 years, aClive motion, average Same gmllp as C, passive motion, average range (± 2 X s.d.). Iluetti-Ilauml
(1954):
D
=
.�- 31
7-26
8-27
9-16 11-23
12-22
15-26 17-27
14-25 18-26
9-2:,\
7-23
10-16
n = 30;
B = Penning (1960): n = 20; C =
- [0-30
4- [2
C7-TJ A
F
n
-
range
(±
2 X s.d.).
E
= Van Mameren el al. (1990): n = 10; 19-221'ears, spread of ranges, extension ---7 flexion: negative values occipllt-CI inuicate par,l
F
;:::;
morion. Same group as E, nexion ---7 extension.
Table 4.2
Ranges
offlexion-extension motion
A
B
6-19 1 3 - 20
C4-5 C5-6 C 6 -7
15- 25 16-24 12-23
15-23
C = 8 females D
18-28
years, average age
12-27 15-29 [3-22
22
10 males 29-55 years, average age 41 years, active motion.
= =
G
=
[2-20
12-21
15-26
13-26
1 3 - 22
12-20
10-24
13-25 t 1-22
yea rs , active motion.
Groups A and C together.
E
8-21
8-25 1 3 -24
years, active motion.
=
F
5-15
8- 1 9
[4-26
8- 17
15-24 1 5 -29 17-25
22
4-14
8-23
6-16 12-22
7-15
males 18- 28 years, average age
6-15
E
11-23
9
C;
D
C3-4
B = Same males ;lS in A, passive motion.
F
C
C2-3
A =
2 s.d., in degrees) according to Vortman (992)
(average value ±
LO females 29-55 yea rs , average age 4 t year s , active motion. Grollps E and F together.
Passive::: motion increases the range of motion by an average 1.50 per seg me nt . There is no difference between Olen and women, except for C2-3
(larger range.in wo m en). Smaller range of motion .in
elderly group, significant at C2 - 5, Jess significant at C5 -6
Copyrighted Material
anu
not significa.nr at C6-7.
Normal kinematics of the cervical spine 55
Table 4.3 Average ranges offlexion-extension motion according to Markuske (1971)
Cl, moti on in 90% of people under the age of 40, and in 40% of people over 40 years of age. With a dynamiC m e thod Van Mameren et al. (1990) were able to show that paradox motion is a physiological phenom enon, not only occurring at occiput to Cl, but occasionally also at Cl-2, and in the lower cervical spine at C6-7 and occasionally at C5-6 (Van Marne ,
B
A C2-3
C3-4
C4 - 5 C5 - 6 C6 - 7
16.9 21.0
E
F
G
17 . 7
18 . 1
17.9
158
105
213
21. 7 21.7
22.4
22.5 22 . 8
22. 8
21 . 7 26 . 1
21.6 21.4
22 . 6 20 .0
22 . 8 21.1
24 . 6 22.9
24.6 22 9
26.4 22.8
16 . 6 20.7 22.2
A = 20 boys years; D
D
c
=
3-6
16.0
22.3
years; B
=
20
girls 3-6
20 girls 7-10 years; E
girls 11-14 years; G
Buetti·Ballml
=
=
225
years; C
=
185
7-10
20 boys
20 bo)'s 11-14 years; F
ren et al., 1990). Flexion -extension of separate segments can also be stud ied by comparing lateral radiographs of the cervical spine in maximal backward tran slati on (chin in position) and in maximal forward translation (chin out position) of the head (Fig. 4.2). During this chin in/chin-out manoeuvre the upper and lower cervical spine move in opposite d irection s (Table 4.4). In the chin-in position the upper part is flexed and the lower part extended, and vice versa. Reversal of direction of motion takes place anywhere between C2 and C5; range of motion in and around the region of reversal is reduced (penning, 1992a). A5 flexion - extension occi put to C2 is maxim al, without paradox motion occiput to Cl, mobili ty of the craniovertebral j unc t ion is
=
20
comparison with average values of
(J 954) (25
adults 20- 3B ycars).
sion). Paradox motion was first descri bed by Gut mann (1 960) as an extension motion, occiput to Cl, during the end p hase of flexion of the cervical spine. It occurs only in flexion of the whole cervical spine, not in f l exion of the upper part alone (stich as in nodding yes). Arlen (1977) noted paradox, occiput to -
\
\
A� - - - -- - - - If - - - - - - - -�-'{)�\\ \
\
\
\
\ \ �O \\)rf" \:t\J lb� ,,9 rp/ \;\ 0\ \ --
--
o
c
/K
\�G
G /\ P �O
\
\
\
C] C] M�D Ld
�i �
(} (\-/ L� �\7 N(6� C)f\ ({5\ -I�- - - - - - - -C0/\ -(-�.
V\
\
\
�
E
\ Fig. 4.2
\
Motion during chin-out/chin-in manoeuvres. Left;
occiput to T 1
in
cllin·out position.
Right;
Lateral v i ew of cervical spine translation dist
c hin -in position. Line AC
=
of head (basiocciput). Because of co-motion of the upper thora c ic spine (the centre of
Tl moves over distance DE), actual head translation with respect to the TI body is over the dist
centre of the
=
Copyrighted Material
56 Clinical Anatomy and Management of Cervical Spine Pain Table 4.4 Cervical spine motion during head translation
The pattern of motion between rwo vertebrae is represented by a movement diagram, demonstrating
vertebral relationship in both end-positions of move
Occiput-C] CI-2 C2-3 C3-4 C4-5 C5-6 C6-71
-19 - -40 -6 - 30 -12 - +5 -10- +10 0- +15 +5 - +19 +2 - + 19
-290 -16.0 -4.8
-
-1.9
+5.6
+ 13.1 +13.2
ment, range of motion ancl location of the instanta
neous centre of motion. A fl exi on-extension move ment diagram type I is shown in Figure 4.3 left, ancl type II in Figure 4.3 right.
The movement diagram serves as
a
starting point
for further elaboration of vertebral kinematics (Pen
ning, 1960, 1968). Motion is described as rotation
about an axis perpendicular to the plane of motion;
ranges (Ul degrees) and spread of ranges of flexion (+) Or extension ( ) motion during chin-in � chin-out manoeuvres in J I normal adults (5 women. 6 men. mean age 36 years. rAnge 25-45 years; Patijn and Penning, unpubLished data, 1994). Mean
this axis is represented on the film or movement
-
diagram as a pa in t, and caUed the instantaneous
centre
of motion. The
designation
instantaneous
indicates that the centre relates the end-positions of flexion and extension only and does not suggest that ,
motion in berween is a circular motion about trns
preferably studied by the chin-in/cl1in-out manoeuvre. Flexion-extension C5- Tl
is not maximal, motion
centre. Centres tend to shift during motion along a certai.n
being more equalJy distributed over several segments,
Vortman
including the upper thoracic segments.
cervical
Practic aJl y
performed,
the
chin-in/crnn-out
(992) has shown that centres of the spine
proper
for
motion
from
maximal
extension to mid-position differ in place from those
manoeuvre seems to allow a considerable degree of
for motion from n1icl-position to maximal flexion.
rnation of the upper thoracic spine (Fig. 4.2). With
differences in position prove to be negligibly small.
head translation, but for a large part this is due to ca
the centre of vertebral body Tl remaining in pl ace
However, in radiographically normal spines
,
these
Figure 4.4 demonstrates how the instantaneous
,
of
motion
can
be
constructed
from
the
the range of head translation proves to be limited to
centre
an average of 45 mm with a spread of 2 -75 mm
movement diagram. Another method to construct the
(penning, 1992a). This implies that already relatively
instantaneous centre of motion from flexion-exten
small but sudden translatory movements of the head,
sion radiographs is elucidated in Figure 4.5. Trns
as in backward acceleration in rear-end collisions,
methOd, used by different authors (Pennal et aI.,
the craruovertebral region (Perming, 1992b).
(Vortman, 1992).
may theoretically result in damaging hyperflexion of
1972, Vortman, 1992), has less measurement error
" " . .... .. . , .. . ... .
.
Fig. 4.3 Move me n t diagrams w ith instantaneous centre of mot i on Left: Movement d i ag ram C5-6 type I, with lower vertebra C6 in fLxed po si ti on and upper vertebra C5 in en d position s of flexion (solid l in es ) and extension (b ro ken lines). J)otted circle, with the instantaneous centre of flexion-extension motion (smaU circle in lower vertebral body) as centre point, passes through the intervertebral joint spaces (shaded). Right: Movement d iagra m C5-6 type II, with the LIpper vertebra C5 in a t1xed position and the lower vertebra C6 in end positions of flexion (solid lines) and extension (broken lines). The dotted circle, with the instantaneous centre of flexion-extension motion (small circle in lower vertebral body) as centre pOint, passes t h rou g h the .
-
-
intervertebral joint spaces (shaded).
Copyrighted Material
Normal kinematics of the cervical spine 57
motion is projected about the centre of a circle encompassing the outline of the OCCipital condyles (Fig. 4.7 bottom ) . The instantaneous centre of fleXion - extension motion C1- 2 is proj ected in the dorsal half of the dens, or immediately dorsal to the dens (Van Mameren et al., 1990; Fig. 4.8). As shown by paradox occiput-Cl motion, flex ion-extension i.n the occiput-C1 and C1-2 segments are not obligatory coupled motions. Consequently, the posterior arch of the atlas may be found somewhere between the occiput and spinous pro cess of the axis, and not necessarily halfway between (penning, 1978). By systematically comparing lateral radiographs of the cervical spine in the neutral pOSition and in Fig. 4.4 Const ru ctio n of instantaneous centre of motion (1). Left:
Identical
vertebral body
la nd ma r ks
and
(smalJ
circles)
of the
upper
a rch in flexion (solid lines) and in
extension (interrupted
lines) are connected;
perpendicular
lines constructed from their m idpoints converge on the
instantaneous centre of motion (star). As inhe rent measure
ment e r ror is considerable, the result sho uld be checked by supe rimposing images of the lower vertebra, marking the constructed centre of mo tion on both mms. Pierce a needle through the superimposed centres of motion, and rotate the upper film upon the l ow er fUm (penning, 1978). If th e centre of motion has been cor re ctly determined, rotation out of the superimposed positio n of the lower ver te b ra wiU result in exac t superimpOSition of the outlines of the upper
vertebra.
The anatomist Fick (1904,
instantaneous
axis
I
< "-
"
"-
"-
"
"-
"
1911), described the
centres of cervical flexion - extension motion C2 - 7 as located in the caudal vertebral bodies, not in the intervertebral discs. In 193], Dittmar concluded from functional radiological studies that the centres were located in the nuclei pulposi of the intervertebral discs. Exner (1954) confirmed this and added that the centres moved with the nuclei, backwards in flexion and forwards in extension. The a ut h or of t h i s chapter proved radiologically that the instantaneous centres of f lexion-extension motion are located in the caudal vertebral bodies (penning, 1960), with a typical segmental difference: at C2 - 3 in the lower posterior half of the body of C3; and at C6-7 at the midpOint of the upper end-plate of the body of C7. The results in 20 cervical spines of young adults are shown in Figure 4.6 left. By optimization of teclll1ical errors, Amevo et al. (1991a,b,c) we re able to locate the in . stanraneous Van Mameren et al. (1990) and Vortman (1992) achieved comparable results.
The
I
of
flexion-extension
motion occiput-CI traverses both anterior condyloid
foramina (Spalteholz, 1953; \Verne, 1959). The dis tan ce of thi s axis from the occipitoatlantal joints is a bout 15 mm . On lateral radiographs the centre of
I
Fig. 4.5 Construction of instantaneous centres of motion 01). Flexion tl l m (OCCipital and vertebrAl outlines shown) is taped o nto the viewing box. Part of the upper and left film edges
is
shown.
To
deter mine
instantaneous
extension centre of motion of, for example, extension
film
f lexion
C4-S,
the
(vertebral outl i n es not shown) is super·
imposed with outUnes of C5 vertebra exactly matching, after which
edges of the ext ension
underlying flexion
fum an d
film are drawn on t he
the viewing box (solid lines).
Next, outlines of C4 are ma de to match and the edges of the
extension extension
film agai n are drawn (interrupted lines). After the film has been removed, a line is drawn from the
intersection (smaU circle) of both drawn upper edges of the
extension
film to
the intersection of both drawn lower
edges of th e extension film. Another line is drawn from the
intersection of the left drawn ed ges of the extension mm to the in te rs ec ti o n of the right drawn edges. Intersection of
both lines (star) is t h e centre of flexion-extension motion at
C4 - S .
The
angle
between
the
dr awn
edges
of
both
extension tums is the range of flexion-extension motion at
C4-S.
Copyrighted Material
58 Clinical Anatomy and Management of Cervical Spine Pain
r;}
,
LJd
CE
,
,
,
/
/
I
/
I
r&1 L3J r15.1
�
CJ
Fig. 4.6 Instantaneous c e ntres of f l exion -exte nsion motion Left: Instantaneous centres of flexion -extension
C2-7.
motion C2-7 (dots), With estimated mean instantaneous
centres (small circles), as d etermi n e d by t h e
healthy
subjects
(per1Jling,
1960).
c entres as determined by Amevo
normal subjects (dots
Right:
author in 20
Instantaneous
et al. (I991a,b,c) in 40 are as
mean c e n tres; shaded
=
two s.d . clistribu tion of centres; solid lines
=
=
superimposed
range of technical errors).
Fig_ 4.7
Instantaneous centres of occiput-Cl
motion.
Top:
Anteroposterior projection (frontal plane) of basiocciput
(presumed to be fixed) with outlines of o cc ip it al condyles, and of lateral masses of atlas
in lateral bending
to right (solid
lines) and lateral bending to left (interrupted lines) Con struction of the instantaneous centre of motion (star) is as in
flexion, occasionally parallel motion (translation)
of the axis with respect to the occiput may be observed (penning, 1995). As Figure 4.8 top shows, backward
translation
of
the
axis vertebra (with
respect to the occiput) is accompan.ied by upward motion
of the
posterior atlantal
arch
(extension
occiput-Cl, flexion CI-2); forward translation (Fig.
4.8 bottom) moves the posterior atlantal arch down
wards (f l exi on occiput-Cl, extension C] -2). Parallel
occiput to C2 motion is limited by unequal distribu tion of elastic tension over the posterior occipita atlantal- axial ligaments.
As rotation takes place in the transverse (axial)
plane, computed tomography (Cn is an appropriate modality to study it. Ranges of rotation OCCiput to Tl
Figure 4.4. lnstama neolls
centre
is projectecl in the mid
sagittal plane high above the foramen magnum. drawn
from
the
cen tre of motion
passes
A
circle
through
the
ou tlines of the occipital condyles. Bottom : Lateral p roj e ction
(parasagittal
plane) of t he
fIXed) with an outline
basiocciput
(presumed to be
of superimposed OCCipital condyles,
and of at/as in f l exion (solid lines) and extension
(inter
rupted lines). Construction of the instantaneous ce ntre of motion (star) is as correspo nds more
in
F igure 4.4. The instantaneous centre
or less with
the
axis
through
both
anterior coodyloid foramina (canales nervi. h ypo gl o ssi ). A circle drawn from
the
centre of m ot io n passes through the
outline of the occip i ta l condyles (ourline more curved than o u tline
in
fro ntal p l a ne , typical of OVOid-shaped joint). Note
that instantaneous centres of motion for flexion-extension
and lateral bencling are on the same side of the occipi
toatlantal joint.
may be determined by scanning the cervical spine in the supine position of the body with the head actively
maximally
rotated
to
the
right
or
the
left,
and In this study, full rotation (i.e. both sides together)
subsequently measuring on the obtained radiographs the dUIerence in rotat ion of each of the vertebrae Cl
up to Tl with respect to the occiput (penning and
WiImink, 1987). From these measurements rotation of each of the segments can be calculated. The results
in young adults are presented in Table 4.5.
between occiput and upper thoracic vertebra Tl averages
144.4°. Occiput-C1
rotation is n egligibly
small. In accordance with the literature (White and
Panjabi, 1978), 55% of total rotation of the cervical spine occurs at CI-2 (in our measurements 81°, or
Copyrighted Material
Normal kinematics of the cervical spine 59
Table 4.5
26 healtby Wi/mink, 1987)
Ranges oj rotation in
years (Penning and
Occiput-C! C3-4
C4-5 C5-6 C6 - 7 C7-TJ
=
J\1ean ranges
c
1
-2-5 29-46 0-10 3-10 1-12 2-12 2-10 -2- 7 61-84 22-38
6.0 98 10.3 8.0 57 4. 7
7 2. 2 30 7
C2-TJ A
B
2.1
Occiput- TJ
(in degrees)
of rotation to left or
group as A, upper and lower limits rotation to C
=
and
Lysdl (1969), In right IOgether.
vitro
21-26
A
40.5 3.0 65 6.8 69 5.4
CI-2 C 2 -3
adults
study,
left
44.5
right; B right;
=
same
or
mean values of rotation to \eft
head in fIXed anteroposterior CAP) position, and the
atlas and axis vertebra in both end-positions of rotation to the right and left.
However, for better under
standing of kinematics, motion of the head w ith respect to the atlas and axis vertebrae should
be
I I
!) I
Fig. 4.8
Parallel motion occiput
to C2. Parallel
mo tion
occiput to C2 is occasionally observed when fddiographs in
the neutral position and flexion are systematicaUy compared . of flexed cervical spine. Occipnt Cl segment is in extension (due to paradox motion); CI- 2 is in no r mal flexion. Bottom: Occiput to C2 region of the cervical spine in the neutral position. Compared with the flexion radiograph (lOp), the axis vertebra has translated anteriorly with respect to the head (follow vertical lines drawn along anterior and posterior rims of the foramen magnum). This example shows forwards translation of the axis vertebra, to he accompanied by downwards motion of the posterior atlantal arch, and vice versa. A: instantaneous ce nt re of flexion-extension motion; oCCiput to CI. B: instantaneous centre of f1exion·extension motion; CI-2. Top: Occiput to C2 region
56%). Rotation C2 TI (both sides together) avera ge s 61.4°. Rotation here proves to be largest in the C3-7 region, and smallest at C2-3 and C7-Tl. Figure 4.9 -
presents a drawing of the superimposed vertebral i mages as obtained d ur i ng CT sca nning of the cervical
spine in head rotation to th e right.
The pattern of rotation OCCiput to C2 is best
depicted
as
shown in Figure 4.10, with the rotated
Fig. 4.9 Computed to mographic reconstl"Ucrion of the rotated cervical spine. Top·view of vertebrae CI-TI (with adjOining p arts of the first rib). The head is rotated to the ri gh t side (star). The head is repre sen ted by the foramen magnum and a line corresponding with the mid sagittal plane of the head. With respect to the atlas, the head has shifted to the righl but il is virtualJy not rotated. The total range of rotation occiput-T I in tNs example, is 70°.
Copyrighted Material
60 Clinical Anatomy and Management of Cervical Spine Pain
Fig. 4.10 Pattern of rota tion OCCiput to C2 (I). Left: Drawings from anteroposterior (AP) radiographs of the head ro t ated on th e cervical s pin e (with only the for:1men magnum and the lateral condyles depicted). The r igh t side i s indicated by a star. Right: Views from above. showing ftIm pl a n e direction of X-ray beam and the posi t i on of the head and shoulders. The ri gh t shoulder is indicated by a star. Note the st ri c t (AP) proj ec t io n of the head. Top left: Head rotation to the right. Head and atlas in AP projection with no OCCiput to C 1 rotation With respect to the head and atlas, the axis vertebra has rot a t ed [0 left (shift of SpinOllS process to the right). Occ i put to C2 r eg ion is l a te ra lly hent to the left: the ve r tical line berween the inner border of the OCCi pital con dyle (small circle) and the l a t e ral mass of the axis vertebra (black dot) is shor ter on the left si de with shift of th e atlas to the left side with respec t to the head. Bottom left: Head rotation to t h e left. With resp ect to the head and atlas, the axis vertebra has rotated to the right (shift of s pin ous process to the left). OCciput to C2 region is laterally bent to the right (the vertical line is shor ter on the r i gh t side), w i th a shift of ,
.
,
the atlas to the right side with respect to the head.
considered. Head rotation to the right (Fig 4. 10 top .
the triangular lateral masses of the atlas being wedged
left) then proves to be attended by occiput to C2
laterally during app roximation of the co r responding
rotation to the right (which is the same as C2 rotation
occipital condyle and lateral mass of the axis ver
to the left); by occiput to C2 lateral bending to the left;
tebra. During rotation, the head thus slides in the
and by lateral sliding of the head upon the atlas to the
direction of the rotation.
right. Head rotation to the left (Fig. 4.10 bottom left) is
According to the CT study of rotational Illotion
attended by OCCiput to C2 rota t ion to the left ; by
(Penning and Wilmink, 1987), average occiput to
occip ut to C2 lateral bending to the right; and by
rotation to the right or left of 400 produces an average
lateral sliding of the head upon the atlas to the left. Head rotation is thus attended by occiput to C2 rotation in the same direction
(which has to be
C2
lateral sliding of the OCCipital condyles upon the atlas of 4.5 mm (spread 3-6 mm), bot h sides togeth er
9 mm .
total
Lateral shift with respect to the odontoid
expected as the whole cervical spine is rotated in the
process
same direction); and by occiput to C2 lateral bending
7.8 mm
in the opposite direction (which will be explained).
odontoid process dur ing rotation withi.n the atlas is
is slightly .
less:
Consequently,
both sides togethe r total average lateral shift of the
The head always slides laterally upon the atlas away
negligibly small, averaging 1.2 mm . Thus, in agree
from the direction of lateral bending; this is related to
ment witll classical anatomical textbooks (Fick, 1904,
Copyrighted Material
Normal kinematics of the cervical spine 61
1 9 1 1 ; S p alteholz, 1 9 5 3 ) , t h e c e n t re of a t l antoaxia l
the
right
(Fig.
4. I I
to p
le ft)
then
proves
to
be
a bo u t the ce ntre o f t h e
attended by OCCi p u t to C2 rotation to the le ft (which
The range of lateral bending occip ut to C2 (both
OCCiput to C2 lateral ben ding to the right; and b y
sides togethe r) i n the s t u dy ofWerne ( 1 959) a v e ra ged
lateral sliding of t h e head upon t h e atlas t o the left .
5 . 5 ° (s p rea d 1 - 1 4 °), a n d in the s t u dy ( 1 964) 80 (a sp re a d of 4 - I 3 S)
of Lewit et al.
Lateral he ad ben d ing t o the left (Fig. 4. 1 1 bottom left)
The patte r n of latera l bend ing occi p u t to C2 is best
OCCiput to C2 la te ral bending to the left, and la teral
rotation m a y b e
loca ted
is t he same as axis verte b ra rot a t ion to the r igh t) ; by
o d ontoid p rocess .
is at ten d ed b y OCCiput to C2 rota tion to the right,
d ep i c te d in the way shown in Fig u re 4 . 1 1 , wit h the
s l i d ing of the heael upon the atlas to the righ t .
l a terally bent h ea d in the fLxed AP p os i t i on , and the
T h u s l a te ral head be n d ing is attend e d by latera l
both e n d -p o sit i ons of
OCCi p u t t o C 2 be n d ing in the same d ire ction (w h i c h
la te ral bend ing to th e right and left . However, fo r
has to b e e xp ecte d as the whol e cervica l sp i ne is
atlas and axis vertebra e
in
better understa n d ing, t he kinematics of mot i o n of the
la terally bent in the same el i recti o n) , and by OCCip u t
head with res pect to the a tlas and a xi s verte brae
t o C2 ro tation i n t h e opposite d irection
should also be considered . Lateral head b ending to
be explained) . As has b e e n expl ained in the prev i o u s
Fig. 4 . 1 1 Pattern of l a te ra l b e n d ing m o t i o n oc c iput to C2 . Left : d rawings from radiographs of l a tera l bending of the head and c ervic a l s p i ne (on ly th e fo ra men m a g n u m a nel l a teral co nelyles a re depicted). The r i gh t side i s i n d icate d by a star. Ri g h t : Bird 's-eye views showing film plane , shoulders anel the l a terally ben t head and n e c k . The ri gh t shoulder i s ind i c a t e d by a star. Strict u p ri g h t and an teroposte rior po s it i on of t h e heael with respect to ftlm (non-rotated). To p left: Latera l head a n el neck bending to the righ t . The vertica l line berween t h e inner b orde r of t h e OCC i p i tal condyle (s m a l l circle) a n d t h e l a te ra l mass of tile axis vertebra (black dot) is s h o rt er on the right side. With respect to the heael, the a t l a s has sh ifted t o t h e rig h t . With respect to the h e ad a n el atl a s , the ax.is ver tebra has rota ted to the right (shift o f spinolls p rocess to the left) This situation is com para b l e to that of heael ro t a t i o n to the left (Fig. 4 . 1 0 bottom) . Bottom left: Latera l head and neck b e n d ing t o the l eft. The vertical line is shorter o n the left
side. W i t h respect to t h e head , the a t l a s has s h ifted to the left. W i th respect to the head and atlas, the a x i s vertebra has rotateel to the l e ft (sh ift of spin o u s p rocess to the righ t) . This s i tuation is comparable to that of head rota tion to the ri g h t ( F ig . 4 . 1 0 top).
Copyrighted Material
(wh ic h
will
62 Clinical A natomy and Management of Cervical Spine Pain section, the head always slides la tera lly upon the atlas away from the direction of latera l bending. I t is tempting to attribute the coupling of rotation and contralateral bending occiput to C2 (and vice versa) to the fu nctional anatomy of the c raruoverteb ral region itself (Reich and Dvorak, 1 986). However, the exp lanation of the coupling has to be found in the biomec h a ru cal behaviour of the cervical spine p ro p e r C2 - T 1 , w h i c h is described below. Rotation and lateral bending C2 - T1 are c o u p led motions. I n 28 a u topsy specimens C2-T3 o f ages ranging between 1 1 and 67 years, Lysell ( 1 969) fo und an average full rotation C2- T l o f 45° to be associated with 24° lateral bending to the same side. Full latera l bending C 2 - T 1 of 4 9 ° p roved to be coupled w i t h 28° rotatio n to the same side (Ta ble 4 . 6). If t h e thoracic spine with T I i s supposed to be fixe d , the coupled ro tation - lateral bending is grad ually b u ilt up from C7 u pwards, to reach a maximal va lue a t C2. La teral bending a n d rotation C2-T l th u s are obligato rily coupled , a l though in fu ll latera l bending full rota t i o n is not a c hieve d ; in fulJ rotation, fu ll lateral bend ing i s not a c h ieved . The study of Lysell (1 96 9) p roves that C2 motion is the result o f the behavio u r of the cervical s p ine proper, C2 - T l , as the craniovertebral segments occiput C1 and C 1 - 2 did not fo rm part of the specimens. This is further substantiated by stu dies in the dog (Penning and Badoux, 1 987). In this quad rupedal mammal, C2 does (virtually) not rota te du ring lateral bending of the cra niovertebra l j u nc tion, despite the fact th a t cra n i overtebral anatomy is comparable to that in humans. The explanation i s the virtual inability of the canine cervical spine proper (C2-T l ) to rotate: laterdl bending C 2 7 does not p roduce an appreciable amount o f C2 ro tatio n . A s opposed t o C 2 motion, head motion is relatively independent of motion of the cervical spine proper, due to the possibility of compensatory counter movements in the occipitoatlantoaxial segments . I n -
-
Table 4 . 6 Coupled ranges of rotation/lateral bending, and lateral bending/rotation
A C2 - 3
6.0 9.8
C3 - 4 C4- 5
1 0. 3
C5 - 6 C6 - 7 C7 - T J
8.0 5.7 4.7
B 5.4 6.8 5.7 4.5 3 7
2.0
C
D
7.9 9.8 9. 1
6. 1
9.0
4.7
8.4
3.4 2.0
6.8 6. 1
63
degrees) determined b y Lyse l l ( 1 969), i n a n in vitro of 28 cervical spine specinl e n s C2 - T3 ( 1 1 - 67 yea rs) .
Va lues ( i n study
A
=
Mean values of ror a t ion to l e fr and right
l a te ra l b e n d i n g d u ri ng rotJt ion
in A;
together;
B
=
coupled
C = mean v a l u e s of lareral
bend ing {O left and righ r toge t h e r ; 0 = coupled rota t i o n d u r i ng l a ter,,1 bendi ng in C .
o c c i p u t to T l rotation, the a x i s vertebra is laterally bent (with respect to T l ) in the d i rection of rotation , but the head is kept i n an erect position by contralateral bending in the occiput to C2 segment. As has been shown in Figure 4 . 1 0 , ro tation occ i p u t to C2 is attended by late ra l bending occi p u t to C2 i n the opposite direction . In occiput to T I l a teral bending, the axis vertebra is rotated in t h e d i rection of l a tera l bend i ng , but the head i s kept i n the non-rotated pOSition by counter rotation in the C l - 2 segment. As has been demon strated in Figure 4 . 1 1 , l a terd l bending occ i p u t to C2 is attended by occiput to C2 rotation i n the opp osite d i rectio n . Thu s , the seemingly c o u p led motions of contra lateral bending occiput to C 2 in rotation C 1 - 2 , and o f counter-rotation C 1 - 2 i n lateral bending OCCip u t to C 2 , are com pensatory move m e n ts needed to keep the head in the imposed erect or no n-ro tated position (Figs 4 . 1 0 and 4 . 1 1 right) .
Functional anatomy Functional a n a tomy is the study of fo rm a n d properties of the a n a to mical structures in the l ight of their kinematics . Having gained i.nsight i n to the normal kinematics of the cervical spine, it i s o f interest to have a re trospective look at the form a nd orientation of bones and joints, at properties of discs and l igaments, and a t the cou rse and fu nction of m uscles . The alar l igame nts, connec ting the (odontoid p rocess of) the second vertebra with the (in ner sides of the) occ i p ital condyles, a llow movements between the heael and axis vertebra in aLI directions. Ranges a n d patterns of these movem ents are regula ted by th e interposed atlas, which articulates with the occipital condyles and the axis verte bra i n the occip itoatlantal and atlantoaxial j o ints, respectively. Tightness of the alar ligaments e n sures firm contact between the jOint s urfaces . Further stability i s e n s u red by the tectorial membrane (Oda e t al. , 1 992). The occipitoatlantal joints, occiput to C} , are relatively stable joints, guiding their own m ove ments d u e to the marked l y rounded and congruent anatomy o f t he ovoid joint s u rfaces. They a l low flexion extension and , to a fa r l esser d egree, l a teral bending, but rotation is hard ly possi b l e . I f, i n an anato mical specimen, the head is forC ibly ro tated with respect to the atlas (or vice versa) , the occipital condyles a re lifted out of the superior atlantal j o i n t soc kets . Such occip itoatla n tal lifting (and hence ro tation) i s nor mally prevented by the tightness of the alar liga ments and the tectori al membr,m e . E"Xperimental tt-a nsec tio n o f these ligaments results in significant i.ncrease of occip u t - C l rotation (Dvorak et ai., 1 987) . The lateral atlantoaxial joints Cl - 2 have o p posed co nvexity of their j o i nt su rfaces, the gaps between the anterior and posterior m a rgi n s being
Copyrighted Material
Norm al kinematics oj the cervical spine
mled by la rge t ri a n g ular meniscoid stru ctures (Schon strom et at. , 1 995). Due to their op posed convexity, the j o ints lack in ner sta b i li ty, but this enables t h e m to perform movements in aU d i rections: flexion - exten s i on , lateral bending and, above aU, rotation . During flexion - extension the j o i nt su rfaces make tilting m ovements a n d d u rin g la teral b e n d i n g they slide laterally over small d istances (average 2.4 mm , both sides together; Lewit et al. , 1 964 ) . Rotation is characterized by sliding movements over l a rge r d is tances (20 mm or more), w here the j o i n t surfaces on each side a re moving in o p posite d irections. Chang ing incongru ities between the j o i nt su rfaces may be compensated for b y the triang u lar m e n i s co i d struc tures which , due to their contents (venous blood , flu i d , fat) are easil y re modelled and/or d istent1ed o r comp ressed . Stability of t he atlan toaxial relationsh ip is ensured by the nave formed by atlas and transverse ligament, k e e p i ng the odontoid p rocess of the axis vertebra in situ du ring rota tional move m e n ts . The freedom of movement of the odontoid p rocess in latera l or ante roposteri o r d i rect ions is l i mited to 1 - 2 mm . I n c hi ldren, the freecl o m of a nteroposterior motion of the oclontoid p rocess is l a rger (2 - 5 m m ; Pa w a nd Moir, 1 949). As may be cIe rivecl from Figure 4 . 1 0 , C 2 ro t a t io n is attendecl by laterdl shift of the odontoid p rocess in the direction o f C2 rotation . Figure 4 . 1 2 makes clear that this shift with resp ect to the OCCiput has a ' w heeling' character (Pe nni n g , 1 978) . This can be attributed to the more posteriorly placed i n sertion of the ajar l i g am e n t s on t h e odontoid (Spalteholz, 1 9 55), kee ping the posterior portion of t h e o d o n t o i d i n situ; the cen tre of motion is found here . The possi b i l i ty of parallel motion (trJ n slation) OCC iput to C2 (Fig. 4 . 8) provides, i t seems, the craniove rtebral j unction with elastic resistance against sudden head accelera t i o n . As s how n in Fig. 4 . 1 3 , su clcl e n backward tra n s l a t i o n o f the head with respect to C l and C 2 is absorbed by passive flexion o cc i put - C l , and does not imme d i a tely result in posterior occ i p i toatlantal dislocatio n . The same seems to be valid fo r sudden forward s translation of the head with res pect to C I and C2 (F ig. 4 . 1 4) . W h i l e i n t h e s p i n e p roper, a ttac h ing muscles bridge s ev e ra l segme nts, part o f the attaching mus cles in the cranio"Uertebral junction a re restricted to one segment (occiput - C l or C l - 2) , o r to two segments (occip u t - C 2 ; Ta ble 4 . 7) . Th e fu nction of these muscles can be understood fro m thei r c o u rse with respect to the centres of motio n . A muscle cannot be effec tive if its course is rad ial (in the d i rection of the cen tre of motion): a wheel cannot be turned by p ulling at the centre of its axle . A muscle will be maximally e ffec t i ve if its cou rse is tangential with respect to the cen tre of motion . Figure 4 . 1 5 shows the m e n tioned craniovertebral muscles projected in the three main planes, d e fming
Fig. 4.12
Pa ttern
of rota t i o n
63
OCCiput to C2 (I I ) . Top : 4 . 1 0 w i t h o utlines of
S u p e r imposition o f d rawings o f Figure foramen
magnum
with
condyles,
rota t i o n to the right (solid lines) (interru pted
Lines).
The
and
and
axis
vertebra
in
rotat i on to the l e ft
l a t e ra l borders of the
dens a re
ma.rked by s m a ll circles. The right side is indicated by a S\:;ll". Centra l d rawi ngs: Axis vertebra shown in
plane,
the transve rse
with the position of the dens corre l a ting with
position o f the
dens in
the
rap drawi ng
the
(vertical lines).
Upper cen tral d ra w ing: axis verte bra rotation to the right
(sol id lines);
lower c e n tral draw i ng:
rotation
to the
l e ft
(in terrupted lin es) . Bottom : superimpositi on of both central d rawings with outlines of the dens and spinal ca n a l onl)'. Th e d e n s is seen to rotate (w heel) about a centre at its posterior wail (small circle).
the i r course with respect to the corresponding centres of motion. Ta ble 4 . 7 s h ows that the pred icted fu nction o f each of the muscles, a s derived from its cou rse with respect to the correspond ing centre of
Copyrighted Material
64 Clinical A natomy and Management of Cervical Spine Pain
Fig. 4. 1 3
Elastic a b sorption of sudden backward transla·
tion of the head. To p : Lateral view of the c rani overtebral region
in
rhe n e u t ra l positio n . The b lack dot indicates the
Fig. 4. 14
Elastic absorption
of s udden
in the neu tral position. The b l a c k dot ind icates the poste
a n terior rim of the fo ra m e n magnum (basion). The occipi·
rior
toatlanral joint is shad e d . Centre : In (sudden) b a c kwards
toatlantal
acce l e ration of the head
acce leration of the head (long
axis
vertebra
without
in
m o tion
p l ace of
the
(long a rrow), inertia keeps the (compare atlas,
along
posterior
vertical
lines) ;
occipitoatlantal
dislocation wou l d occu r ( l a rge shaded area). Botto m : Due to t h e downwards movement of t h e posterior a tl antal arch (i . e . flexi o n of OCCip u t to Cl and ex tension of C l - 2 ; s hort arrow) , sudden backwards acceleration of the head (ove r
forwards t ra n s l ation
of the head . Top : Lateral view of the c ra n i ove rtebral regi o n
axis
rim
of
foram en
joint
ve rte bra
in
is
magn u m
(opisth ion). The
shaded . Cen tre:
occipi·
(sudden) forward s a r row) , inertia k ee p s the In
p la c e ; wit.hout motion of t h e atlas, anterior
shaded the posterior atlantal arch (i . e . extension OCCiput to C l ami flexion C 1- 2 ; short arrow) , sudden backwards acceleration of t h e h e a d (over the same distance as in th e central d raw i ng) is occipitoatlantal
dislocation
wo u l d
occur
( l a rge
area). Botto m : Due to upward movement of
same
distance as in the central d rawing) is elasticaUy
elas ti c ally a bsorbed by stretching of the
a b sorbed
by stretching of t h e posterior occipitoatlantal
toaxial liga mentous and musc u l a r structures; there
and muscular dislocation.
occipitoa tlantal d islocation .
the
ligamentous toatlantal
s t ructu res; there i s no occipi
Copyrighted Material
posterior a t l a n
is
no
Normal kinematics of the cervical spine 65 motion in Figure 4 . 1 ; , is in good agre e m e n t w i t h t h e
extension motion re m a in about t h e sam e . We there
data provided by a n a tomists (Sp a lteh o l z , 1 9 ; 3 ) .
fo re
suspe c ted
the
difference
in
location
of the
D u e t o t h e more o r l e s s p a rallel orienta t i on of t h e ir
cen tres of m o t i o n at C2 - 3 and C7 - T1 (with gra d u a l
j o i n t s u rfaces, t h e zygapophysial jOints C 2 - T l lack
transitions i n between) to h e re la ted to d iffe re n c es in
inner
s t a b i l i ty.
Sta bil i ty
is
ensured
by
inte r
the
he i g h t of the sup erio r artic u l a r processes (Penning,
vertebral d isc a nd f1a v a l l igame nts . The j o ints pe rfor m
1 960, 1 968). Nowitzke et at ( 1 994) p ro ved that this
only sl id i ng movements, n o t t il t i ng movements. Like
conj e c tu re was corre c t ,
the a tl an toaxial j oints, they con tain ea sily defo r m a ble
there was no relat ionship betwe e n t h e location of the
menisco i d
structures
which
are
presu m ed
to
c o m pe n sate for cha nging inco ngnl ence s b e tween
the a rtic u la r s u rfaces d u ring motion (penn ing and To n d u ry, 1 9 6 3) . Figure 4 . 1 6 d emo ns t ra te s t h a t t h e superior articu lar processes C2 - T1 fro m Tl upwards d e c rease in h eight w i t h respect to the superior end-pla tes of t h e ve rtebra l bod ies , b u t the distances between these tops
and
(
,
the
in sta ntaneous
c e n t res
of
flexion -
(Ta ble
4 . 8) .
rela ted
to
a
I I I \ -'
Fig. 4 . 1 5
\,
p l a n e ( t o p left), with instan t a n e o u s
Cl
and
C 1-2 ( i n d icated b y small circ l e s) ; i n t h e frontal p l a n e (top
right),
with instantaneous cen tre o f l a tel-J l bending m o t i o n
a t occi p u t to
C2;
and in the transverse p la n e (bottom right) ,
w i th instantaneous centre of rota t i o n a l m o t i o n at C 1-2 vert ebra i s shown i n i.nte rrupted l i nes;
atlas
(axis
vertebra , o n ly
partly d rawn , h a tched). Names o f the muscles are l i sted i n
Ta b l e 4.8.
A
m u s c l e c a uses
motion if
its
cou rse
in
a
correspond ing p l a n e is t ange n t i a l with respect to th e centre of m o t i o n : muscles
3
3
a n d 4 cause exte nsi o n , m u scl es
2
and
l a tera l b e n d ing to the same s i d e , and musc l es 5 and 6
rotate to the same s i d e (Ta b le 4.8). A muscle is not effecti v e
if its
cou rse is ra d i a l
with
respect to
the
centre: muscle 6 i s
u n a ble to fl e x or extend a n d m uscle 4 to bend l a t e ra lly.
A
more rad i a l cou rse with respect to the c e n tre of rota t i o n
makes m u s c l e 5
less effective
in rota t i o n
than
mu scle
6.
Bilateral action o f muscles differs from u n i lateral action; for
instance, bilateral c o n traction of muscle 6 will stabilize the Cl - 2 segment (with no flexion o r extensi o n , a n d n o lateral
bend i ng
or
ro tation of
rotation);
CI-2.
u n i l a te ra l
contraction
will
the
S uc h prototype·like discs a re fo u n d in the hu man
Function of t h e c r a n i overtebral m us cl e s . Geo
in the s a git ta l
in
disc, resem bling the classical (Greek) d isc s h a p e .
metric represe n ta t i o n of six m uscles o f the upper c e r v i c a l regi o n
of motion
C7 - T l a m o re tilting type (Fig. 4 . 1 7 ; Penn ing, 1 988).
'\/
cen tres o f flex i o n - extension m o t i o n of O C C i p u t t o
pattern
The til ting type of motion is typical of t h e prototype
....
-.... \ / J" ..... ..... ,
d ifferent
intervertebral d isc : a t C2 - 3 a m ore sliding type , a t
II
\
esta blished that
T h e difference in location o f c en tres o f m otion is
' -�
'-<::.. - '" y -. ",-
also
c e n tre s and the s l o p e of the superior articu l a r fa c e ts
/
II }
and
cause
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66 Clin ical A natomy and Management of Cervical SjJine Pain Table 4.7
Function of muscles of the crcmiovertebral junction
i'>1ttscle name
No.
Segment
F +
1
Rectus capitis anterior
Occipu t - C 1
2
Re ctus
latera l i s
Occiput- C l
3 4
c a pi ti s
Rectus capitis posterior minor
5
Re c t u s c a pi t i s
6
Obliquus capitis inferior
+
O cc i p ut C l
+
Occiput-C2
+
-
poste rior major
+ + +
(F),
+ indicates t h a t correspond ing ] eft-sided muscle causes flexion
and/or ro t a rion (of head with res pect [() C2) to Spalteholz,
Rl
Cl-2
This table lists muscles of the cranjoverte brJl j u n c t i o n serv i n g segm e n t s occiput - C l
(number 6).
Rr
Ll
+
O cc i p ut-C l
O bl iq u u s capitis superior
Lr
E
1 953).
righl (Rr)
or left
(RI);
-
(numbers 1 - 4),
OCC i p l l t to C2 (number
5)
and C t - 2
extension (E), l a t e ra l hending [() right (lr) o r left
i n d i cates no effect
(data
(L1)
eXl racted from the . n a t n m ical tex t book of
lumbar sp ine , a n d the cervical and lumbar spine of
Table 4.8
quadrupedal mammals (Fig . 4 . 1 8 left; Penning, 1 989) .
in tervertebral joints
Height of articular processes and slope oj
The slig htly bulging anulus fi brosus of such a disc al lows
o nly
til t ing
movements
of
the
adjoining
A
Vertebra
B
vertebra l end-plates, a ttended by stretching of the anular fi b res on one side a n d increased b u lging of the a nu l a r fi b re s on the opposite side . In the sagittal plane rhe t il ting movements co rrespond with flex ion - extension, a n d in the frontal plane with l a te ral
(24 - 5 1 )
C3
6.2 (0 - 1 4)
36.4
C4
8.7
4 0 . 3 (28 - 53)
C5
c6 C7
(4 - 1 5)
4 1 .7
1 1 . 7 (7- 1 8
39.7 (26-64)
1 3 6 (8-1 8)
3 1 . 4 0 7-46)
Results o f meJSure m e n t s of Nowitzke e/ al.
A
=
(22 - 59)
1 0. 2 (7- 1 5)
( 1 994)
of:
Mean he igh t (and spre
|
C3 - 7 w i t h respect t o cr;m i a l end-plates of ve rtebrol bod ies;
[3
=
m t: a n ori e n tation
(and
s p re a d , i n degrees) of superior
arricular
fa c e t s C 3 - 7 w i t h rcsp<.:: c r [0 posterior borders of t h e verteb ral bod ies.
b e n d ing. The c ross-wise arrangement of the anular fibres m a k e s p a ra U e I (slid ing) move m e n ts a n d rota tion vi rtually impossible (not more than 2 mm and 2 ° , respectively; Rolander, 1 966) .
The cervical
disc h as
a quite d ifferent shape. The
typ ical uncinate p rocesses have given the cervic a l d i s c marked upward s concavi ty i n the frontal plane
4. 1 8
(Fig .
right) .
This
combination
with
slight
upwards convexity in the sagi ttal p l ane gra nts the cervical elise a saddle shap e . Saddle-shaped joints have two axes of moti o n , perpendicular to each other and
located
on
opposite s i d e s of the j o i n t . The
flexion - extension axis of the cervical disc is in t he
Fig. 4.16 Articular and u ncinate processes C 2 - 7 . D rawing from a lateral radiograph of the cervical spine. Top s of the sup e rio r a rticular processes (smaller circles) rise high e r above [he correspond ing crani al ve r te b ra l end-pl ates at C7 than at C 3 . Instantaneous centres of motion (large r circl e s) a re nearer to the corresponding intervertebral di s c at C6-7 than at C2 - 3 . D i s t an c es between the tops of the art icular processes and the instan taneous cen tres o f motion a t aU l ev e ls are about equal . U n c i nate processes (shaded) are sm aller at C7 t ha n at C3 (wi th intermediate sizes in between).
lower
vertebral
rota tion
axis
is
body, in
the
and
the
lateral
u p p e r vertebral
bending body.
In
contrad i c ti o n , the two a x e s o f ovoid joints (like the oc c ipu t C 1 joints) a re located on the same (concave) -
s i d e of the joint (Fig. 4 . 7) .
The o b lique ori e n tation o f the upper axis i s in accordance with the coup l ing of rotation a n d latera l bending.
I f t h e orientation were parallel t o the
tra nsverse p l a n e , motion wou ld b e p u re rotation ; , if the orientation were parallel to the frontal plane ,
Copyrighted Material
Normal kinematics of the cervical spine 67
Fig. 4. 1 7
Sliding and t i l ting types of motion. Left : Flexion - extension at
200).
(range of motion
c ircle) is far from the intervertebral disc
C3
b o d y with m a rked step-off
in
C 2 - 3.
Slid ing of the
C2
20°).
C6 -7
and
(range of
I n s rantaneous centre of motion (indicated by s m a ll c i rcle) is near
the i n tervertebral disc of w i t hout
body upon t h e
end-positions of flexion (solid l i n es)
extension (i.nte rrupted lines). Right : Flexion - ex te n sion a t morion
C2 - 3
I n s t a ntaneous centre of motion (indicated b y small
step-off in
C6 -7.
Tilting of the
e nd-positions
of flex ion
C6
body upon the
(solid
lines)
and
C7
body
extension
( i n terrupred lines) .
motion would be p u re la teral bending. S i n ce t h e orientation i s in b e twe e n , m o t i o n i s a combination o f
ro tation a n d l a t e ra l ben d i n g in the same direction . On ana tomi c a l gro und s , the rotatio n - lateral bend ing axis is ex pec t ed to l i e in the mid sagittal pla n e ,
Fig. 4_18
a n d to be oriented more or less perpendicular to the p la n e
of
Wilmink,
the
1 987;
j oints
intervertebral Penning ,
steepness
of the
axis
I nstantaneous axes of motion in prototype disc and cervical disc . Left:
2
=
4
=
I
=
anuJus fi b rosus with cross-wise arrange m e n t
o f a n u l a r fi b res, a llowing t i l t i n g m ove ments only ; 3 flexion - extension;
and
and ori enta t i o n of the axis were d e t e rm in e d by Milne
( 1 993) . The
Prototype disc (resembling classic d isc) between two vertebral bodies. Posterior aspect of vertebral body ;
(Penning
1 989) . P re c i se localiza tion
=
instantaneous a x i s for
instantaneous axis for lateral bending to right and left. The
lumbar disc compares functionally with the p rototype disc. Right : Saddle-shaped
disc and uncovertebral j o i n ts between two cervical vertebral bod ies. 1 of Ilncovertebral joints indicated by uncinate processes; 2 an teri o r part of a n u l u s fi b rosu s ; 3 instantaneous axis for flexion - ell.1:e nsio n ; " instan taneo u s ax is for coupled l a t e ra l bending a n d rotation . Steepness o f the l a t t e r ax i s varies, depending o n the primary movement - steeper in rotation, less steep in lateral bend ing (M ilJle, 1 993). Note that ax e s fo r flexi o n - extension, a n d la teral bend ing ro tati o n , a re on op posite sides of the d i s c . cervical
=
S i te
=
=
=
Copyrighted Material
p roves
to
be
68 Clinical A natomy and Management of Cervical Spine Pain uncovertebral joints i s re f l e c te d by the s i z e o f t h e
u n cinate processes, a t C3 covering th e w h o l e latera l aspect of the ve rtebral body, while a t TI only cove ri n g i ts p oste ri or part (Fig . 4 . 1 9). Accord ing to Tonel ury ( 1958) and EcJdin ( 1 960), natural ageing of the cervical disc is re l a ted to the uncoverte bra l j oints. At the C2 3 and C3 - 4 levels -
a dvan ci n g age te n d s to extend t h e re l a tively l a rge j o i n t s p a c e s medially and s p l i t the cartilaginous d i sc into cranial and c a u d a l halves of about e q u a l thickn ess (Fig.
4. 1 9
ri gh t) . As t h i s leaves the c a r t il age i n ta c t
,
d i sc
he ight re ma i n s p reserved w i th o u t development of spondylos i s . At t h e lower le vel s , notably C5-6 and
C6- 7 , t h e s m a l l or absent joint spaces do not se rve a s a
starting point fo r regular splitting of t he disc . Fissuring h e re te n ds to s ta r t a t the c e n t re of the d i s c , rad i a ting
into aU di rec t ions ( F i g .
4. 19
r i gh t)
.
When fissures
become c o n f l u e n t , se qu est ra a re formed , fo l l owed b y d is a p pe a ranc e of c a r t i l age, d e c rease of elisc he i g h t and
Fig. 4 . 1 9
ageing. Left: FrOnGl1 uncinate processes ( 1 ) a n d u ncoverrebral joint spaces (2). The C2 - 3 d i sc (3) h a s relatively large u ncoverrebral j o ints while t h e C6 -7 d i s c h a s Un covertebral j oints a n d disc
section of adult cervi c a l spine with
rela tively s m a i l uncoverreb ra l j o ints (4) . Right: frontal section
C2 - 3 d i sc has been fissured by medial spaces (5); C6 -7 has been by irreg u l a r fissu ring, sta rting a t t h e cen rre (6).
of e l d e rly spine.
extension of u ncovertebra l join t cru m bled
d e pendent on the pri m a ry movem e n t : l ess steep in primary
l a teral
bending,
m ore
in p rim a ry
steep
rotati o n . The v ari ation in steepness is s m a ll at C2- 3 and large a t C7-Tl (lyse II
1969 ; Milne , 1 993) . An essential pa rt of t h e s a d dle·shaped ce rvical discs ,
are the uncovertebral jOints , flfst d escribed by von
Luschka in 1858 (Hall, 1 965) . In childhood , these
joi n ts sta rt a s fissu res i n the p oste ro l a te ra l anular fi bres of the cervic a l d iscs , between the d evelo pin g
uncinate processes and the co rresp on d in g excava· tions in the cranial vertebral bod ies (Fig.
4 . 1 9)
,
and
evo l ve i n t o d i a rthr o t ic j o i n ts in adult We (To n d u ry,
1 9 58) . They a l l ow the ty p ica l cervical sliding a n d rotation moveme nts, virt ual ly im p o ss ib l e in p roto·
type·like d is c s . Uncovertebral j oin ts a re best devel·
o pe d a t C2 -3 a n d C3 - 4 , and least, or n o t a t all, a t
C 5 - 6 a n d C6 - 7 (Tondury, 1958; Ecktin, 1 960). Th i s is
in accord a n c e with the extent o f sliding move m e n ts between cervica l verte brae which are
C2- 3
and
minim a l
at
C6-T l . T h e
maximal a t size
of
the
Fig. 4.20
backwards
by ro ta ting the
Botto m : Qu adnlped look i ng backw a rds by
rhe cervical spine.
Copyrighted Material
qu aclrupeds . cervical spine. latera l bencling of
Looki ng backwards in bipeds and
Top : B i ped l o o kin g
Normal kinematics Of the cervical spine 69
d e ve l o r m e n t of scle rosis a n d o s teop hytos i s of the
a d j oin i ng vertebra l k i n e m a tics,
d isc
bo d i es .
Seen
d egene ra tio n
in
thus
li ght of seems to be the
t i l t i n g type of flexion - extension m o t ion and re ta rd e d b y a s l i d ing typ e . Al tho ugh the c an i ne cerv i c a l s p i n e proper, C2 - T l , as opposed to the h u m an c e rv i ca l s p in e proper, is p romoted
a
by
,
v i rtua l ly
u na ble to rotate (rotation C I - 2 h a vi ng a b o u t
t h e s a m e ra nge a s i n h u m a n s ; Pe n ning a n d Bad oux,
) 987), its range of lateraJ be nd i n g C2 -T l l a rgely
exceeds that of h u m a n s : a bou t 3 0 0 p e r segment (bo th
P en nin g a n d Bado LL,( , 1 987) , as 1 2 0 per segment in the h u m a n spine (Penning, 1 968) The human ce rvical spine p rop e r thus h a s acqu i red its ability o f ro ta tion , it s e e m s , a t the c o s t of l a t e ra l bending. In a comp a rative a n a tom ical s t u d y of d r i ed ce rvical vertebrae, Hall ( 1 965) esta blished that uncinate sides
together;
o p posed to
processes (a nd hence also u ncovertebral joints) are
absent in quadrupedal animals, l ik e the dog, b u t
i n ob ligatory or fac u l ta t ive b i p eds li k e p rima tes rod ents and m a r s u p i a l s . Al l these bi ped a l a n im a l s h a v e to ro t a t e the i r neck to l o o k a bout them in the u p r i gh t p os i t i o n , whe reas quad rupeds d o this by b e n d in g t h e i r necks la t e ra lly (Fi g . 4 . 20). present
,
,
Accord i ng to M i l ne ( 1 992) , a l l species w i t h un
c in a te processes have a hand capable of m a ni p u la tion , p re h e nsi o n and b ri n gin g food to the m o u t h , the
u p p e r l i m b being s uppo r te d by an ossifi e d c l avic le
(spec ies without u n c i nate processes lack a c la vicle ) . He
s uggests
sta b i l i ze
the
that neck
u n c i nate
processes
a ga in st the
func t i o n
to
tu rning effe c ts of
latera lly d irected m uscle s s u pp o rt i ng the upper lim bs (scal e n u s ,
l e va to r
masto icleus) .
sca p u l a e ,
t ra pezi u s
and
sterno
(SupP/)
123: 5 - 61 .
Markuske, H. ( 1 97 1 ) U n te rsuchungen z u r Statik und Dyna mi k del' kindUchen Halsw irbe lsa u l e . Der Aussagewert seitlicher Rbntgenaufnahmen . Die Wirbelsaule in For schung lmd Praxis, vol. SO. Stuttgart: H i p pokrares. M ilne, N. ( l 992) The effecr of uncinare processes o n motion i n the neck. Proc. A ustrctlas. Soc. Hum. B ioi. 5: 3 4 5 - 3 5 7 . Mil n e , N. ( 1 993) Composire motion in cervical disc seg ments. Cfin. B io m ecb a n . 8: 1 9 3 - 202. No wi t z k e , A. , Westawa)', M . , Bogd u k , N. ( I 994) Cervical zygapophysea l join ts . Geometrical parameters and rela tionship to cervical kinematics. Clin. Biomechan. 9: 342 - 348. O d a , T., Panj abi , M . M . , C risc o ].]. , Bueff, H . U . , Grob, D., Dvorak, ]. (1 992) Role of tecto rial membrane in the sta b i l i ty of t h e upper cervical spine. CUn B iomecba n 7 : .
Amevo, B . , Wo rth , D. , Bogd u k , N . ( 1 99 1 a) I n stantaneous axes of rotation of rhe typica l cervical motion segments. I . An em p i ri c a l s tudy of tec hnical errors . Clin. Bio
6: 3 1 - 3 7 .
Arnevo , B . , Worth, D. , Bogd uk, N. ( 1 99 1 b) Instantaneous a xes of rotation of the typ ical cervical motion segments. I I . Optimization of tech n i cal errors. Oin. Biomecban . 6:
38 - 46 Arnevo, B, Worth, D. , Bogd u k ,
N. ( l 99 I c) Instantaneous axes of rotation of the typ ical cervical motion segments. m . A study in normal volunteers. �in. Biomechan. 6:
1 1 1 - 1 1 7.
Ar l e n , A . ( 1 9 77) D i e " paraeloxe Kip pbewegung d e s A t l as i ll tier Funktionsdiagnostik tier H a lswirbelsa u l e . Man. Med. "
1 5 : 1 6 - 22.
748 - 7 5 5
Eckli n U . ( 1 960) Die Altersverdnderungen del' Halswirbel saule Berli n : Springer. Exner, G. ( 1 9 54) Die Halswirbelsdule. Pa tbologle und Klin ik. Stuttgart: Thieme . Fick, R. ( 1 904 , 1 9 1 1 ) Handbuch del' A natomie und Mechanik d� Gelenke. Jen a : Fischer. Gertzbe i n , S . D . , S e l i gm a n , ]., Holtby, R. et al. ( 1 985) Centrode patterns a n d segmental inst.1 bility in d egen e ra t i ve e1isc disease. Spine 10: 2 5 7 - 26 1 . Gutmann , G. ( 1 960) Die Wirbelblockierung und i h r radi ologischer Nachweis. Die Wirbelsdule in Forschung und Praxis, vol . 1 5 . Stuttgart: Hippokrates , pp. 8 3 - 1 02 . H al l , M . e . ( 1 9 6 5) Luscbka's joint. Spri ngfiel d , I L : Charles C. Thomas. Lewit, K . , Kra usova, L. , Kneidlova , D. ( 1 964) MechanislDus tlnd Bewegungsa usmasz der Seitneigung i n den Kopfge l e n ke n . Fortscbr. Rontgenstr. 1 0 1 : 1 94 - 201 . Lyse l l , E. ( 1 969) Motion in the cervical spin e . An experi mental study on a u topsy specimen s . Acta OrthOp. Scand.
,
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70 Clinical A na tomy and Management of Cervical Spine Pain Pen n in g , by
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].
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Spine
17:
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de
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,1llrnpsy specinl e n s . A cta Ortbop Schonstro m ,
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Penn ing, L. , Wilmink, J . T. ( 1 987) ROl.a tion o f t h e cerv i c a l spine.
der A nato
Bewegungsa{l{loral.
( 1 958) Entwicklungsgesch irhll1
spine in the dog c o m p a re d
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1.
(ed . ) Amsterdam : S c h e l teInll
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Pe nnin g ,
f-Iandatlas und Lebrbuch
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some
Re ich,
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35:
Taylor,
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The l a t c rlli
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�ri n e . sum m a ry in Engli sh). Thesis, G ro n i ngen
')59)
Cl''' "lO\ ('I'l ebral
The
possibilities 01
j oints.
A cta
Ortho{l
Pan j a bi , M . M . ( 1 978) Clinical Phil adelp h i a : Lip p i ncott.
Copyrighted Material
72 Clinical Anatomy and Management of Cervical Spine Pain that same year the Insurance Institute for High w ay
muscles of the neck, including s tretching , tear ing and
Safety reported a 24% incidence of th ese injuries
haemorrhaging of the longus co lli longus capitis, scalenes and sternoc!eidomastoids, have long been though t to be the primary reason for pain (lieber man, 1986). Re cen t work ut i li z ing surface electro myography has d emonst rated, within the limitat ions of this technology, that neck muscles foll owin g injury are abn ormal in terms of their functioning (Donald son, 1995). A critical element of the debate a bout pers istent pain revolves around the normal antici pated time for musc uloligamentou s healing to occur. The Quebec Task Force (1995) notes:
following rear-end collisions. Similarly, Macnab (1964, 1969, 1971, 1982) estimated that neck injuries occurred in one-fLfth of all accidents invol v ing rear-end coll isions Schutt and Dohan (1968) calculated the number of neck injur ies sustained in automobile accidents to be 14.5 per 1000 indus tr ial employees The cost of whiplash injuries is high. In Briti sh Columbia and Saskatchewan , two Canadian prov .
.
inces
with
single-payer
motor
vehicle
insurance
programmes, 68% and 85% respectively of all claims
,
paid Ollt were for whiplash injuries (Sobeco et al., 1989; Giroux, 1991; Quebec Task Force, 1995). The Quebec Task Force (1995) es t imated that the annual incidence of com pensa ted whip las h in the p rovince of Quebec in 1987 w as 70 per 100000 inhabitants.
Apart from anatomic studies, much of the understanding of soft ti ssue injury and hea ling is derived from animal models, and there is little informa tion 0.11 the normal recu peration period. In th e animal model of soft tissue healing, there is a brief period (less than 72 hours) of acute inflammation and reaction, followed by a per iod of repair and rege ne ra tio n (approximately 72 h o urs to up to 6 weeks), and finally by a pe r iod of remodeling and rematuration that can l ast up to 1 year.
sc ientific
Biomechanics and pathophysiology of whiplash injuries Typically the injured individual is the occup a n t of a sta tiona ry vehicle which is struck from behind (Commack, 1957; Macnab, 1964, 1969, 1971, 1973, 1982; Hohl, 1974; Frankel, 1976; laRocca, 1978; Bogduk, 1986; Deans, 1986) although injury fre quently occurs followin g side and head-on collisions (Deans, 1986). Injury results when neck musculature is unable to compensate for the rapidit of head and torso movement res ulting from the acceleration forces gene ra ted at the time of impact (Hohl, 1989). y
When the physiological limits of cervical structures are
exceeded,
anatomical
disruption
of the soft
tissues of the nec k (including muscles, l i gaments and
joint
capsules) results.
While the mechan ism of injury is relatively well understood and gen erally agreed upon, the actual
pathological lesions accounting for chronically symp tomatic whiplash injuries are by no means certain. Possible pathological lesions following whipl ash in juries are listed in Table 5.1. Injuries occur rin g to the
Table 5_1 Possible pathological lesions in wbiplash injuries
Muscle strain Zygapophysial joint sprain or fracture Anterior and/or posterior longitudinal ligament strain or tear Intervertebral ligament sprai.n or tear
herniation haematoma trunk injury
Supporting struct ure s around facet join ts may also be sprained or suffer c a rtilaginous d amage or fracture (Lord et
al., 1993;
Barnsley et aI., 1994). This was ele
ga n tly demonstrated in a carefully controlled trial with
diagnos tic local anaesthetic blocks. In t his double blind study, over half of consecutively referred whi p lash patients experienced temporal)T relief from injec tions and the expected temporal difference in symptom relief was observed between injections of l o ng-act ing or short-acting local anaes thetics (Barnsley et aI., 1993b, 1995; Lord et al., 1993). The anterior and posterior 10ngitudinaJ spi na l l i g a ments can theoreti ca Uy undergo stret ching and possi ble tearing (Macnab, 1964,1969,1971,1973,1982; Clemens and Burrow, 1972; Bogduk, 1986) although the recent introduction of ma gnetic resonance i maging (MRI) sca n ning has failed to re veal major injuries to these structures. Eso phage a l and laryngeal damage as well as injury to the cervical sym pa t h et i C chain have also been reported (M acnab, 1964, 1969,1971, 1973, 1982), although evi dence that these injuries are common or significant is lacking Finally, injury to th e brain (discussed later), temporomandibular join ts and low back following whjpla sh has been reported b ut remains controversial. The pathophysiology of whiplash injuries is discussed in more detail elsewhere (Bogduk, 1986; Barnsley et al., 1993a; Lord et al., 1993). .
Intervertebral disc Retropharyngeal Sympathetic
Vertebral artery ischaemia ConCUSsion or mild traumatic brain injury
The clinical picture of whiplash injuries
Thoracic outlet syndrome Temporomandibular joint dysfunction
The clinical picture of whiplash is d ominated by head, neck, and upper thoracic pain and is often
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Whiplash injuries 73
associated with a v a riety of poorly expl a in ed symp
Radiological findings
toms such as dizziness, tinnitus and blurrecl vi sion . The sym ptom complex is remark a bly consistent from
Radiological studies of the cervical spine taken at the
patient to patient and freq uently is complicated by
time of the accident are ge nerally unremarkable or
psychological sequelae such as a nger, an.,'(iety, dep res
reveal evidence of pre-existing d egen erative changes .
sion and concerns over litigation or compensation. In
The most commonly reported abnormal X-ray
their cohort study, the Q uebe c Task Force (1995)
is straighteni ng of the nor m al cervical lord otic curve
found
the
highest
incidence
of
whiplash
claims
1974).
(Hohl,
H oweve r,
HohJ
fmding
(1989) noted that
among the 20- 24-ye ar age group . The potentiaJ array
straig htening of the cervical spine was not necessarily
of physical and psychosocial co m plaints
indicative of a pathological condition (Bor den et at.,
is listed
in
Table 5.2. Females appear to experience whiplash injur ies
1960; R achtman etal., 1961; Hohl, 1974) and can be 1989). Rar el y,
regarde d as a normal variant (HohJ,
1980; Quebec Task
X-rays may reveal evidence of bony injury such as
Force, 1995). Women generally have slimmer, less muscular necks which, theoret ically, are less able to time of impact. Other possible reasons for the sex
posterior joint crush fractures or minimal subluxation (Macnab, 1971). Radiological i nvestigations are of limited value in diagnO Sis an d prog nosis and their main use is in ruling out surgically correctable
difference are that women may be more likely to seek
anatomical
medical attention; be sent to med ical specialists for
scannin g and MR.I shoul d be reserved for cases where
men (Balla,
more often than
resist damaging acceleration forces generated at the
complaints of
p ai n; respond to their injuries in a way
that aggravates their cond ition ; or be s ubjected to
cervical
injuries.
Computed
disc protrusion or
tomographiC
(Cn
spinal cord injury is
suspected. Radionucleotide bone scanning is war
more external stressors making it m ore difficult for
ranted if there is Significant clinica l s llspicion of an
them to
undiagnose d fracture (HohJ, 1989).
cope. At present, the sex difference with
respect to those p resenting with whiplash symptoms remains unexplained.
A delay in onset of symptoms of several hours following im pact is character i stic of wh ipl ash injuries
(Dunsker, 1982; Deans et at., 1987; Evans, 1992).
Clinical features of whiplash injuries Local tenderness and referred pain
Most patients feel little or no pain for the fi rst few sym ptoms
Local tenderness and pain referred to areas distal to
gradually intensify over the next few days . In the first
the original injury are two hallmark features of the
minutes few
injury,
following
hours
findings on
after
which
examination are genera l ly
minimal (HohJ, 1975). After several homs, limitation tigh tn e ss ,
aetiology
of these two
muscle spasm and/or
although a poorly understood clinical entity, is felt by
swelling and tenderness of both anterior and pos
many (arguably most) clinicians to accou nt for the
of neck
motion ,
syndrome. The
w hi p las h
clinical features rema in s enigmatiC. Myofascial pain ,
terior cervical strllctures become apparent (Hohl,
majority of persistent neck, head and upper thoracic
1975; Wickstrom and la Rocca , 1975). T his delay is
pain following whiplash injury (Fricton, 1993). The
likely due to the time requi red for traumatic oedema
tr igger po int is reg ar d ed as the characteristic feature
and haemorrhage to occur
of myof ascia l pain (fravell and Simons, 1983). Myofas
in in j ured soft tissues
Oeffreys , 1980; Lieberman, 1986)
cia I
trigger poin ts are circumscribed,
2-5 mm in
diameter, self·sustaining, hyperirritable foci of tender
ne ss reported to be located within
Table ;.2 Potential presenting problems in whiplash Neck and shoulder pain
Headache
Arm
pa.in/paraesthesiae/\"Veakness
Dysplusia
a
ta ut band of
skeletal muscle 'or its associate d fascia. Compr essing this tr igger point is localJy pa i nful and may give rise to ch a racte ristic referred p ain ,
tenderness and
auto
nomic phenomen a . The area of pain refe r ral, which is
often
surprisingly
consistent
across
patients ,
is
termed the zon e of reference.
Visual symptoms
Myofascial pain is thou ght to result from an acute
Dizziness/verrigo
muscle strain or overload which occurs at the time of
Tinnitus
im pact .
Low back pain
neuromuscular ir ritability d evelops
Temporomandibular joint symptoms Depression Anxiety (including paniC attacks)
Anger and frustration Loss of job and income
Marital
and
family
Drug dependence
disruption
One
hypothesis
is
th at
a
small area
and
of
becomes self
sllsta i ning , resulting in a tr igger point (Trave ll and Simons, 1983). Aggravating factors are usually related to activities or postures which lead to contraction or tension of involved muscles while alleviating factors often contribute to relaxation of the involved mus
cles. Myojasciat trigger points throughout the cer vical
and
upper thoracic musculature often sen d
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Copyrighted Material
Copyrighted Material
76 Clinical Anatomy and Management oj Cervical Spine Pain setting of the individual patient. This is illustrated by
As well, since the perception of pain represents an
one particularly
of
interaction of sensory, affective and cognitive pro
with
cesses (Melzack and Wall, ) 983), clepression and/or
patients,
the
difficult
excessively
and troubling group busy
perfectionist
chronic whiplash pain.
anxiety may heighten the affective component of pain perception. Thus increased anxiety, depression, and continuous attempts to 'push through' the pain
The excessively busy perfectionist
often result in significant emotional and physical
The influence of a person's personality or life-coping skills
in dealing
with
the
pain
and
subsequent
disability of a whiplash injury cannot be under
deterioration. The perfectionist patient may become increasingly
depressed
and irritable
as goals
are
blocked. Emotional distress may lead to interpersonal
estimated. In our practice the most common dysfunc
and occupational difficulties which further increase
tional coping style is seen among whiplash patients
anxiety. Marital, financial and job security stressors
who premorbidly were excessively busy perfection
may further compound the problem.
ists. Research on perfectionism and its significant role
As a consequence of their high internal standards,
in psychological disorders , particularly depreSSion, is
perfectionists often see themselves as totally disabled.
relatively new (see Blatt, 1995, for a review). One
An inability to do their jobs perfectly is viewed as an
type of perfectionism,
referred to as self-oriented
inability to do their jobs at all. Emotionally, it is more
(Hewett and Flett, 1991) is particularly germane. SeLf
acceptable to be physically <.lisabled by pain than to
oriented perfectionists have exceedingly high, seLf
do a less than perfect job with resultant feelings of
imposed and often unrealistic standards. Premorbidly,
inadequacy and self-denigration. A premorbidly suc
this is associated with some very adaptive traits and
cessful and seemingly well-adjusted individual sud
associated accomplishments. However, there is an
denly becomes an irritable, argumentative, anxious
underlying self-scrutiny and self-criticism with an
and depressed individual claiming total disability. A
attendant inability to accept personal f laws or fail
feeling of lack of control eventua.lly leads to a sense of
ures. These individuals are particularly vulnerable to
helplessness and defeat. Third-party payers often inadvertently make the
react to experiences of failure with significant levels of depression (Blatt and Zurloff,
1992) and stress
situation worse by withholding or delaying financial compensation, thus contributing to an..xiety about
(Gruen et al., in press). Self-oriented perfectionists have an intense need to
meeting fLl1ancial obligations and increasing feelings
maintain their excessively high standards which post
of inadequacy, helplessness and victimization. This
injury are no longer realistic given pain-imposed
decision to withhold benefits is often based on the
limitations. When the physical limitations inlposed by
belief that the patient is not disabled and the problem
maintaill their
is really psychological or motivational. The perfec
exceedingly high levels of productivity, they experi
tionist interprets any suggestion of psychological
their pain do not allow them to
ence considerable distress and try even harder to
difficulty as tantamount to being viewed as emotion
push themselves despite their pain. Sustained lligh
ally inadequate
levels of activity in the face of pain combined with
assault on an already deteriorating self-esteem. Any
and weak, resulting in a further
high levels of anxiety further increase their pain, thus
suggestion that the problem is motivational is viewed
requiring sustained periods of rest. However, these
with disbelief and outrage, especially in light of
periods of rest are viewed as non-productive, leading
previous
to more anxiety and compelling the individual to
morbid levels of activity and productivity despite
make up for lost time with further overactivity. This
increaSing
continues until pain again becomes overwhelming,
expect others (including insurance representatives)
unsuccessful attempts pain.
Moreover,
to
maintain
perfectionists
pre often
requiring the individual to rest. Rest is again viewed
to conform to the same unrealistically high standards
as non-productive and again generates anxiety and
that they expect from themselves. This further fuels
overactivity. The injured individual cycles between
their outrage and sense of victimization. The end
periods of overactivity followed by underactivity with
result is that they vacillate between intense anger at
escalating levels of anxiety as overall productivity/
the third-party payer, for withholding benefits and for
activity levels continue to drop. Depression ensues,
questioning their adequacy and integrity, and intense
as self-esteem in these individuals is dependent on
anger at themselves for failing to overcome their physical and now mounting emotional difficulties.
their excessively high standards of productivity. Although the role of emotional distress in exacer bating
musculoskeletal pain
dence
suggests
that
is controversial,
stress-induced
elevations
Self-directed anger is also experienced as very sig
evi
nificant depression. In many cases, what appears to
in
be an extreme preoccupation with the unfairness
extended period of tinle lead
(albeit real) of the system and an inability to 'let go' of
to increased pain in patients with facial, back and
their anger is a self-protective mechanism (defence)
head pain . This tension may increase pain through
against underlying intense feelings of inadequacy and
muscle tension over
an
reflex muscle spasm, ischaemia and/or the release of
worthlessness. This emotional turmoil , in turn, fur
pain-eliciting neurotransmitters (Turk and Flor, 1984).
ther exacerbates pain and disability.
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Whiplash injuries 77
Natural history and prognosis of whiplash injuries It is difficult to be definitive regarding the natural history of whi plash as there is a paucity of longitudi nal studies in anything hut selected populations, e.g. individuals who attend specialists or who seek attention in a local emergency room. However, it appears that in many cases, the natural. history of soft tissu e injuries follow i ng motor vehicle accidents is for recovery over a limited time period. It is only a minority of patients (fewer than 10%) who go on to develop chronic disabling pain (Nygren, 1984; Pearce, 1989) although, as discussed below, many more patients have persistent symptoms. Defming recovery can be problematic. As part of the Quebec Task Force study (1995), a cohort of 4757 subjects who submitted claims in 1987 to the Quebec provincial (single-payer) insurance plan were reviewed. A significant munber were excluded because of lack of police collision reports (1745) and because of a previous i.njury accident (204). This left 2810 patients. Cumulative recovery rates were 22. 1 % within 1 week, 53% within 4 weeks, 64% within 60 days, 87% by 6 months and 97% by 1 year. It was not clear whether patients had actually returned to work (or usual activities) or were simply deemed able to do so by the insuring agency. There was no indication whether patients suffered residual pain. It is of note that the percentage of motor vehicle claims paid out for whiplash under the Quebec no-fault system was only a fraction of that paid out by Canadian provinces with a tort system (Quebec Task Force, 1995). Accordingly, the high recovery rates in the Quebec Task Force cohort may s imply reflect a higher threshold for allowing con tinued claims of d i sability. Compare this to a study by G a rgan and Bannister (994) who studied 50 consecutive patients with soft tissue neck injuries attending an emergency room within 5 days of the accident. At 3 months 15 patients were asymptomatic. Of these, 14 (93%) were still asymptomatic at 2 years. Thirty-five patients were symptomatic after 3 mont h s ; of these, 30 (86%) remained symptomatic after 2 years. After I year, 26 of the 50 (52%) reported they had recovered com pletely but only 19 (38%) at 2 years. Radanov et al. (1994) studied 117 patients referred by primary care physicians with a diagnosis of whiplash. Patients were referred speCifically for the study which limited selection bias. Initial assessment was conducted on an average of 7 days: 51 (44%), 36 (31 %) and 28 (24%) of patients were symptomatic at 3, 6 and 12 months respectively. Hilclingsson and Toolanen (1990) prospectively studied 93 consec utive cases referred acutely to an orthopaedic depart ment because of a 'noncontact injury to the cervical spine resulting from car accidents'. At fOllow-up, an
average 2 years after the accident, 42% recovered completely, 15% had minor discomfort, and 43% had discomfort sufficient to interfere with their capacity to work. Bannister and Gargan (1993) reviewed both pro spective and retrospective studies and concluded that symptoms present at 12 months post-collision were not likely to resolve further. In the only long-term study of note, Gargan and Bannister (1990) found that patients who were symptomatic at 2 years remained symptomatic 8-12 years later.
Mild traumatic brain injury associated with whiplash: the controversy The presence of traumatic brain injury in association with whiplash has been postulated based on the observed similarities between the whiplash syn drome and post-concussion syndrome. Alves et al. (1 9 86 ) reported that 6 months after injury the most common complaints following concussion in order of frequency were: headache, memory defiCits, dizzi ness, tinnitus and hearing abnormalities, numbness, weakness, nausea and diplopia. Many of the com plaints lasted for over 1 year with the majority of patients exhibiting at least one or two symptoms. In concussion there is evidence for a tranSitory impair ment of information processing (Radanov and Dvorak, 1996). Like post-concussion syndrome patients, many whiplash victims report feeling dazed or in shock immediately post-trauma and whiplash amneSia has appeared in case reports in the neuro logical literature (Fisher, 1982). In recent years, a number of researchers have argued that the cognitive difficulties reported by patients with whiplash are the result of a mild traumatic brain injury sustained as a consequence of the violent hyperflexion and hyperextension of the neck (Berstad et ai., 1975; Yarnell and Rossie, 1988; Olsnes, 1989; Kischka et aI., 1991; Radanov et al., 199 2) This has been postulated to occur on vehicu lar impact because the skull accelerates faster than the brain and subsequently impacts with the brain as it rotates backward s or accelerates forwards. Mild traumatic brain injury has been postulated to occur despite the fact that at the time of the accident patients with whiplash rarely experience loss of consciousness or post-traumatic amnesia, both con sidered by some authorities to be important diag nostic criteria for mild traumatic brain injury (levin et at., 1989; Gronwall, 1991; Kay et at., 1 992 ). Althou gh some laboratory studies using non human primates indicate brain damage can occur in simulated hyperextension - f1ex.ion injuries without loss of consciousness (Ommaya .
Copyrighted Material
78 Clin ica t Anatomy and Management oj Cervical Spine Pain et at., 1968; Wickst rom et at., 1970; Domer et al., 1979; Liu et at., 1984), th e anatomy of non human of
primates
humans.
but
in
This
need
of
mark edly
is
different
from
that
ren d ers a nimal data su gges ti ve hum a n
confirmatory
traumatic
brain i nj ury
awaits a
prospective
tional fu nctioning.
research
(Sha piro et al., 1993).
A rev i ew of human research finds little or no evidence for endur i ng brain injury after w hi pl ash (Shapiro et at., 1993; Radanov and Dvorak , 1996). There is no conclusive
mild
study that adequately controls for p ain and emo
evidence fo r neuropatho
logical abnormalities after whi plash . A number of studies have reported electroencephalogram (EEG)
abnormalities suggestive of br a in injury in p a tients
with whiplash; however, the reported incidence of th ese abnormalities ranges from 4 to 46% (Torr es and Shapiro, 1961; Gibbs, 1971; Jacome, 1987). Although all of the EEG stu d ies have methodologica.l problems , the study r eporting th e h ighest incidence of EEG abnor malities (46%) is par tic ularly flawed (Torres anel Shapiro, 1961). Neuropsychological assessment is
Medical management of whiplash injuries A wide var iety of interv ent ions are available to treat patients with whipl a sh injuries (Table 5.3). Unfortu n a tely, th e re is a paucity of a dequate clin.ical trials, and reports of efficacy r ema in largely anecdotal No treatment con s ist ently cures the pain of whiplash i njuri e s . Treatment programmes should attempt to balance pain control with increased Junction, although in rec ent years there has been a t rend towards focusing primarUy on the latter. The concept that some injuries resu l ti n g in pain may be inacces
sible to p hys ica l and pharmacological treatme nts is
a
thought to be more sensitive for detecting mild b ra in
difficult one for many p a tien t s (a11(1 some clinicians)
injury,
to grasp and acc ep t .
and
a
number
of studies
report
poorer
Since there is
a lack of good
of
clinical trials the discu ss ion that follows is based
in groups of chronic
largely on OUf own a nec dota l ex perienc e. Table 5.3
whi pla sh patients 1 year or m ore after injury (yar nell
are
performance
on
neuropsychological
concentration and memory
measures
divides available treatments into those which first,
and Rossie , 1988; Olsnes, 1989; Kischka et al., 1991; Rad anov et aZ., 1992).
Patients in these stu d i es
are
usually recruited from specialty clinics and typ ically represent a select sample with long-standing com plaints
of
disabling
pain,
e mot ional
distre ss
the
d ocum ented effects of pain, medica
tions , depression and anxiety/arousal on cognitive
(S h a piro et at., Dvorak, 1996).
functioning
The
only
prospecti ve
1993;
study
Radanov
and
an
un
evidence of cog nitive deficit 6 months after injury
et at., 1993). It is of note that the literature on mil d traumatic brain inj u r y suggests that difficulties in cogn.i tiv e function.ing as assessed (Radanov
neuropsychological
testing
no rmalize
by
3 months after injury (Ge n til ini et al., 1985; Huggen h oltz et al., 1988; Gronwall, 1989; Ruff et at., 1989). Given tllis li te ra ture on recovery of function in mild traumatic brain injury and
research documen ting the del eterious effect of pain
distress on cognitive func tion ing (Stromgren, 1977; Weingartner and Siberman, 1982; Coyne and Gotlib, 1983 ; O'Hara et at., 1986; Jami son et at., 1988; Kewman et at., 1991) one need not pos t ulate a trau m atic brain injury to account for persisting cognitive problems in samples of chronic w h ip l ash patien ts (Shapiro et at., 1993). The two prospe c tive studies to assess neuropsychological fun c tioni ng w it h in a week of inj u ry have failed to use adequa t e cont rol groups (Et t lin et at., 1992; Radanov et al., 1993). Accordingly, a definite con clusion regard ing acute cognitive deficits related to and
emotional
Treatments oj obvious benejlt Education Exercise·oriented physiotherapy (stretching
Treatments to follow
sel ec ted sampl e of patients with whiplash found no
by
Medical management oj whiplash
an d
cogni ti ve difficulties. These studies have failed to control for
Table 5.3
and
aerobic
exercises)
whicb decrease pain
Cervical coliar Physical modalities (e.g. local heat,
ice,
ultrasound,
interferential current)
Analgesics, muscle M an i pu la ti on
relaxants, antidepressants,
TENS
Cervical traction Massage therapy Relaxation therdpy Trigger point injections Acupunctllre Treatments wbich improve
coping skills
Psychological counselling Vocational counselling
Treatments oj dubious value Occi pital nerve blocks Non-steroidal anti-inflammatory drugs Intra-articular (facet j oint) corticosteroid injections Discecromy /surgical fusion MagnetiC neck/;Ice
Potent/al treatments tbat sholl' some promise Selective muscle retraining
denervation programmes
Percutaneous facet joint Functional restoration TENS
Copyrighted Material
=
Transcutaneous electrical Ilcrve s(imul:ltion.
Whiplas!J injuries 79 agreed to be of benefit; second, serve to decrease fourth, are of
pain; third, improve coping skills: dubious value, and
beneficial in the short and long term. This suggestion sbould be confirmed in future studies'. note. McKinney et al.
promise.
receiving 2 weeks of McKenzie and Maili:lnd
to be of
Treatments benefit
demonstrated and soft collars. However,
Education
bet,veen t h e two groups
Education of the patient (and family) is a critical
2-year foLlow-up.
element of any treatment programme. Patients must
given advice on early activation and a home pro
Moreover,
a third group simply
clearly understand the goals of treatment - return of
gramme of exercises did better than either group.
function, control of pain - and the W(ely prognosis .
Mealy et al.
Education helps patients plan realisticaLly for their
Maitland mobilization techniques had m ore short
future, provides them with a sense of control, and
term relief of pain and range of motion than patients
increases their confidence in the treating clinician.
prescribed rest and a soft cervical collar.
(1986)
reported that patients receiving
Patients must understand that 'hurt is not equal to harm'. Many patients
activities and allempt to avoid
movement of their
This may result
pain and by inferene!" in gen eral decondillolli n g
Treatments decrease
serve primarily
constriction o f neck that advice
muscles. McKin ney to mobiJize, exerci�c,
pain tolerance
and avoid dependencc
:malgesics was
These
are listed in Table
the
53
used treatmen ts in the
mem uj
They provide subsets
as effective as a phYSIOtherapy-directed programme.
patients With consistent relief of pain. Unfortunately,
Information
it is impossible to predict in advance whether a
aggravate pain (heavy lifting or maintaining pro
particular treatment will relieve pain for a given
longed postures) help prevent signit1cant exacerba
patient. As well, the b e nefits of these treatments are
For chronic whiplash
tions of pain.
patients, an
emphasis on proper pacing of activities is helphll often critical.
invariably
short-lived.
Patients
ofte n
regard
these
treatments as their only consistent source of pain relic{ and many believe these treatments improve their
quality
of lite,
fo r
a
often
short time. view
utility
are reluctant t o fund
graduated is thoughl
maximal healing of
This
as to how long one
damaged soft tissues
enroLled in a
fu nd
temporariJy reduce pain wit.h
programme
efficacy. It is of notc
exercise.
of
Stretching of muscles
to their normal
In
them
without proven l o ng-ter m
expenSive, is gentle an d
Early mobilization
albeit payers
contras\.
Exercise-oriented
some
are more readily
length has long been thought La maximize function
(e . g . medications) [han others.
ing . Stre n g the n i ng exercises are con t roversial and
such as physical modalities, massage, manipulation
Passive treatmellts
often aggravate pain, particularly if introduced too
and even medications, if not performed within the
early or too aggressively.
framework of an active rehabilitation programme
Isometric strengthening Theoretically,
may potentially result in greater dependence on the
strong neck musculature is desirable to provide an
part of patients and discourage them from taking
exercises
may
be
active physiological
tolerated
better.
splint which can potentially
reduce pain. Formal exercise programmes should be time-limited with a programme. divided
by
Exercise the
active
responsibility
for
their
own
rehab
home exercise I reatments
(1995)
Quehec
were into
mobilization and
mobilization
they noted: 'The CUIJ1Iilal
suggests that
mobilization techniques
an adjunct to
strategies that promote
combination
with activating intervenuons,
Illore
ilitation.
they
Cervical collar still enjoys popularity,
Initial
1.0
be declining. Researc·h
its
efficacy.
A
controlled.
demonstrated that patients
double
appear to be
Iizecl early wlthom a collar experienced a greater
beneficial in the short term but the long te r m benefit
reduction of pain and improved cervical range of
has not been established'. R ega rdin g
exercise
they
noted: 'The cumulative evi cl en ce suggests that active exercise as part of a multimodal intervention may be
motion (Mealy
et al., 1986) relative
to rest and use of
a coUar. This result was confirmed by McKinney
(1989). H owever,
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another prospective study failed to
and
ad
80 Clinical A nato m v and MalUi,gement of Cerl'ical Spine Pain d e m o n s t ra t e d ifferences between e arly ac tive tre a t
a n ts a p p e a r to work p r imarily t h rough their anxi
ment w i t h traction a n d p hysiothe rapy c o m p a red w i t h
olytie effe c t a nd have n o t been adequately s tu d i e d
collar and u n s u p e rvised mobilization (penn i e
(Quebec Task Forc e , 1 99'i) N a rcotic �nalgesics must
rest in
a n d Aga m h a r, 1 99 1 )
soft
truly i m m o b i lize
collar
carefu l ly trloll itored
not
1 97 3 ;
neck (Col a c h is et
the risk
their use
toleranct"
becau,;c
a d d i ctio n ; t il e issut"
Fisher et at. , 1 977; Johnson et al., 1 977). If a cervic a l
n a rcotic use in c h ronic pain i s not fu lly reso lved
c o l l a r i s prescr i b e d , c o ntinu o u s u s e for m o re t h a n 2
(B re n a and S a n d e r s , 1 99 1 ) . Long-term narcotic use
weeks should be d is c o u raged (Tl"aseU a n d S h a p i ro ,
has
1 99 3 ) . Accord i n g
1 9 H 6) a n d
Liebe r m a n ( 1 986) , prolonged
i n g d is u s e a t rophy o f t h e nec k muscles, soft-tissue
rl iscouragerl
(Lieberman .
o p m l o n p,l t l en t s
avoi ding
variety of c o m p l i c a t i o n s i n c l ud
l e a d s to
collar
been
tra d i tiona llv
better SeriTe!
al. ( 1 996) .
Moulin
a ra ndom
ized controlled tria l , fou nd that a lthough morph ine
c ontra c t u res , shortening of m u s c l e s , thicken in g of
red uc e d p a i n in
s u b c a p s u l::! r
w h o m h a d su ffe re d wll i p l ash i n j u rie�. there was no
tissues.
enh a n c eml� n t
of
i n c reased
fcc l mgs
chronic collar use
of
d e p e n dence d i s a b ility.
the risk
and
A l t h ough
i a troge n i c c ompli
c orresp o n d i n g
chronic
p a in s ufferers, m a ny of in
i m p rovel1l e ll t
do ta l ly we suspect m a m
fll nction.
Ane('�
strong
patients
c a t i o n s , a necdotal ly we h ave observed that w h i p l a s h
c o t ic medications m o re fo r their mood-e n h a n c i ng
p a tients freque n t ly fmd
p ro p e r t i e s .
control
p a in
periods
when
t h a t c e rvical c o llar s h e l p
used
j u d i c i olls l y
fo r
l i mited
Tricyclic a ntidepressants (TeAs). i s te red
t im e .
doses i)cf(lre
in
a n t I(jepressan I doses,
or i n
often h e l pf u l in chroll.ic
pain patients, espe c i a lly those with a n o n-restorative
Physical modalities
sleep pattern (Bu t l e r, 1 9 8 4 ; Ward , J 986) . TeAs have
I c e packs may be h e l pfu l in t h e early a c u te p hase o f
(3 - 10
whiplash
e i t her admin-
beci t i m e
l im i t
after t h e a c c i d e n t) the acute phase,
m u s c l e ,we Uin g .
hot
p a c k s , u l t rasound and int e rfe re n t i a l c urrent o r tra ns
heen shown to h ave an a n Cl lgesic f"fft>n i n a n i m a l s t u d i e s (Sp i egel et al.,
TeAs ' mechanism
anion is not
re lated
b u t IHav
their
to block t h e r e u p t a k e of sero t o n i n , t h e r e b y e n h a nc
c u taneous e l e c t r i c a l nerve stimul a t i o n (TENS) may
ing e ndogenous p a thways of p a in c o n t rO l , i m p rov
serve to red u c e p a i n te m p o rariJy Recent research on
i n g n o n-restora t i ve s leep patterns a nd/or trea t i n g co
TENS
low back
showed
be no
fro m TEN S ,
the
pos i t ive
e ffect
gen e ra lly
d e c reases over time.
befo re
stre t c h in g
d rowsiness
and
weight
g a in . Despite the fac t that TeAs are regard e d as the best
medication
fo r
c h ro nic
pain,
most
patients
ex perience signifi c a n t sid e-dfects w h i c h t h e y ti nd
Moist h e a t tends Many ptll i c n ts fmel
morn i n g
d ry
of
p a t i e n t s (Deyo et al. , 1 990) . I n patients who b e n efit i nitially
Th(' m a j o r s i d e cllects of TCAs
than
may assist specific
p l a c e b o ; neve r t h e l e s s
more effe c t i ve than lI seful to the
invo l ved
heat.
i c e for reg i o n a l
muscl e s .
T here is s o m e l i mited evidence t h a t p u l s e e l e c tro m a g n e t i C tre a t m e n t m av be llsefu l i n the early stages
992). T h e
o f w h ip l ash (Foley-Nol a n et
i lllo l e ra bl e .
min
of
physical m o d a l ities serves p rima r ily as a n
Manipulation
T h e re is no d efi n i tive resea rch on the efficacy of c e rv i c a l m a n i p u l a t i o n i n w h i p l a s h patients (Quebec Forc e ,
to
995). Anecdotal experiente a nd
therapeutic exerc i se a n d s h ould not take the place of
pu blished study (Cassidy et al. , 1 992) suggest it offers
a n active exercise progra mme (Teasel l a n d S h a p i r o ,
short-ter m rel ief of sym p to m s i n ch roni c w hiplash
1 99 3 ) .
p a t i e n t s . Phvsi c i a n s a re concerned m o s t a b o u t the h igll-velo c i ty/low-amp l itlldr
t hrust m a n oeuvre
ra re b ur serious c o m p l ic a t i o n ot vertebral a rtery d i ssection (rease l l and Marc h u k , 1 994) . D r u g s h ave a limited ro le in t h e m a n a g e m e n t of whi p l a s h Tl1ey
i nj u ries,
d e spite
signi.fica n t
their
potentia l
adverse sid e-effe c t s . t'vlcdicatioll s used
m
wid espread
li se.
for
and
misuse
frequcntly over
c h ronic wlupJas h inj llfles because the:: treat
CeJ'vicai traction
Al t h o u g h
t reatment.
has
been
c e rvic a l whi p la s h inj u ries ( M a c n a b ,
tlt!\,oca ted
1 97 1 ; Jackson ,
i n g p hys i c i a n is uncerta i n how e l s e to ease the p a in
1 978), t here i s n o evidence i t is o f benefi t i n whiplash
and
injuries. The o n ly contro l l e d t r i a l fa i l ed to demon-
emotional
distress
of
A nalgesic medications h a ve tion
acute
the
suffe r i n g
patient.
greatest a p p l i c a
Non-s teroida l a ntHnf]amma
strate a ny
')85). In
(Zylbergold and P i p e r.
experie nce, mech a n ica l c e rv i c a l t ra c t i o ll often aggra
t o ry d rugs (NSAlDs) are m o re likely of benefit d u e
vates
to t h e ir a n algeSiC properties t h a n t h e ir anti- infl a m
c o n t ra i n di c a ted because the d i s trac tive forces may
symptol1\S.
In
m atory properti e s . long-te r m usage carries with i t a
increase
s u b s t a n t i a l ri s k of stomach ukC!J t i o n . M u s c l e re lax-
(Wei n be rger, 1 ')76) .
Copyrighted Material
pain
and
the
mit i a l
fu r t h e r
stage,
d amage
traction
healing
is
tissue
Wh iplash injuries 81
Massage
Treatments of dubious value
M a s sa ge th e ra p y is a t i m e- h o no u red treatmen t for m u s c u l oskeletal prob le m s , in pa rtic u l a r myofasci a l
co n tro ll ed study to be e ffe c tive i n tre a t in g wh i p la s h
Occipital nerve blo ck s have not been s h own in a n y
p a i n a nd muscle tens i o n . Th e re is no e vi de n c e that it
i nj u r i e s .
p rod uce s l o ng-lasting b e n efi ts a n d contro lled trials
have rec e n t l y been s u b j ected to a ra n d o mized co n
Cervical facet jOint corticosteroid blocks
are l a c kin g . Ma ssage can pl ay a role in ke e p i ng the
trolled dou b l e-bl i n d s tu dy which fa iled to d e m o n
pati en t fu nctional b y p rovid i ng t e m p o rary rel i e f of
strate effe c t ive n e ss in wh ip l a sh p a ti e n t s w i th p a in of
been o bserved in
t h e ra p y m u s t be ge nt le
greater than 3 m on th s duration . In th i s study, the level of facet joint pa thology was i d entified usi ng cervical facet joint d iagnos t i c blocks (Ba rnsley et al., 1 994) . H a m er et at. ( 992) used discectomyljusion i n 0 . 5 % of cases a nd fou nd sign ifi c an t relief of pain in only 10% of those o p e rated o n . This lack of effica cy i s
beca use aggressive o r deep friction massage is often
consistent w i t h o u r expe ri e nce . The Q u e b e c Ta s k
p a in . Ane cdota l ly, some w hi p l as h
benefits have
pa ti e nts who are
w hich mu s c le tens io n a nd ( i . e a n offi ce work e r o r a exam) because .it p romotes decrease in p a in . M assage
i n situations in
p a in gra d u a Uy b u ild u p s t u d e n t stu dyi ng f o r a n
.
muscle re laxation a nd a
poorly tolera t e d , resu l t i ng i n i n c reased pain .
'
Forc e ( 1 995) fou n d no acce p ta b le stu d i es on su rgic a l interventions i n whip la s h inj urie� Cervical epidural
injections have been reported to b e beneficial in uncontro Ued tr i al s Theoretically they s hould n ot be
Trigger point injections
.
he lpful because the damaged t i ss u e s a re p resu m a bly
Te nder points wi t h i n cervical a n d u pp e r thoracic musc les can p roduc e a n a bru p t onset of p ain from the p o i nt of pa l pati o n w i t h d ista l refe rral of pai n in a c h aracte r i stic pattern (Trave l l a n d Simons, 1 983).
o u tside the e p id ur a l space . The magnetic necklace is
I n j ectio n of local a n aesthetics and corticosteroids is a
pai n pat i e nts fa iled to d e m on stra te a ny benefit (Hong
p o p u l a r, a lbei t u n p rove n , tr e a tme nt . It is n o t clear
et al. , 1982) .
that
a naesthetics are esse n t i al
to
the
mentioned by the
Que b ec Task
Force ( 1 995) because
of its w i d espread use a m ong l a y p e op l e . A c on t ro ll ed trial using active a n d s h a m treatment in c h ron ic n eck
th e rap e u tic
effect since in j ecti o n s of sterile water, n o r m al saline or d ry n e e d ling into trigger p oi n ts may also prod uce a
the ra pe u t ic response . A recent study fo u n d that
s u b c u taneous i nj e c t i ons of s te r i l e wa te r were more
Unproven treatments that show some promise
effect i ve t h a n injections of normal sa li n e in pa tients with ch ro n i c neck and shoulder p a i n from w hi pl ash
Selective muscle retraining
inj ury (Byrn et ai. , 1 99 1 , 1 993) . Some rec ent work with selec tive muscle retraining suggests t h a t this fo rm of tre a t m e n t may offer benefits
(Donaldson , 1 995). S e l ective mu scle retra in ing uses surfac e elect romyogram to identify muscles whi c h
Treatments which improve coping skills
are n o t fu nc t i o ning properly, either b ecau s e t h e y are und eractive wh en they s hould contra c t o r overactive w he n they should relax . This tec hniqu e not only
The Q ue bec Ta sk
Force ( 1 995) found no q u ality
provides obj ective evi d e nce of musc l e d ysfu ncti o n
researc h rega rd ing ps ych o s oc i a l interve n t i o n s i n the
b u t a l s o has been reported to tre a t many p a ti e n t s
t rea tm en t
of
s u rp r ising
given
wh i p l ash the
is
successfll Uy. The muscles that app ea r un d e racti ve are
of psychosocial
se l e c t ive ly exercised to achieve more symmetrical o r
Al th o u gh
injuries.
i m po rta nce
t h.i s
issues, it may r e fl e c t excessive re l i a n ce on the a c u te
app rop r ia te mu scle fu n ctio n i n g .
medical mod e l on t he pa rt of both treating c l ini c i a ns and w hip l ash patients. These t rea t me n t s a re us ua l ly em pl oye d to h e lp p a tients cope be tte r or move on
Percutaneous facet joint denervation
with their l i ves in the fac e of chronic pain . Th ey d o n ' t
n eces sa rily red uce pa i n per se a ltho ugh in some cases, they can Signi fica n t ly d ec re a s e emotio n al d istre ss a nd im p rove the p a tien t s ove ra l l level o f function.i ng. TIl e re may be greater ac cep ta n ce on the ,
'
These p roced ures have been re po rted to offer benefit to
a
s u bset
of p atien ts
in u ncontrolle d s t u di es . on 3 5
Hildebra n d t a n d Argy ra k.is ( 1 986) reported
pati e n ts p rese n ti ng with headach e , neck , shou l d er
treatments
and a r m pain who und e rwe nt zygapop hys i a J jo int o r
because they offer some opportu nity for lo ng- term
d ors al ra mi d i agn o s tic bl ocks . The involved joints
part
of
third-party
paye rs
for
these
benefit. Th e need fo r these treatm e nt s vari es widely
we re then partially den e rvated u s i ng ra d iofrequency
a m o n g p a tie nt s a n d does n o t n e cessarily co r re l a te
electrocoagulation . Thirteen of 3 5 p a t i en t s rep orte d
with the seve r i ty of in j ll ly.
s i g nifi ca n t re li ef, 1 0 some i m pro ve m ent , and 1 2 n o
Copyrighted Material
82 Clinical Anatomy and Ma nagement of Cervical Spine Pain b e n e fi t . Ve rkest and Stolker ( 1 99 1 ) performed fa cet
i n crea s i n g a p a tient's l evel of fu n c t i o n re d u ces his or
j o i n t d enervation procedures o n 53 p a tients with
her overa l l level o f suffe ring and, in some cases pain ,
c e rvical fa cet joint p a i n . They reported that over 80%
h a s resul ted i n a p ro l ifera t i o n o f FRPs . While some
received
patients may d o we ll in functional restoratio n , fo r
l ong-l ast ing i m provement
in
this
u ncon
trolled stu dy. Lord
others i n c reasing p hyS i c a l ac tivities i n evita b ly results
et al.
roanatomy
( 1 996),
of
the
using
dorsal
rad i o freq u e n cy
c e rvical
rami
neu
achi eved
in
a
significan t in c rease in pain. Even those who
benefit a re left with significant li m i tatio n s .
virt ually complete relief of chronic whiplash p a in in
Tre a t m e n t gea red only to wards p a in control a t the
patients with a medium pain duration of 34 months.
expense of maxinl i zi n g fu nction is
In this randomized d ouble-bli n d clinical trial, 7 o f 1 2
Curren tly the focus of re h a b ilitation m a n a gement has
inappropriate.
p a t i e n t s receiving the a c t ive t reatment obta i ned p a i n
been and should remain i n crea s i n g fu n c t ion . Some
in ex cess of 6 months . Only 1 of 12 p a tients in
c lin i c i a n s h ave argued that improved fu nction shoul d
relief
t h e s h a m surgical placebal c o n trol was pain fre e . Th is
be t h e o n ly goal (Cliffo rd , 1 993), i f not the d r i v i n g
t rea tme n t
fac t o r
req u ires fu rthe r evaluation
but
is very
(Gatchel,
1994). Wh i l e
the
term
b e nign
chronic p a in i s used to e ncourage patients to remain
p ro m i Sing.
active desp i te t h e pain, one must be ca reful not to fo rge t t h e ofte n
Functional restoration programmes Functio n a l
restoration
p rogra mmes
patien t's l ife .
(FRPs)
h ave
encoura g i ng
destru ctive effects of p a in on a
Most clin i c i a n s take a m i d dle roa d , i nc reased
fu n c t i o n
while
provid i n g
become very popular because of the limitations of
restrictions to preve n t s i g n i fi c a n t exacerbations o f
current t re a tment p rogra m mes and
the frequ e n t ly
p a in . T h e va l i d i ty o f these restrictions has not b e e n
observe d d i s c o rd a n c e b e tween pain , impairme n t and
well-established fo r whiplash p a t i e n t s a s a w h o l e a n d
d i s a b i l i ty (Ga t ch e l , 1 994). G a tchel has noted that the
i s d iffi c u l t to establish fo r a ny g i v e n ind ividual. Ki ng
hypot hetical
et al. ( 1 994) questi oned the need fo r a ny restri ctions
constru cts
of imp a irme n t ,
pain
and
d i s a b i lity defy objective outcome measure m e n t a n d
i n chro n i c pai n . BalanCing pain c o n trol and increased
re l i a b l e
be
fl1 Qction (or d e c reased disability) has always been a
whi c h a llows
m a j o r area of c o n t roversy in the manage m e n t of these
assessme n t .
observed
In
c o n t rast,
fu n c t i o n
a n d objectively m easured ,
ca n
re h a b ili tation t rea tment p rogramm es to avo i d reliance on
s u b j e c t ive
(and
s u p posedly less
rel ia ble)
patients a nd w i ll probably re m a i n so for some time.
self
reports of p a in and d i s a b ility (Gatchel, 1994). FRPs c o m bine a ggressive exercise
regim e n s , d iscourage
pain be haviours and atte m p t to a d d ress psych osoc i a l issues.
Future directions
FRPs h a ve a r i s e n as a n a t u ra l evo l u ti o n of
behavi o u ra l t heories of p a in (Fo rdyc e, 1 97 6 , Fordyce
Medicine is being p a radoxic ally d riven in two oppo
et at., 1 98 5) . Most FRPs provide a m u l t i d i s c i p l inary
site
approach d e s igned to improve fac tors c o n t r i b u t i ng to
trea t m e n t of whiplash patients. T h e first t r e n d is a
d i s a b i l i ty apart from the pai.n i tself. FRPs have been
natu ra l p rogress ion of t h e science of med icine w i t h
described
as
a
tertiary,
m e d i c a lly
which
will
d i rect
the
fu ture
of
in ter
its re lianc e o n technology a n d the n e e d to prove t h e
d isci plinary a m alga m of a sports m e d i c i n e approach to
efficacy of tre a tme n t utilizing ra ndo mized c o n t rol led
restoring physical
clin i c a l
capacity
and
a
d i rected ,
d i rections
cognit ive
crisis
tria l s .
This
scientific
emphasis
not
only
manage m e n t
removes the ex ter n a l biases of t h e treatme n t - patient
of p rope rly co ntro lled evidence that FRPs actually
of h a rd-pressed insuring or f u n d ing age n c i es . The
work for chronic l o w back pain (Teasell a n d Harth, in
second t rend i s patient-focused care, the so-called a rt
in terve n t i o n
technique
fo r
d is a b il i ty
(Gatchel et al. , 1 992) . U nfo rtunate ly, there is a p a u c i ty
in teraction b u t is i n kee ping with t h e fiscal concerns
p ress) and there are no p u bli shed s t u d i e s specifi c to
of medicine which foc u ses on the person a n d not
w h i p l a s h . FRPs offe r a p romising app roach b u t must
s imply the i n j u ry. Such a n approach deals with the
b e consi dered u n proven until adequate c o ntrolled
phys i c a l , psychologic a l , social and spiritual as pects,
trials with whiplash p a t i e n t s u p p o rt the u n c o n trol led
a n d sees the person as greater than the s u m of his o r her p a r t s . T h i s approach is also bette r equipped t o
low back pain studies c u rrently ava iJ a b l e .
d e a l w i t h the many c o m p licatin g fa ctors including the
The medical dilemma: maximizing function vs relieving pain
patie n t ' s
c o p ing
abilities
and
bel ief systems,
family i nfluences, work and emp l oyer-re l a ted issues, a n d the i mportance of li tigation and compensation (Shap iro and Rot h , 1 99 3). As we begin to a ppreciate m o re the role of these factors a n d pa rtic u larly the
For c l i nicians the goal o f rel ieving pain (and s uffe r
ind ivid u a l 's coping stra teg ies, such a n a p p roach i s
maximizing
takin g on a great e r rol e . TIle c h a l lenge of t h e 2 1 s t
fu nction . For examp l e , maxi mizing fu n c t i o n in evit
century will be to i ntegrate the science and art of
ably
med icine to t reat w h iplash patie n ts successfu l ly.
i n g)
ofte n res u l ts
clashes in
with
increased
the
goal
pain. The
of
concept
that
Copyrighted Material
Whiplash injuries 83 B a r n sley,
L. ,
B.]. ,
Lord , S . M . , Wa l lis,
Bogdllk, N. ( 1 994) Lack
of effe c t o f in tra-arti c u l a r cortic,?stero i d s for c h ro n i C j o in t p ai n . N Engl. ] Med
Summary
\\la ms, B .]. , Bogd u k , N . ( 1 99 '»
Patients with c h roni c
cervica l zygap o p hysi a l j O i n !
a re d ifficult to
20-25
the n a t u ra l
trea t . It is importa n t
Loehe n ,
h i story o f a c u t e w h i. p l :lSIl w i l l i m p rove o r reCOH'l
S u p p o rtive
education a n d a p rogressive progra mme of exercis e s , involvi n g stretch in g of t h e i nvolved reg i o n a s wel l a s a n a e r o b i c exe rcise progra m m e , a re regard ed a s t h e m a i n s tays o f m e d i c a l m a nageme n t . O t h e r physi c a l treatments (phys i c a l m od a l ities, m a n ip u l a ti on , TENS) and ph a rmacological t re a t m e n ts p rovi d e short-term pain red u c ti o n a t best and should not b e used in Inj e c t i o n s a nd s u r g i c a l i n t e rventions are
i s o l a t io n .
rarely useful soci a l
ling, a re becoming not
M ogsta d , T E. ,
B l a tt , S . ( 1 995) Th e destructi veness o f perfectionism , A m.
Psychol. 5 0 : 1 00 3 - 1 0 2 0 . Blatt,
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Zu rloff, D . C ( 1 992) I n te r p e rson a l re l a t e d n e s s a n d
s elf-defin i t i o n : two prototypes for depre s s i o n
ciJol. Rev. 1 2 :
A S . , Wiesel ,
S. ( 1 990)
retraining o r
fu n c ti o n a l res t o ra t i o n p rogrammes offer p o t e n t i a l l y n e w b u t u np roven t re a t m e n t approaches for subsets of patients. At p rese n t , t h e Quebec Task Force (1 995) ,
TS.,
Mark,
res o n a n c e
;matomy a n d pathophysiology fllf.'IJUflfl 1 :
92 - 1 0 1 .
A . M . , Gershom-Coh e n , ] . ( I
a w h ip l a s h
techniques s u c h a s
Dina.
) "'2: 1 1 78 - 1 1 84 .
recognize t h e However,
0.0 ,
Ab n o rm a l magnetic
s c a n s o f the c r- rvicai s p i n e i n a sy m p t o m a t i c s u b j e c t s .r
Rogcll.l k ,
just
CUn. Psy
527- 562.
Bod e n , S . D . , M c Cowin, P. R . , Davi s ,
i o n a l c o u nsel-
psychoso c i a l intervc m i o n s
ex vaCllO. A cta Neurol.
,.,v·,· ,,': , ·, : ,
5 1 : 268 - 28 4 .
Bone
importance o f t re a t ing and
w l l h o ut
Psycho-
in
interventions.
injury
EA,
c hroruc o rga n i C b ra in s y n cl!!)ll.I!
k,ni o s i s . Ra diology
74: 806. ( 1 955) Sympto m a tology a n d n e c k N Y ) Med. 5 5 : 2 3 7 ( 1 99 1 ) Op i o i d s i n n o nmali g n a m
B ra a f. mcnt B ren a ,
p a i n : q u e s t i o n s in s e a rc h o f a n swers. Clin. } Pain
7:
3 4 2 - 34 5 . B u t l e r,
S. ( 1 984)
Prese n t status of t ri cyc l i c a n ti d e pressan ts in
a.nd
desp ite i t s selfack n owledged l i mitations a n d p a rt i s a n
chroruc p a i n t h e rapy. I n : Advances in Pain Research
fun d i n g ,
Therapy. vol. 7 (Ben e d e t te C et al. cds). New York : Raven
o ffers
the
best
s c ie n t ific
g u i d e lines
for
treat i ng these p a t i e nts. The c h a l lenge of t reatment is
to
integrat e
the
art
and
science
of m e d i c ine
efficiently a n d effec t ively to i n c rease fu n c t i o n and red u c e p a in and s u ffning
Press, p p . 1 7 3 - 1 97 . Ryr n ,
C,
Bore nstein,
P. ,
Lind e r, L E . ( 1 99 1 ) Tre a t m e n t o f
n e c k a n d s h o ul d e r pain i n w h i p l a s h synd r o m e p a t i e n ts s t e r i l e w a t e r in j e c t i o n s . A cta
with
L.
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Diagnostic imaging of mechanical and degenerative syndromes of the cervical spine 1.
J.
Rowe
Introduction
This distribution most likely reflects the degree of
Degenerative conditions of the cervical spine are
in bone mineral
the most common clinically significant pathological entities encountered in the cervical spine. They are
Cury l o et al. (1996) to be the most dense, followed by
readi ly depicted
biomechanical stresses and susceptibility to injury wh.ich is also mirrored in intersegmental differences
C6, C4 and C7.
imaging
modalities,
The lack of c1inicoradiological correlation in DOD
radiography,
computed
tomography (CT) and magnetic resonance imaging
has been well-documented (Heller et aI., 1983). MRl studies of the cervical spine in asymptomatic indi
including
by
various
density with C5 considered by
conventional
(MRl). Each im aging method exhibits its own advan
viduals have shown degenerative changes in almost
tages and disadvantages dependent on the condition
20% of these spines (Teresi et al., 1987; Boden et ai.,
being imaged (Modic et al., 1989). In this chapter imaging features of various degenerative syndromes of the cervical spine are examined.
presence of neck pain is not a reliable outcome
1990a).
Radiographically
diagnosed
DOD
in
the
predictor for conservative or surgical intervention (Dillin et at., 1986; Gore et at., 1987; Ruggieri, 1995). In whiplash patients, degenerative changes present at the time of injury diminish the prognosis (Torg et ai.,
Degenerative disc disease
1986;
Maimaris
et a/.,
1988).
Current
literature
supports the notion that whiplash injuries do prediS Degenerative disc disease (DOD) is characterized by
pose to premature disc disease (Davis et at., 1991;
dehydration, fissuring, anular disruption and osteo
Watkinson et at., 1991; Rowe and Yochum, 1996a).
phytosis. The preferred term is degenerative disc
Restricted post-traumatic cervical motion has been
disease, although alternative nomenclature is used,
correlated with a hig h incidence of degenerative
including spondylosis, discogenic spondylosis and spondylosis deformans. The term spondylosis defor
changes in the following 5 years (Hohl, 1974).
mans can be applied to advanced disc degeneration associated with radiographic findings of multilevel severe loss of disc height and large anterior osteo phytes which pathologically buttress disc herniations producing
deformed
vertebral
bodies
(Resnick,
Imaging features Conventional radiography Degenerative disc changes are graphically depicted,
1985). Degenerative disc disease is extremely common,
such as
occurring in up to 5% of women and 13% of men
fractures, dislocations, neoplastic and other patho
during the third decade, more than 90% of adults over the age of 50 years and almost 100% by 70 years (Irvine et al., 1965, Schmorl and Junghanns, 1971).
logical processes. Loss in vertical height is assessed by comparison with adjacent discs. Normally the disc height is Jess
The most common levels are the C5-6, C6-7 and C4 - 5 interspaces respectively (Gore et ai., 1986).
the thoracic spine. There is a lag time between
a
loss in disc height,
displacement.
at C6-7 and C7- Tl
Copyrighted Material
osteophytes and
In addition, th ey assist to exclude
as the transition is made to
90 Clinical Anatomy and Management of Cervical Spine Pain dehydration as shown on MRl and loss of disc height. Bony outgrowths from vertebral bodies occur initially at the insertion of the anterior longitudinal ligament and the latent time between disc injury and the first appearance of radiographicaJJy detectable osteophyte formation may be demonstrated as early as following
injury.
3
months
Intersegmental subluxation
as a
sequel to DDD is common and most frequently is retrolisthesis
(retrodisplacement,
retroposltlOning,
posterior translation). Any anterior displacement is typically related to deforming facet arthropathy. Loss of lordosis occurs commonly from the seg ment above the DDD level due to segmental exten sion as the uncovertebral joints approximate (Ede ken and Pitt, 1971; MacNab, 1975). Neck pain is more prevalent and most severe when the lordosis has
Fig. 6.2
plat e sclerosis. A density of the end-plates and verteb· ral bodies a d jac en t to the narrowed intervertebral disc space is demonstrated (arrows). There is associated retrolisthesis Degenerative disc disease, e n d
-
prominent increase in
of the superior segment and anterior osteophytes.
Comment This appe aran c e
is uncommon
an osteoblastic bony process such The distinctive
as
and can
mimic
metastatic carcinoma.
convex superior border is
typical
of
a
degenerative process.
been
lost (Batzdorf and
Batzdorf,
1988). Vacuum
phenomena are occasionaJJy observed, usuaJJy on extension views,
as
a
horizontal translucent cleft
within the anterior aspect of the elisc (Fig. 6.1). Until recently, such vacuum phenomena have been erro neously implicated as a
soft-tissue sign for
post
traumatic elisc tear, which has now been shown to represent
Fig. 6.1 D e gene ra tive disc disease. At the C5-6 in te r vertebral di sc level a loss of he ight is evident. Note the radiolucent l ine a r density within the substance of the disc representing the accumulation of n i tro gen gas w it hi n de genera ti ve clefts (vacuum pheno menon; arrow). An ter i o rly the calcifications lie w i t h i n the anular fibres (intercaUary bones; arrowhead). Comment: These are common hallmarks of degenerative disc disease and can occur either in c onc e rt with ea c h other or separately. Th e vacuum phenomenon is best demon strated on extension views.
degenerative
fissures
(Reymom1
et al.,
1972; Bohrer and Chen, 1988). End-plate sclerosis is uncommon but periodically can be quite marked, mimicking
an
metastatic
carcinoma.
osteoblastic bony Such
process such
sclerosis
can
as
display
features reminiscent of hemispherical sponclyloscler osis in the lumbar spine with a distinctive convex superior border
which
may or
may not involve
contiguous vertebrae across a single degenerative disc (Rowe,
1988; Rowe and Yochum, 1996b; Fig.
6.2). End-plate irregularity anel poor definition may
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Diagnostic i m aging of mechanical and degenerative syndro m es of the cervical spine 91
produce an appearance ident i c a l to t hat of infe ct ion.
cor d itself and i ts surrounding spaces (Ra him and
Occas ionally, spont aneous a nkylos i s c a n be o bserved
Stam bough,
(Fig. 6.3). Canal s ize can be es ti m a ted on the lateral vie w
1992).
computed tomograph)!
from t h e po int o f t h e posterior m i d vertebral body to t h e adjacent spino lamina r line and normally is a round
Ax i a l i mages throug h degenerative cervical discs are
17 mm in anteroposterior d ia m eter. A measu rement
especially useful for t h e depiction of osteophytes an d
cord
the resul ta n t canal stenosis. In contras t to the l u m bar
impingement and less th an 10 mm i m p ing e m ent w i l l
s p i n e, inherent ana tomical limitations in t h e cervical
of less
than
13 mm suggests stenosis with
invaria b ly be present (Edwards and laRocca,
1985).
spine
Generally, spinal canal diame ters of 17 111 m or greater
3.3
i mp air
the
detection
of disc
herni ations,
lig a m e ntous h y pertro phy neura l ele m en ts and extra ,
to imp inge
dural lesions. These include t h e paUCity of epidural
upon the cord, while those canals less than 17 mm
f a t, low tissue diff erential densities and s m al l e r-siz ed
will only need 2.1 mm spurs to c reate the same
foramina. UtiliSing CT co mbined with myelography
will n ee d an osteophyte of at least
mm
compression effect (Edwar ds a n d LaRocca, 1985).
(CT myelography; CTM) and thin slic es of 1.5-3 m m
Pa tients w it h canal sizes of 1O-13111m are premyelo
t h i ck n ess, these s hortcomings can be compensa ted
pathic since the average s p i na l cord s ize from Cl to
for producing diagnostic accuracies approaching tha t
C7 averages 10 mm (Robinson et aI., 1977). Although
o f M Rl (L a rsso n e t al.,
t h es e dimensions e s t im a t e canal size on plain ftIms,
Myelography on i ts own h as virtually no role in the
CT or MRl provides more accura te assessment of the
1989;
Wilso n e t aI.,
1991).
evaluation of c erv ical spine DOD given its invasive n ature an d lack of sensitivity. Intravenous contrast enhanced CT CIVeT) can be used to evaluate spina l canal s ize and its contents when MRl is not availabl e (Baleriaux et al.,
1983; Russell , 1990). Degraded
i m age qual i ty due to the effects of the sho ulder g irdle can im pa ir evaluation of the lo w er cervical discs.
CT featu res of DOD inc lude osteophytes, sclerosis, en d p l ate irre g ular ities, vacuum phenom e na, calcifi -
cation and disc bulging. Ost eo phytes are
read i ly
apparent on bon e window images as ro ugh and i rregul a r bony excrescences from the vertebral body margins. Anterior osteophytes may be seen to dis pla c e or impress on the ad ja cen t retropharyngeal wall. Posterior osteophytes extend into the central
canal and may be seen contacti ng and deform i ng t h e a djacent cord. S ag ittal reconst ru c tions will assist in visu al izi ng this effect. Posterolateral os teophytes o rig inate from t h e u ncovertebral and zygapophys ial joints to com promis e the lateral foramina (see Fig. 1 .12 ). Scl e ros is occupies the suben d-plate bone and may be
intersperse d
rad io luc encies
w it h foc a l represent
radiolucencies. T hes e
ei th e r
focal
end-plate
depr essions (S chmorl's nod es) o r raised calcified end p la te foci. Intraosseous gas beneath the end-plate is
rarely seen (ver tebral pneum atocyst) and s hould not be confused w ith linear, waf e r-like vacuu m p h enom ena within a collaps ed ver tebral body due to co rt i co steroid induced osteo necrosis (iYlalghe m et at., 1993;
Grunshaw and Ca r e y, 1994; Laufer et at., 1996). More frequ e nt ly, vacuu m pheno m en a can be seen in the periphery of the d isc as expressions of a n ul ar tears and centrally wi t h in nuclear clefts. Exte n sion into the
disc di s e a se , spontaneous ankylosis. absence of il1lervertebral disc spaces at multiple levels in this octogenarian patient (arrows). Comment: Fusion at degenerative discs is unconunon and
Fig. 6.3
Observe
Degenerative the
spinal canal, with or without d is c h e rniation, can occasionally b e o bserved (Elster and J e ns en, 1984). Calcification w i thin the anulus is usua lly focal and near the circumf e rence of the d isc wh i l e nuclear
most commonly occurs in the elderly. Differel1lial considera
calcifications
t ions include rheumatoid arthritis, post-trauma and post-infection.
are recognized b y a broad- based soft-tissue convexity
ankylosing spondylitis,
ar e p lac e d
more
inter n al ly.
Bulg i n g
discs, unlike the IU111bar spi n e, are unco mmo n and
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92 Clinical Anatomy and Management of Cervical5jJine Pain exten ding
less
than
beyond
2 mm
the
adjacent
posterior vert e bral bodies.
Magnetic resonance imaging This is the imag ing modality of choice for defLnitive examination of D DD in the
cervical spine.
In compar
ison wit h CT in lateral and central canal pathology,
MRl s ensitivity is at least 9 0%, in comparison to
75-80% for CT (Brown et al., 1988; Wilson et at.,
and
1991; Rao
Williams, 1994).
The myriad of protocols that have been developed for cervical spine MRJ reflect attempts to overcome
the inherent anatomical complexities that make its imaging difficult. As a min imum , axial and sagittal views must be obtained.
in c l ude Tl
and those
general, Tl acquired .
and T2
To
reduce
Pulse sequences a T2
producing
axial
and
long
views
sagittal
acquisition
should
effect. times,
In are and
pulsation arte facts , to prod uc e T2 inuges, it is usual
to use grad ient echo or fast spi n echo pulses. As with CT, the reduced disc volume requires thin slice
a cquisition (3-4 mm). The Tl
i mages are
most useful for delineating
vertebral body marrow and
spin al
cord outlines. The
posterior vertebral body cortex and phytes can
by
be masked
the
protru ding osteo
pulsation of cer
ebrospinal fluid (CSF); therefore it is best appreciated
on T2 images . These images produce an tlLUTIista k able myelogram
effect
which
enhances
the
posterior
v e rtebral surfaces, the extradural space, he rn iated discs and cord myelopathy. In herniated discs, T2 images show the extruded material as a relatively high
signal
allowing
separation
from
low
signal
osteophytes. Where there is diffic ulty differentiating osteophytes from disc herniation, especially in the
lateral canal, the intravenous in j ection of gadolinium, as with IVCT, enhances the adjacent epidural venous plexus an d disc margin which can increase the signal of
disc material
(Ross
et at.,
of oedema, tumour or multiple sclerosis plaques and
low signal of gliosis (Rao and Williams, 1994). MRl hallmarks of DOD are readily identified . The uuervertebral disc s how s reduced signal, ref lect ing dehyd ration best seen on T2-weighted images. Loss of signal can be d emons t ra t ed within weeks fo llowi ng injury such as whiplash (Davis et at., 1991). The presence of vacuum phen omen on will show a signal void, as will c alcium onTl andT2 ( Bern s et at., 1991).
p osterior
Degenerative disc disease. magnetic resonance Protruding posterior osteophytes art visible as low signal extensions b eyond the vertebral body margins (arrows). The effecL on the adjacent spinal cord can he readily appreCiated.
Comment: Differentiation of osteoph)'tes from herniation can be achieved by noting onT2 images that disc herniations wiJi exhibit higher signal. Posterior corel impingement from thickened ligamentum f1avum can also be demonstrated. especially on mid sagitral images.
1992). Mye l o p athy
requires CSF-ga ted T2 un ages to show the high signal
B ulging of the
Fig, 6.4
imaging.
disc margin can be observed.
Protmding osteophytes are low in signal on Tl and
studies have been made to define its signifi c ance (Rao and Williams, 1994). Vertebral bone marrow changes en d -plates are
adjacent
to the
extremely common findings in ta ndem
with DOD. As in the lumbar spi ne , three patterns can be recognized r eflecting altered vascularity, marrow conversion
and
bone
denSity.
Type
1
end-plate
change s show decreased intensity on Tl-weighted
images
images
and increased signal intensity on T2-weighted
( white- black). Type
2
end-plate
changes
show u1Creased intensity on T 1-we ig h ted images and
T2, while soft disc herniation s will become high er in
increased or isointens e signal intensity on T2-weigh
signal
ted images (white-white). Type 3 en d-p l at e
on T2,
which
aUows
Posterior cord impingement
their from
differentiation.
thickened liga
mentum flavum is best seen on mid sagittal images
ch anges and
show deCl'eased intensity on Tl-weightecl ima ge s decreased
signal intensity
on T2-weightecl
(Fig.
6.4). Paraspinal muscle atrop hy is often o b se rv e d in DDD with increased fatty replacement
(black- bl ack; Mod ic et al., 1988a,b).
and dimin i shed bulk, although no clinical co rrel.ative
inflammatory marrow (Toyone et aI.,
images
Low signal of the end -pl ates on T 1 correlates with
Copyrighted Material
1994). Con-
Copyrighted Material
94 Clinical Anatomy and klanagement of Cervical Spine Pain
A
B
Fig. 6.5
Cervical disc herniation. (A) Myelogram. A smooth extradural filling defect in the ventral surface of the contrast
column at the level of the disc can he seen (arrow).
(8)
Magnetic resonance imaging
(MRl).
At the C6-7 intervertebral disc
note the posterior herniation, which is impinging directly on to the adjacent spinal corel (arrow).
Comment:
Although
bulge, osteophyte
if MRl
or
the
myelogram demonstrates compression of the spinal cord it does nOt distinguish between (lise
herniation. Such a
is available. On
MRJ
study
should be performed in conjunction with computed to m o graphy, or not at
the posterior discal extension is clearly visible.
asymptomatic and symptomatic disc herniations and
CTM
is
parti cularly
useful
for
may
MRI
all
generally cannot distinguish between
not detect significant anllla!" tears.
d emons t ra t i ng
impingement upon the exiting n er ve root with a
failure for the axillary sleeve to fill with contrast. Both bone a n d soft-tissue windows must be utiJized, o t herwise calcification and osteop h yt es will be overlooked.
Magnetic resonance imaging
will have a disc her n iat i on , and over 15% less than 64 ye a rs will have sp in a l cord i mpingement (M od ic et al., 1989; Boden, 1990a). Signifi ca nt anular tears can escape detection with Mill and may only be demon s t ra te d with discography (SchelJas et at. , J 996). The Mill f e a t ure s of a cervical disc he rni a ti on include extension of nuclear material beyon d the p oster i o r margin of the ve r teb ra l body seen on T1 which, on sagi ttaJ image s has been referred to as the s q u eez ed tooth pa ste sign (Simon an d Lukin, 1988; Fig. 6.5B). On T2-weighted images disc materia l is sLiglltly higher in signal intensity, which allows differentiation f ro m a p ro truding osteophyte (Fig. 6.6). Radiculopathy i s best evaluated by oblique projections to demonstrate the intervertebral foramen and its cont ent s and their relationship to any disc material or bony e le men t (Modic et at., 1987). ,
Mill is the most sensitive i ma g i n g modal i ty i n depi ct i n g cervical d isc he rni a tio n and neural com pression. It is the best method for evaluating the patient with ra d i culop a t h y or mye lopat hy (Modic et ai, 1989). M Rl generally cannot d i s t in guis h berwee n asy mp tomatic and symptomatic d isc herniations. At least 10% of an asymptomatic population under 45 years
Copyrighted Material
'
'
Diagnostic irnaging of rnechanical and degenerative syndrornes of tbe cervical spine 95
Fig. 6.6 the C5-6
P s e u do disc herniation, posterior osteophytcs.
p os t e r io r disc
(A)
Magnetic resonance imaging (MlU)Tl·weighted sagittal image. At
margin a low signal protuberance can be c learly
seen
(arrow). (B) MRJT2·weiglued sagiual image. The
protruding density does not change in its signal characteristics remaining low (arrow). The characteristic my e l o gra m effect obtained w it h
this
sequence is readily appreciated as the cerebrospinal fl u i d becomes accentuated and clearly depicts the
MRJ TJ·weighted axial image. The effect 00 the adjacent spinal cord from the posterior osteophytes is graphiclUy displayed (arrows). Comment: Posterior osteophytes can simulate a disc he rni ati on on Tl·weigJ1ted images. On T2·weighteo images oise material is slightly higher in signal intensity, whic h allows differenriarion from a protruding osteophyte which remains low in signal. The presence of these osteophytcs is oc caS i on a l l y referred to as " hard disc herniation. impingement. (C)
Copyrighted Material
96 Clinical Anatomy and Management of Cervical SjJine Pain
A
B
Fig. 6.7 Uncovertebral jOint degeneration. (A) Plain film. TI1ere are early dege nera tive changes in the uncoverteb ral joint on the left side wit h the tip of the uncinate process being more pointed (arrow). Progression of degenel�Hive changes is evidenced by the rounding of the tip to a bulbous form with the uncinate spur slanting laterally (arrowhead). CB) Axial computed tomographic scan . Prolifer.ltive changes at the uncovertebral joint extend into the adjacent intervertebral foramen creating stenosis (arrows) . Comment: The degree of ul1covertebral joint arthrosis parallels the loss of disc height. Osteophytes from the ul1covertebral joint can potentially impinge upon (he adjacent exiting nel"Ve root and can deflect the course of the vertebral arrery (compare with Figures 1.4 and 1 . 1 2) .
Copyrighted Material
Diagno s tic imaging of mechanical and degenerative syndromes of the cervical spine 97
Uncovertebral joint disease
height produces impaction of the uncinate process into the opposing fossa. The initial
The uncovertebral joints are a unique anatomical
Yochum, 1996b). When the disc height is Jess than
lip originating from the posterolateral border of the
50%, the lmcinate spur slants laterally and begins to impinge into the adjacent foramen (Fig. 6.7A).
inferior vertebral body (the uncus), which invagi nates into a reciprocal depression on the superior
Uncovertebral osteophytes do not impinge on nerve
vertebra (uncinate fossa). It was von luschka (1 850)
roots
who first called attention to these joints, to which his
least
50% of the
the foramen. Uncovertebral osteophytes can deflect
Significance and
the course of the vertebral artery (Oga et al., 1996;
imaging findings. Early histopathological changes of
height
1.12). The combination of decreased disc anel uncovertebral joint arthrosis on the
lateral
view
see Fig.
the joints between the ages of 9 and 14 years are well a
at
coexist, they create an hourglass configuration to
joint or are extensions of the intervertebral discs has
docLUnenred; they consist of
obliterate
zygapophysial joint facet and the uncovertebral joint
The debate as to whether they represent a synovial clinical
they
bough, 1 992; Fig. 67B). When osteophytes from the
them as eschencrure (tailor-made).
their
until
foraminal volume (Dunsker, 1 981; Rahim and Stam
name has become inexorably linked; he referred to
to
a
rounding of the tip to a bulbolls form (Rowe and
feature of the cervical spine, consisting of an elevated
little relevance
change is
sharpening of the uncinate process followed by a
short horizontal cleft
that appears bilaterally at the lateral margins of the
can
combine
to
produce
a
linear
pseuclofracture appearance adjacent to the inferior
disc, adjacent to the uncinate processes as a func
end-plate,
tional adaptation to axial rotation (Haughton, 1 995;
most commonly at C5
(Daffner et al.,
1986; Rowe, 1 990; Fig. 6. 8 ).
see Chapter 2 ao d Fig. 3.6). Eventually, this horizontal cleft coalesces across the midline to form a con tinuous horizontal fissure. Degenerative changes in these joinrs will
always
coexist with a
Additional imaging
level of
degenerative disc disease.
The proximiry of
Imaging features
changes
uncovertebral joint to the
nenTe
within
root
compression
as
it
degenerates,
most
commoruy involving the C5 -6 and C6-7 foramina.
Conventional radiography Degenerative
the
exiting nerve root accounts for the frequency of
CT with thin axial images is the best method for the
uncovertebral
accurately demonstrating mineralized uncovertebral
joints invariably coexist with DOD as the loss in disc
osteophytes (Russell, 1995; Fig. 6.7B). MRl has the
Fig. 6.8 Pseudo frac ture
,
uncovertebraI joint arthrosis. The combination
of decreased disc height and uncover te bral
jOint a r thro s i s on the l a teral which can Simulate
view combines [0 produce a linear trilaminar density th e presence of a fracture (arrows).
Comment: This
pseudofracture appearance adjacent
end plate is most commonly seen -
invariably
ass oci ate d
with a loss in
at the
disc
C5
to dle
inferior
vertebral body and
height.
Copyrighted Material
is
98 Clinical Anatomy and Management of Cervical Spine Pain added ad v antage of showing non-invasively the rela
Imaging features
ti onship to th e exiting nerve root.
Conventional radiography
Zygapophysial joint degenerative disease
Degenerative zygapophysial joints produce distinc tive fe a t ures which may include diminished joint
space, blurred facet surfaces, osteophytes , sclerosis, subluxation anel subchondral cys ts (Rahim a nd Stam
Clinical syn d rom es associated ""ith tbe zyg a pop h y sial joints are well-documented anel incl u d e radiClI lopathy, m yel op a thy, headaches and refe r re d pain
bough, 1992; Russell, 1995; Rowe and Yochum, 1 996b; Fig. 6.9). Osteophytes on frontal views can be seen to extend laterally, and on oblique views foraminal encroachment can be assessed. On the
(Bogduk and Marsland, 1986; HeUer, 1992). Imaging,
lateral study, osteophytes may be seen projecting
in general, is highly sensiti ve and specific in identify ing the presence of zygapophysial joint facet arthrosis.
from the superior or inferior ti ps of the articular joint facet arthrosis (d egenera tive spondylolisthesis)
A
B
Fig. 6.9
(A) lateral view. Osteophytes can be idcntitied extending from the The zygapophysial joint spa ces are also diminished and there is a small degree of anterolisthesis of c4 on C5 (arrowheacl). (B) Oblique view. AJI zygapophysial joints show degenerative !Catmes with loss of joint space, osteophytes ancl subchondral sclerosis (arrow). Osteophytes may be d i s pl a ye cl on this projection protruding into the dorsal aspect of the foramen (arrowhcacl). Comment: D eg e nera tive ch anges in the zygapophysial joints on conventional radiographs are most clearly depicted on oblique views. The characteristic features are diminished joint space, blurred jOint surfaces, osteophytes, sclerosis, subluxation Zygapophysial
joint dege nera t i ve
pillars. Anterolisthesis of 2-9 mm from zygapophysial
disease.
posterior zygapophysial jOint margins (arrows).
and, rarely, subchondl
Copyrighted Material
Diagnostic imaging of mechanical and degenerative syndromes of the cervical sp ine 99
Fig. 6.10 Dege n e ra t ive spondylolisthesis. The zygapop hysial j o ints exh i b i t a c o m b ination of d i m i n ished j Oint anel re m o d e l ling o f th e facet s u rfac e to a more h o r i zontal p l a n e (a rrow) . Note the resulta n t
space
a n terol isthesis (arrowhead) .
Comment:
Degenerative a n t erolisthesis is most common in the l ower cervical spine, especialJy at
U s u a l l y t h e re is
2-9
mm of
displacement,
w h ich s h o u l d not be
c onfu se d with a
C7 - T l .
tra umatic s u b l u xation o r
dislocation.
is due to
a
combination of d i minished jOint s p ace and
facet c o rtical surfa c e , a re lost in t h e p resence of
remodel l i n g o f the fa cet su rface to a m o re hori z o n t a l
a rthro s i s . The
plane ; i t is m o s t comm o n in t h e l ower cervical s p i n e ,
intense,
especi a l l y
carti l age , o s te o p hyt e s a n d s c l e rosis . Hypertrophy o f
C7 - T 1
(Lee
et
a/. ,
1 986;
Rowe
and
Yoch u m , 1 99 6 b ; Fig. 6 . 10).
MRl a p pearan c e is t h a t of a hypo
blurred
mass
repre se n t i n g
loss
of j o in t
t h e j o in t capsu l e c a n a lso be s e e n . A lthough synovi a l fo lds (see F i g .
l . 1 0) a n d menisci c an b e s e e n i n
normal cervical zygapophysia l j o i n t , a l te red appear ances
Additional imaging
or
positions
have
not
been
described
to
deli n e a te t h e i r c l i n i c a l significa n c e (Yu et al. , 1 987) . CT bone w i n d ows are ideal fo r demon strating degen
MRl does n o t show osteophytes p a rticu larly we l l
e ra t ive
irregularities,
b u t n e u ra l compromise i s well depicted with a n
oste o p hytes and subchondra l cysts . Compression of
accu racy o f u p t o almost 9 0 % ( B e l l a n e l Ross , 1 99 2 ;
adjacent
Rugg i eri , 1 99 5 ) .
cha nges, n e u ra l
especially e l e m e nts
surface
can
be
i d e n tified
with
accuracy ra tes as h i g h a s 9 6 % wh en CT i s c o m b ined m y elo gra p hy
(Be l l
synovial cyst, most commonly at C6 - 7 , which has t h e
gra phy on i ts own can detect b e t wee n 67 and 92% of
potential to act as a space-occupyi n g m a s s p ro d u c i ng
n e rve
nerve roo t , or even cord , p ressu re ( Pa te l and Sanders,
c o m p ressions
root
and
Ross,
(Be l l
1 99 2 ) .
Evagination of hypertro p hic synovi u m c a n form a
Myelo
with
and
Ross,
1 992).
Technetiu m-99m p h o sph a te bone scans w i ll s h ow
1 988) . On CT, a synovial cyst i s seen a s a rounded
disc rete foca l u p ta ke at t h e s i te of zygapophysial j o i n t
s o ft -t i s sue
facet arth rosi s . b u t
do not correl ate
clinically w i t h a
mass
zyga po phys i a l
contiguous
j o int;
with
a
d egenera tive
t h e cyst may ex tend poste ro
latera lly into the fora m e n . With CT a n d i n trave n o u s
pa i nfu l j o int . The n o r m a l M Rl ap peara n ce of a n intermediate
con tra s t t h e cys t ' s periph e ral rim will e n h a n c e , and
it
signa l of the zygapop hysial joi.nt space o n T l -we ight
occasiona lly
i ng
M Rl , t h e rim is well-defined a nd hypo intense rela tive to the central zone which , on T2-weighting , re ma i n s
which
is
hyperintense
clear definition of
a
on T2-weigh ting,
and
hypointense zygapophysial j o i nt
Copyrighted Material
is c alc ifie d (Nijenso h n et at. , 1 990) . On
1 00 Clin ical Anatomy and Management of Cervical Spine Pain low, often d ue to calcificati o n or blood p ro d u cts
Imaging features
CN ij e nso h n et al. , 1 990) . The rim will e nh a n ce with gad olini um administration (S n ow and Scott, 1 994)
Conventional radiography
a nd
the
co re
central
can
be
of h ig h
si gnal
on
On the fron t al open-mouth view the most frequently
T 1 - w eigh ti ng due to contained pro t e in o r ha e m or
observed abnormalities are unilateral lo s s of joint
rh a ge within the fluid .
space, subchond ral sclerosis a n d osteophytes a t the l a teral j o in t margin (Fig.
6. 1 1).
Lateral
su b l u x a t io n of
C I on C2 toward s t h e side of arthrosis can occasi o n
ally be o bserved . These fea t u res c a n sometimes be
Atlantoaxial degenerative joint disease
a p p re c i a ted on the lateral film p roj ec te d over the
Dege n e ra tive j oi n t disease at the atl a n toaxial joint is a
fibrocartilagi n o u s
rel a tive l y uncommon, but c l inicaJly i m p o rt a n t , e n t i ty.
atlantodental i nte r sp a c e shou l d re main normal a t Jess
odontoid silhouette. Also, widening of the adja c e nt
re t r op h a ryn ge a l space i s oc c a siona l ly obset-ved d u e to
P rim a ry
d egene rative
j O i n t d isease of the upper
an
a n te ri o r ly p ro j e c t i n g o s te o phy t e d eb r i s
(Sta r
,
b a s il a r inva gina t i o n may OCC lU'
p a ti e n t morb i d i ty though it may not be re a d ily amenable to trea t me n t (Ha lla and
j O int space
and
c o m p re s sio n
sec o n d a ry to loss of re mode ll i n g of the
lateral masses.
1 987; S t a r et al.,
1 992). At least 4% of in d ividuals with spinal oste o a r t hr i t i s will have atlantoaxial o s t e o a rt h ritis (H alla and Hardin, 1 987) . Hard i n ,
or due to 1 992) . The
th an 3 m m . Tn severe c a s e s some de gre e s of pseudo
c e rvical comp lex is a n unde rd iagnosed c o n d i t i o n that carries s ig nifican t
et al. ,
De ge n e ra t io n of the C l - 2
j oi n t may also be second
Additional imaging CT with bone wind o w s demonstra tes osteophytes
ary t o , and the only s ign for, pre exis tin g pathology
which may p ro j e c t a n teriorly a n d deform the adja
s u c h as o s odon toide u m , ag e n e si s of the od ontoid or
cent p h a ryngeal wall . U nd erly i n g atla ntoa xial rotary
u nu n i te d fracture (Rowe and Yoc h u m 1 996a) . Unlike r h e u m a to i d and p s o ria t i C a rth ritis, the tra n sverse li g a m e n t re mains in tact w i th no inte r s e gme n t al i n st a bility (Rowe and
s u b l LL'( a t io n can also be d i s c e rned . MRI c a n be used
Yoc h u m , 1 996b) .
axial jOint can be assoc iated with c or d compressio n ,
-
,
inflammatory a r t h ropa th i e s s u c h as
The a t l a n to axi a l artic u l a t i o n s a re composed of two j o int c omp lex e s , the pa ired la t eral mass j o ints and the si n g u l a r central atla n to-od ontoid arti c u l a t i o n .
Each
c o mplex exhi b i ts d istinct c l in i c al and i m a ging fe a
tur e s I mag ing is .
p i vo t al in definin g the d i ag n os i s and
is best d et e r m in e d on conve n tional latera l a n d open
mouth frontal p roj e c t io n s and on CT.
to exclude coexi sting int ra s pi na l p a t h o l ogy such as tumour,
i nfe c t i o n , sp ina l stenosis or d i s c d i sease.
U n c om m o nly, degenera tive cha nges of th e atlanto es p ec ia lly if occurring i n co n j un c tion with a c o n ge ni
n a r rowe d c a n a l , an abnormal odontoid process o r degenera tive cha nge s in the a dj a ce nt c e rv i ca l s egm e n t s (B e n i t a h et at., 1 994). MRJ is pa r tic u l a rly usefu I fo r i so l a tin g sy n ov i a l cysts . Identify i ng at lantoaxial intra-articular me n i s c o i d s has b e en l a rgely unreward in g (Yu et at. , 1 987; M e rc e r and Bogd u k , tally
1 993). Te chnetiu m-99m phosp h a te b o n e scans will s i t e of a t l a n t o axial arthrosis (Star et aI., 1 992). sho w d i screte focal uptake at the
Lateral mass degenerative joint disease The late ral mass a rt i c u l a t io n s are the zygapophysial j o i n ts of the atlas and axis . Clinically, d e ge ne rat ive
Central atlanto-odontoid degenerative j oint disease '
chan ge s affli c t el d e r ly pa tien t s wh o present with at
least a 2-year histo ry of severe occipitocervi c a l pain
The central a t la n t o-od o n toid articul a tion is fo rmed by
n e u ral gi a
the a n te ri or surface of t h e odontoid p rocess a n d the
(S ta r et aI., 1 992) . T h e hallmarks of the d isorder are
posterior surface of the oppos i n g arc h of the atlas . It
loss of more t ba n 50% rotation on the i p sila teral side
remains unclear a s to the cl i n i c a l
which i s frequ e n tly d i a gnosed as occ i p i t a l
i cal tenderness. There may be additional co m p l a in ts
s ig n ifi ca n c e of its p oss i bl e p a i n p rod u c ing c a p a c i ty assoc i a ted w i th de ge ne rat ive c h a nge s w i t h in this jo i n t a l t h o ugh
j oi n t cre p i t u s Con
sy n OV i a l fluid c o mmu n i cation w i t h the lateral j o ints
o f d ege ne ra t i o n a n d l o c a lized u n il a teral occipitocerv of posta u ri cu! ar headaches a n d
servative
treatments
a re
.
u s u a l ly effe c t i v e
,
though
refractory cases may require surgi c a l fusion (Harara et
-
,
has
been
d emonstrated
D e ge n era t ion appears
to
( M e lls tro m et aI.,
1 980) .
be m o re c o mmon at the
aI., 1 98 1 ; Sta r et aI., 1 99 2 ). I n t ra-arti c u l a r inj e ct i ons
cen tral
may, at times, relieve symptoms (Busch a n d Wilson ,
in c i den c e as h igh as 3 5 % i n the 40- 5 0-ye ar age gro up ,
1 989; Dre yfu s et at., 1 994).
i n c reasing to
Copyrighted Material
jOint
t h a n a t the l a te ra l j o i n ts, with an a l most 90%
in
t h e over-60-ye a r age
Diagnostic imaging of mechanical and degenerative syndromes of the cervical spine 1 0 1
Fig. 6.1 1 L� t era l mass degenerative jOinr disease. Observe the u n ilateral loss o f j o in t s p a c e , subchond ral s c l e rosis a nel osteop hytosis a t the la teral j o int margin (arrow) . Comnwnt: Dege n e ra tive joint ciisease of the atl antoaxial j o in t is a relatively llncommon but cli nica lly i m porta nt entity w h i c h is an L1 nderdiagnoseci co n d i ti on a n d carries S i g n ificant p a t i e n r m o rb i d i ty. At least 4 % of p a t i e n ts w i t h s p i n a l osteoa r t h r i t i s w ill h a ve a t lantoaxial osteo a r t h ritis.
group (Shore, 1 9 3 5 : von To rk u l u s and G e h l e , 1 97 2 ; Hara ta e t aI. , 1 98 1 ) .
most com m on ly proj ect from the tip of the dens (80%) , s u perior as pect of t h e a tlas anterior a rch (70%), atlas median fac e t (60%) and the inferior a spe ct of the a t la s a nterior a rch (20%) . Cyst ic rad i o l ucencies are
Imaging features
most comm o n within the odontoid process (30%) , with loose ossicles ( 3 5 %) and c a l c ifi cation in t h e
Conventional imaging
transve rse ligame n t ( 1 0% ; G e n e z et al. , 1 990) .
On a la teral view stu dy, n a rrowi n g of t h e atlan to dental j O in t sp a ce to less t h a n I m m , osteop hytes at the s u p e ri or and i nferior m a rgins of the atlas anterior a rch , and some sclerosis of the o p posing surfaces, are the m a i n signs. Occasiona lly, a n osteop hyte can be
Degenerative disorders associated with congenital anomalies
iden tified exten d ing from the tip of the dens. The a n terior arch of the atlas may beco m e ivory-li ke clu e to sclerosis. On flexion there will be no change in the atlantodenta l interspac e .
Block vertebrae Congenita l
block
emb ryogenesis
vertebra
is
c h a racterized
a by
defect a
sp in al
in
fa il pre
in the
verte bral segmentation p rocess p rod ucing fu s i o n of
Additional imaging
two or more contig u o u s verte b raJ se gme n ts (see Fig.
Lateral t om o gra phy a n d CT c a n show the d egene ra tive
1 . 3B). Any
fea t u res to adva n tage (Genez
at., 1 990) . Axial a nd
most commonly i n t he celvical s p i n e , foUowed by t h e
reconstructed CT bone w i n d ow i mages a ccurat ely
l u m bar and thora c i c s p i nes respec t i vely ( Eva ns 1 93 2 ;
display t h e loss of jOin t spac e , osteo p h yt e s
R a m sey and B l i z n a k , 1 97 1 ) . The most common site s
et
,
s u b
chondrd l cysts, smaU ossicles and calcification of the transverse ligam en t (Genez
et
at., 1 990). Osteophytes
s egme n t of [ h e spine c a n be i nvolve d ,
,
for cervical block vertebrae a r e at t h e C 2 - 3 the n C 5 - 6 segments respectively (see C ha pte r 1 ) .
Copyrighted Material
1 02 Clinical A nato my and Management oj Cervical Spine Pain A spectrum of clinical syndro m es can emanate from
dege nera tive
changes
involving a t least s ix
possible a n atom i cal strucmres , e . g . posterior j oint degenerative
changes ,
intervertebral
j o i nt · d egen
era tive c h a nges, spinal canal stenosis, inte rvertebra l c a n a l stenosis, va rious soft-tissue inj u ries (s uch as ligam e n tous and muscular) and a l tered vertebrobasi l a r blood flow (Scher, 1 97 9 ; see Chapter 1). Most notably
it
is
the
imm e dia tely
adjacent
segments
wh ich a re placed under greater biomech a n ical stress and become the focus for the majority of clini c a l m a n ifestatio n s . T h e s i t e o f canal stenosis is character istical ly
immed iate ly
below
or
a bove
the
fusion
coexisting w i th degenerative osteophytic e ncroach ment. I n C 2 - 3 block vertebra e , tra nsverse ligamen t degeneration c a n produce atl a ntoaxi a l instabili ty and cord compression (Barucha a n d Dastur, 1 9 6 4 ; H o lmes and Hall, 1 978).
Imaging features The fused verteb ral bodies a re small in their sagittal d i m ensions with the anterior surface n o tably concave near the site of the vestigial interverte bral d isc (wasp waist or hourgl ass d eformity) anel this is the most re li a ble sign of congeni t a l fusion (Brown et af., 1 964 ; Dola n ,
1 97 7 ; O ' Connor et af. , 1 9 9 1 ; Nguyen and
Tyrre l , 1 993). I mmedia tely adjacent to the fus i o n site t h e firs t m o b ile vertebral body is often flattened and widened, depend ing on age . The interve rtebral disc with i n the fusion is frequen tly calcified (D ussault a n d Kaye , 1 97 7 ; Fig . 1 . 3 B) . At t h e immediately adj a c e n t m o b i l e i n terve r tebral d isc p rema ture d egenerative phenom e n a can be obse rved (Fig. 6 . 1 2) . Jud icious use o f CT and M RI s h o u l d assess for d isc herni a t i o n a nd spinal stenosis w he n n e u ro logical fi n dings are prese n t .
Klippel-Fell syndrome Klippel - FeU syndrome cons ists of a clinical triad of a s h o r t webbed neck (p terygiu m colli) , low posterior hairli ne and reduced cervical motion. The u n d e rlying
Fig. 6 . 1 2
Dege n e rative
d i sc
d i sease complicating
block
vertebra e . Conge nita l sy nostOSis i s evi d e n t , c h a ra c terized by
hyp opl astic ve r t e b ra l bodies and a v es t i g i a l i n tervertebral d i sc (a rrow) . At tbe disc tbe
ad van c e d
s pace i m me d i a t e ly
d egenera t ive d i sc disease
below, o bserve
with
an a n terior
os teo p b y te and loss o f d isc heigbt (a rrowhe a d).
Comment: Co m p l icating dege n e ra tive syndromes are p re s e n c e of block vertebrae a n d u s u a l ly occ u r i n i m m e d i a t e l y a d j a c e n t segm e nts due to i n c reased biomechanical loads. A s p e c t ru m o f c l i ni c a l syn d ro m e s can e m a n a te from dege n e ra tive changes involving at le a s t six possi ble an a t o m i c a l struct u res, e . g . p o ste r io r j o i n t d ege n e ra t ive c b a nges, i n t e rverte b ra l j o in t degenerative c h a nges,
common in the
s p in a l c a n a l stenosis , in terve rtebra l canal stenosiS, va rious soft-tiss u e i n j u r i e s (sllch as l ig a m e n tous a n d muscu l a r)
a nd
a l tered vertebrobas i l a r blood flow.
pathological defect is the presence of conge nital fu sions of m u l tiple verteb ra e ; this has been con sidere d to be l inked to abnorma l i ties
inc l u d i n g
a
wide variety of system i c
degenera tive d isc and zygapophysial joint d isease can
gen itou rinary d e fects (Gray et aI. , 1 964 ; Hensi nger,
p rod uce rad ic u l opathy a n d , i n severe cases, myel
199 1 ) . Co m p l ica t i ng mech a n i c a L anel degenera tive
opat hy, which i s best ima ged with MRl (Ritterbusch
cervical spine chan ges a re common, i nc l u d ing zyga
et a/.,
pophysial
ca tastrophic quadri plegia due to m inor
degeneration,
dysfunction
disc
herniation
and
heart
n e u rological compression syndromes secondary to
and
j o in t
d eafness ,
and
a rthrosis,
and
spinal
d isc
stenosis
(Scher, 1 97 9 ; Born et ai. , 1 988 ; Leys o n , 1 988) .
1 9 9 1 ) . A ra re complication i ncludes sudden t ra u m a
caus
ing dislocation a t u nfuseel l evels (Elster, 1 984 ; Born et at., 1 988 ; O ' Connor et at. ,
d rome patients most
at
1 99 1 ) . Kl i p pe l - Fei l syn
risk for c o m p ressive degen
e ra tive lesions a re those with extensive m u ltilevel
Imaging features
fu s i o n , a n abnormal c e rvico-occi p i ta l
j u n c t io n , occi
The imaging hallmark is the presence of m u l t ip l e
pitalization with a block vertebra at C 2 - 3 , anel a
segmentation defects with a s h o rt neck .
single open i n terspace in an otherwise fused cervical
D i s tinct
Copyrighted Material
Diagnostic imaging of m echanical and degenerative syndromes of tbe cervical spine 1 03
spine
(Nagib
assoc i a te d
et
al. ,
Chiari
1 984).
M RI
m a lfo r m a t i o n
cere b e ll a r h e r n i a t i o n
may
show
an
w h e re
t h e re
is
d isplacement evidence
of
th e
of
atlas
ins t a bility
due
provides to
ra d i ographic
incom p e te n t
alar
p ro j e c t i o n a U ows assessment
foram e n m a g n u m .
with l ess than 12 mm consistent ( M c M :lIln e r s , 1 983) .
Occipitalization
en l a rge m en t a n d s c l e rosis t u b e rc l e s of t he a t l a s , s y nostosis of varyi n g
Occip i ta l i za t i o n is degrees between the al., 1 99 1 ) a rch
.
A w i d e range o f cl i ni ca l p resen ta t i o n s ex i s t , the
anterior t uberc l e rear
(O ' C o n n o r et
Pa r t i a l occ i p i ta l izalion ( h e m i-occi p i ta l iza
t i o n ) . i s m o re c o mm o n , especia l ly of t h e a n terior a l th o ug h
a t l a n toaxi a l in stability, i s often
m a j o r i ty
a re
asymptom a t i c
and
a re
iden tified inciclentally on rad i ogra p hi c examination
is
often
rou n d e u .
F l ex i o n - ex tension
stud ie s
w il l
el u c i da t e t h e degree o f i nstabili ty present b u t d o n o r necessarily c o r re l a te w i t h t h e c l i n i c a l p rese n t a t i o n . A t l antoa x i a l
instability o ft e n
c o ex i s ts
with
l at e ra l
mass degen e ra t i ve c h a nges .
(Ha rco u r t a n d M i tc h e U , 1 990) .
Os odontoideum Imaging Jeatures
Os
Conve n t i o n al imaging
like ly clue to p o s t-tra u rn a tic d e n s , u s u a lly d u ring
we U . On t h e
fro n ta l view there
1 (80) and fro n t a l rad i ogra p h s a hypo pl a s t i c a n d (Hensinger, 1 986, 1 9 9 1
oc c i p i t a l structu res and Barnum, to the s k u ll ,
occasion a lly see n ; t h i s
p rocesse s . T h e a t la ntoaxi a l j o in t
a n d o d o n toid a n o m Jhc� a rc c o m m o n ( M c R a e , 1 95 3 ; The l a t e ral view d e m o n s trates vary i n g degrees o f fusion ,
inva g i n a t i o n
a ncl
s i o n thc
c a n b e s e e n to move through a n a rc
as i t s lides over t h e odontoid stu m p . Very rare ly,
Wac kenheim, 1 974 ; B e n s i nge r, 1 99 1 ) . atlas
b e n d in g . O n fle x i o n
asymm e t r i c a l
a d j a ce n t
verte b ra l
fus i o n of the oss i c l e to the a t l a s ring may occu r b u t tlus is only d e fi n ed by C T exa mi n a t i o n (Hensinger,
anoma l ie s . I n f l ex i o n , the poster i o r a rc h does n o t
1 986) . The a t l as a n te r i or a rc h i s often e n l a rged a n d
separate from the o c c i p u t . U p to 50% of occip i t a l iza
scl e ro t i c a n d i s a useful s i g n to excl u d e a n acute
tions w i l l demonstrate a t l a n toaxi a l i n s ta b i l i ty CvlcRae,
fra c t u re (H o lt et ai.,
1 9 5 3 ; H i nck e t at , 1 96 1 ; Hensinger, 1 99 1) U p to 70%
poster i o r surface o f the a nter i o r a r c h may be roun d or to t h e separating c le ft .
b l o c k vertebra
of occ i p i ta l i z a t i o n ..,
c a n o c c u r a t t h e n o n -u n ion
1 99 1 ) .
a t C 2 - 3 (McRae , I
CT a n d M RI cla r d y
and e s t ablish
,md s c l e rosis . M o s t common.ly
et at., 1 97 7 ;
the anteriorly s i te d l iga ml"nt.s a d va n c ing posterior
1 988) .
f't at,
the c e n t r a l canal (Stratfo rd .
Vertebra l a rtery
e va l u a t e d w i t h M R
a p p ropri ate verte h lohllsil a r
p e rformed in flexi o n to
m a y s h o w agenesj�, p o i n ts
of
at
least
o c c i p i t a l ization
1 98 9 ; H e n s i n ge r, 1 99 1 ) . The
one
vessel
a no m a l i e s
in
up
O a neway
to
2 ') '){'
e t at. ,
of
1 966;
the
d egree
of
c o rd
c o m p re s s i o n
(Roach
et
at. ,
1 984).
Be r n i n i e/ aI. , 1 969) .
Diffuse idiopathic s keletal hyperostosis
Odontoid anomalies the odontoid
The two most i m portant
skeleta l h y p e rostosis (DISH)
D i ffuse
Il1ld non-u n io n
p rocess a re a fa i l u re
d e ge ne ra t ive s p i n a l
(os o d o n to i d e u m )
Agenesis oj the
2% of p e op l e beyond
978a) . DISH is a gen e ra illcd art i c u l a r d isord e r wh.ich
IW"UUtJ,uJ. 'n··' H" �.�
The lack o f a n o d o n t olCl
Iigarncntous c a l c ifi c a t i o n and
pro d u c e s a strik i n g
a ppearance o n
w h ic h i s u n mis-
t h e anterior longitu d i h a ! men t
described b y variolls
taka ble . On th e frontal fi l m no o d o n toid is vi s i b l e ; a
including s p ondyl o s i s hyp e ro s t o t i c a , spondyl i t i s ossi
tnl l1cared, s m o o t ll-su rfaced s t u m p p rojec ting a b ove
fi c a n s l iga me ntosa
the
a tl a n toaxi a l
j o in ts
is
most
common
and
is
deSignated as a hypoplastic odontoid p rocess. Lat e ra l
,
selule a nkylo s i n g
hyperostosis
a n d Fo r restier's d is e a s e , a s well a s o t h e rs (Rowe a n d
Yo chu m
,
1 996b) .
Copyrighted Material
1 04 Clinical Anatomy and Management of Cervical 5jJine Pain DISH is c h a ra c t e ri zed c l i n i c a lly by i t s b road spec trum of p resen ta t i o ns fro m a sy m pt o ma t i c to com
pl a i nts
of spin al
stiffness and low-grade mu sculoskele
tal p ain . Up to 20% o f indivi d ua l s may ex pe r i ence dys p h a gia d ue t o an terior prolifera t ive bone growths from the ce rv i c al s p i n e
,
or oe s o p h a ge a l obstruction
due to a n terior bone growths from the thora c i c spine compre ssing t he a d j a cen t oesoph agus (Re s n i ck et al.,
1 978a; U nd erbe rg D a vi s and levin e , 1 99 1 ) . Removal -
followed
of the offen d in g bony p l aques can be
by
re growth within years (Suzuki et al. , 1 9 9 1 ). There is an a s so ci atio n with a d u lt onset o f d iabetes mellinls in u p to 1 3 - 3 2%
Qulkunen
et al. , 1 966, 1 9 7 1).
Imaging features Conventional imaging The radiographic h a llm a rks of D ISH consist of exu
berant hyperostosis from the anterior verte b ral body
ma rgins which u sua lly b r i dge the in te rve ni n g d isc
spaces (Fig. 6. 1 3 ) Deftn itive criteria for th e d i a gn osis .
of DISH in clude
four
or more contiguous ver te brae
invo lved with anterior hype ro s to sis rel ative prese rva ,
tion of intervertebra l d isc height and an absence
of
zyga pop hys i al j oint ankylosis (Re snick et al. , 197 5 ).
The bony hypero stosi s is m o s t frequ e n t and most
exu b e ra n t i n the lower segme nt s (C4 7) , usually -
begi n ni n g
fro m
t he
ant e roi nfe r i or ver teb ral
margin and ex te nd ing d own ward s
,
b ody
ta pe r i ng at its
distal extent . The t h ic kn e s s of this anterior hy p e r
ostosis m ay be over 1 cm a nd it is thic ke r at mobile levels and thinner at immobile levels (Suzuki et at.,
1 99 1 ) . Frequ e n tly lo ngi t udin a l
the
d eep fibres of the anterior
ligam e n t are
the
last
to
ossify ;
this
p rod uces a di stinc tive ra d ioluc e n t zone of s e p a ra tion from t h e vertebral b o d y (Resnick et a l. , 1 978a). Horizo ntal r a d ioluc en t linear clefts due to a nterior discal extrusi o n s should not be confu s ed with frac
tures
or
pseudarthroses.
Ossification
w i th i n
the
p oste r ior l on git ud i nal ligament COPll) c a n occasion ally
be
observed
(Gol d wi n
1 9 7 9) .
,
.
D e sp i t e
th e
ra d iograp hic evidence of s egme nt a l a nkylos i s , para
Fig. 6 . 1 3 Diffuse The
rad iographic
id iopathic skeletal hyperostosis h a l l m a rk
of
D IS H
is
the
(DISH).
exubera n t
h y p e rost osis from t h e an terior ve rtebrJ I b o d y m a rg i n s b ri d gi n g the i n tervening d isc s p ac es (arrows) . Hori zontal ra d i o luc en t linear clefts due to a n terior discal extrusions s h o ul d n o t be c o n fu s e d w i t h fractu res or pseud,lrthroses (arrowheads).
Comment: Definitive c riteria for the d i a gn os i s of DISH four or m o re c o n t i gu o u s ve rte bra e invol ved with
inc l u d e
a n t e ri o r hyperostos i s , re l a t i ve p reserv a t i o n of i n tervertebral
a nkylOSis. segmental ,m k.1' losis , m a y be remarka bly
disc height a n d an ab s e n c e of zygapo p hys i a l j o i n t Despite t he rad iogra p h i C e v i d e n ce of para d oxical ly,
the
verte b ral
motion
u n
d Oxi ca lly, the verte b ra l motion m ay be re mark a b ly unaffecte d ,
most
likely
re l a t ive
to
the
artic ular
joints. c a n occ ur through the
sp a ring o f the zyga p op hysi a l Compl icating
fractu res
a nky l o sin g new bone , most comm o nly at C 5 - 7 with severe neurol ogical se qu el ae
,
i n clud i ng quadriplegia
inal liga m e n t (O no et at., 1 977), hypertro p h iC pos
terior o ste o p h yt es (Ale n g a t et at. ,
1 982) or l i ga
mentum f1aVllm hypert rophy (Kopman et at., 1 982).
(Yagan and Karlins, 1 986) . In cases o f fused lower segments, a tl antoaxial instability ra re ly occurs (C1u ba
et aI. ,
1 99 2 ) . Additionally,
u n i nvolved
segments,
such
fra ctu res as
of
adj acen t
od o n to i d fractures,
may be seen with no effect o n those involved with DISH (Fa rdon , 1 978) .
ligamentous oss ifications Ossifications within l igaments of the cervical spine
are co mm on l y observed rad iogra p h ic fi n d ings often ,
with no clinical im p li c a tio ns . These i n clude ponricles
Additional imaging
of the atlas, stylohyoid l iga m e n t , nuchal bones , discal
CT and MRI are useful in defin ing c o ex ist i ng sp inal
stenosis d u e to ossification of the p oste r i o r lo n gi tu d
-
calcifications and o ss ifi c a t i on of the posterior longit
u d ina l ligament.
Copyrighted Material
Diagnostic imaging of mechan ical and degenerative syndrom es of the cervical spine 1 05
sp ines. It is encounte red i n D D D , he rni a t ed disc,
Ponticles of the atlas Calcification w i t h i n the
block verte b ra e , in an idio pathic fo rm a n d occasion
borders of the posterior
oblique occ i p i ta l membrane s u r ro u n d i n g the verte b ral arteries as th e y course adj a c e n t to the latera l masses o f the atlas have b e e n referred t o as ponticles, of w h i c h there are two , late ra l a n d po s te r i o r (Bu n a et al. , 1 984). The la teral ponticle is seen on frontal upper ce rvical ra d iogra p hs as a c urv ilin e a r cal cifica tion ex tend i ng from the upper latera l mass of the atlas toward the transverse process. A p ost e r io r ponti c l e (pons posticus, retroarticu l a r process) occurs i n u p t o 1 5 % o f t h e p o pu latio n and i s demonstrated on lateral rad i ogra p h s . I t m a y exist as an i n complete hook-l ike process (Ki mme rle's a n o m aly), or as a complete bridge fo rming a distinct circ u l a r opening (arc u a l fo ramen ; Ko hler and Zim mer, 1 968). The clinical significance of th is fU1ding rem ains in conjecture, th ough its c o mmon occur rence supports t h e contention that it plays no ro l e . Howeve r, it has b e e n s uggested t h a t it represents a risk fac t o r for m a n i p u l ation-ind uced ve r t e b ral a rtery dissection (Ga tterman, 1 98 1 ; Buna et aI. , 1 984), p o s t trau matic s u b a rachnoid haemorrhage (Gross, 1 990)
ally as p a r t of a biochemi c al metabolic d e fect (Rowe and Yoc h u m , 1996b). Dege n e rat ive disc calcification wit h i n the nucleus is best seen on CT as a central conglomerate opaCity or as fragmented d i s p e r s e d d ensiti e s . O n CT, h e r n ia t e d d iscs may be seen to contain c a l c ium and this
dates the lesion a s being of at l east 6 m o n th s . The vestigial d isc space between a congenital block vertebra is commonly observed to have calcified but this is considered to be of n o significance. Idiopathic forms of disc calcification are m os t s ign ific a n t in childre n where , between t h e ages of 6 and 12 years, a p a inful neck, sometimes wi t h torticollis and fever, can occur, with rad i ographs demonstrating den s e nucleus p u l p o s liS ca lcification (Rowe and Yochum , 1 996b; Fig. 6 . 14). Rare ly, metabolic disorders such as gour , pseudogo u r , ochronosis a n d even hyper parathy ro id i s m can un d e rli e t ile calcifica t i o n .
a n d Ba rre - Lieou s y ndro me .
Nuchal ligament Focal ossification w i t h i n
th e l igamen tu m nuchae
(n u c h a l bone) is a common age-related finding, the
incidence i n c reasing w i th age , and i t is of d o u b tfu l clinical Signifi c a n c e . The most common location is within the interspino us spaces from C4 to C7 (Kohler and Zimmer, 1 968) Ossification is usually o vo i d with the l o ng axis orienta te d ve r tica ll y and i t exhi b i t s a di s t in ct cortical shell. Differe n tiation from an un united s ec o n d a ry ossit1cation centre and fracture of the spinous p rocess (clay shove l ler's fra c t u r e ) should be m a d e (Rowe , 1 987).
Anulus fibrosus Calcification wi thin the outer a nul a r fi b res of the
cervical d isc is a very common fi n d ing noted in up to 70% of autopsies (Schmorl and J u n g h a n n s , 1 97 1 ) . Patholog icaUy, hydroxyapatite crystals are deposited within degenerative anlilar fi b res a nel they are often associa ted w i th a loss of disc heigh t and h a ve been called i n t e rc all a ry bones (Fig. 6 . 1 ) . Radiogra p h ically th e s e are most commo nly seen at the C S o r C6 level at t h e anterior discal surface as a 1 - 2 mm thick l inear density, lI s u a ll y n o t attached to the adjacent verteb r a l body ma rg i ns .
F i g . 6 . 1 4 Idiopathic nucleus pulposus ch i l d ren . Dense c a l c ification can be seen Comment: and
Ca lcification within a cervical n u c l e u s puiposus is uncommon, in c o n t rast to the thoraCic and l u m b a r
in
the C 5 - 6
disc space (a r row) . Idiopath i c cal cification is a pe rplexing ch ild
hood condition
Nucleus pulposus
calcification within
1 2 years
typi cal ly presenting
between the ages of
6
with a painful neck, som etimes with torticollis
and fever. As symptoms abate, so
will the ca lcit1cation, the
only sequelae being slightly flattened bodies
Copyrighted Material
adjacent vertebra l
106 Clinical A n atomy and Management oj Cemical Sp ine Pa in
Stylohyoid ligament
towards t h e hyoid bone . U nion with t h e hyoid b o ne i s
The styl o hyoid ligament traverses the soft tissues of
depict the o s sifi cat io n Similarly as an obli q u e l inear
the l at e ra l aspect of the neck , be tw e e n the s tyl o id
d e n sity ori g i nat ing just mediaI to the mastoid process
p rocess a n d the hyo id b o n e , a ct i n g as a sus pen sol),
a n d sloping medi ally. The bony mass ofte n has a d istinct
ty p ic ally at t h e lesser cornu (Fig. 6 . 1 S). Fron tal views
l iga m e n t . Ossification to varying degrees is common,
shell of cortical bone, t h o u g h some specimens a re
e s p e c i a lly w i t h adva ncin g age, and is o cc as i o n a lly
internally fe atureless . M os t are t hi c k with d i a m e te rs up
seen to c oexi s t with DISH . Symptoms associated with
to 1 em and are of vari a b l e l e n gt h Comp lete ossifi ca
,
.
s ty l o hyoid l i g ame n t ossification a re very unc o m m o n
t i o n a long i t s entire length is usually interru p ted with
(Bolto n , 1 987) . Pai n in the pha rynx , p a i nfu l deglu ti
linear l ucencies a n d b u l bous ends simula ting ps e u d oa r
t i o n and refe r re d otalgi a , often i n i t i a ted after tonsil
ticu l a tions (MueUer et al. , 1 983 ; B o l to n 1 987) . ,
lectomy, and a s s o c i a te d with el o n ga ti o n of the styl o i d process more than 2 . 5 cm due to ossification of the s ty l ohyo i d l ig a m e n t , have been referred to a s Eagle 's
Posterior longitudinal ligament
sy n d rome (Eagle, 1 949).
Conventional lateral ra d i ogra p hs s h o w a band of o s si
Ossified
poste r i o r
l o ngitudinal
liga ment
(OPLL)
ficatio n of variable length r u n n i n g obliquely fro m the
is an u n c omm o n d ege nerat ive disorder
s k u ll base i m m e diately a n terior to the a u d i to ry meatus
c h a racte r i zed b y
6.15 Stylohyoid l igament ossification w i t llin t h e liga m e n t
6 . 1 6 Ossified posterior longitu d i n a l l igament (OPLL) characteristic dense bone within t h e l iga ment is depicted as a l i n e a r ra d i o pa q u e stri p of 1 - 5 m m t h i c k n ess paralleling t h e posterior vc rte b r,d body margi ns (arrows). N o t e how i t re m a ins sep a rate from the vertebral
Fig.
ossification. The
band
of
eXle n ei s ohliquely towa rds
the hyoid bone ( a r row) Along its le n gt h l inear l u c e n cies
and
adjacent
bllib o u s
ends
mark
pseucloa rticulations
(a rrow).
Cormnent:
variable length, is com within t h e liga m e n t a n el is usua l ly of no significance . Pain in the p h a rynx, painful d e g l u ti Such c a l c ifica t i o n , of
monly observed c l i n i cal
of the spine
thick bone for m a t i o n with i n the
Fig.
syndrome. The
bod i e s . There is co exjsting d iffu se idiopatllic s k e l e t a l hy p e r· ostosis (DISH) a n te r iorly ( w hite Co mment: The
length
arrow) .
of t h i s ossific a t i o n
body height or it
may be
and assoc i a ted w i t h e l ongation of the s tylOid p rocess more than 2 . 5 cm due to ossilication of t h e sty l o hyo i d ligam e n t , h a v e b e e n referred to as Engle's s y n d rome (Eagle, 1 94 9) .
Com p ression mye l opathy ca n occllr fro m tbe ossification . D I SH m a y be present i n li p to 85% of OPLL pati ents. c o n t i g u o u s segments.
Copyrighted Material
a
one
vertebra l
m:ly
traverse
only
t ion and referred otalgia , often ini tiated aft e r tonsill e c t o my,
n u mber of
Diagnostic imaging of mechanical and degenerative syndro m es of the cervical spi n e 1 0 7
posterior l ongi tudinal l igament of the spine (TS llki 1 960; Te rayama et at. , 1 964). Known assoc ia tions include d iffuse idiopathic skeletal hyperostosis and a n inhere nt predisposition for such to occur in the Japanese population Oapanese disease; Resnick et aI., 1 978b) . The most common location for OPLL to occur is in the cervical spin e , fol lowed by the thoracic and l u mbar spi nes . Many cases a re asymptomatic a l though , when OPLL is prese n t i n the cervical spine, the incidence of symptoms is higher. Pa in is consp icuously absent a s progressive myelopathy d evelops with d isturbed gait and increasing tactil e d isturbances. Cli nical stigmata are usua lly ma nifest when t h e ossification occlIpies more than 60'Yt, o f the s p in a l ca n a l . Spinal cord changes i n O1'LL consist of co mpress ion-related abnormali ties slIch as flattening, grey m a t t e r infarc tion and demyel i n ation of the posterior and l a tera l white columns (Hira bayashi e t aI. , 1 98 1 ) . O n conventional lateral radiographs t h e cha racter istic dense bone w ithin the lig a m e n t is depicted as a linear rad i opaque s trip of 1 - 5 mm thickness paraU eI ing with the posteri or vertebra l body margins (Fig. 6 . 1 6) . The l ength of this ossification m ay b e only one vertebral body height o r it may traverse a n u m ber of contiguous segments . Commonly, a rad iolucent zone mot o
,
is i n ters paced betwe e n the ossified liga m e n t a n d vertebral b o d y corresponding t o the u nossified deeper l igam entous layers. To m o grap hy is an excel lent tool for demonstra t ing these featur e s . Associ a ted features of DISH may be apparent in u p to 85% of patients with exu berant anterior hyperostosis, nor mal zygapophysial joints and normal interverte b ral discs (Hakuda et at. , 1 983). On CT, the mine ralized l igament i s seen as a dense calcil'1c opacity often wi t h a d i stinct cortical surface surroun d ing a l uc e n t core of canceUous bon e . The zone of O1'LL - verte bral body sep a ratio n is seen dearly and the degree of spinal stenosis can b e accura tely assessed . MRl may show OPLL as a high-signal-intense (fatty mar row) or hypointense band (fibrous replacement of fa tty marrow; Yoshino et at., 1 99 1 ) and spinal cord changes sllch as myelomala c i a , a trophy and oedema are shown to greater advan tage t h an by any other imaging m o d a l i ty cYoshino et ClI. , 1 99 1 ; RusseU, 1 995).
Calcific tendinitis of the longus colli A se lf- limiting, transient, and acu tely symptom a t i c h y d roxyapatite deposition can oCClll' a t t h e supero la tera l group of longus coll i tendons as they insert
Fig. 6. 17 C a l c ification of the longus colli . There is sweUing of t h e retropha ryngeal soft tissues anterior to the atlas (a.rrow) . There is a lso very faint calcification w i t hin these soft tissues (white arrow). Commenl:' The clin i c a l syndrome of rapid onset over 2 5 days of a painful stiff neck, muscle spasm, painhtl dysph agia and a sense of globus hyste ricLls is d u e to the deposition o f hydrox)'apatite crystals in the s u pero l a rera l group of longus col l i tendons as they insert anterior to the C2 and C3 vertebral bod ies. Symptomatical ly, resolu tion occurs spon taneously over the next few weeks. -
Copyrighted Material
1 08 Clinical A n atomy and Management of Cervicat Spine Pain anterior to the C 2 and C 3 verte b ra l bodies (H aun,
1 978; Newmark et at., 1 978) . SymptomaticaUy, the patient complains of a ra pid onset over 2 - 5 days of a
Bland , ). , Boushey,
Abnorm a l magn e t i c re sonance scans of the i n asym pto m a t i c s u b j e c t s .
and a sense of globus hystericus (B e r n s te i n , 1 964) but 1 - 2 weeks . demon stra ting
calcification up to 2 e m in diameter a n t er i o r and
et at. , 1 978; Fahlgren, 1 988) . The retropharyngeal inter s p a c e is often increased locally more than 7 mm (Fi g. 6 . 1 7) and , o n MRl T2-we ighted ima g i n g , the supe rio r portion of the longus c o l l i is of high signal i n t e ns ity, co rres p on d ing to oed ema (Arr e n i a n et al., 1 989) . Symp toms s u bsi d e in con cert with re sorption of the prevertebra l calcific ation and swelli ng and no complica tions a re exp ected (H a r tle y, 1 964 ; Sutro , 1967) .
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Sche l l a s , K . P , S m i t h , M . D. , Gund ry, C . R . , Po l l ei , S . R . ( 1 99 6) Cervi Cll discogenic pai n . Sp ine 2 1 : 300 - 3 1 2 Scher, A .T. ( 1 979) Cervical spi n e fu sion and t h e etfects of i n j u ry.
S. Afr. Mea. } 56: 5 2 5 - 5 27 Schmol'l, G . , j u n g h a n n s , H. ( 1 97 1 ) The Human Sp ine in Healtb and Disease, 2nd edn. (Besem ann, E . F. , tra n s ! . ) . N e w York: Gnme & Stratton. S h o r e , L. ( 1 935) O n oste oarthritis i n the dorsal i n ter vertebral joi n t : a s t u dy in m o rbi d a n ato my. B r. ] Surg 2 2 : 83 3 - 849.
Simon, l E . , Lu k i n , R . R . ( 1 988) Diskogenic d i se a se o f rhe cervical spin e . Semin. Roentgenol. 23: 1 8 - 1 24 . Sn ow, R . D. , Scon, W R . ( 1 994) HypertrophiC syn OV i t is and osteoarth ritis of the cervical facet j o i n t . Re p o rt o f two cases. CLin. Imaging 1 8 : 5 6 - 5 8
R.P ( 1 992) A tla n toaxi a l Spine 1 7(su ppl): 57 1 - 576.
Star, M .). , C u rd , ] . G . , T h o rn e ,
lateral
sp ine . Orthop. Surg. 15: 1 0 8 3 - J 086. R e i ch e r, M . A . et al. ( 1 987)
Radiology 164: 83 - 88 To rg, ]. S . , Pavlov, H . , Ge n u a r io , S . E . p raxia of the cervical spin a l
et al. ( 1 986)
N e lll'o
cord with t rans ien t quad
riplegia. J B o ne jo int Surg. (A m.) 68: 1 3 5 4 - 1 3 70 . Toyo n e, T , Ta kahash i, K , Kita h a ra , H. et at. ( 1 99 4 ) Vertebral hone-ma rrow c h a nges in d eg e n erative lumbar d i sc dis e ase . } Bone joint Surg. (Br.) 76: 7 5 7 - 7 64 . Tsu k imoto, H . ( 1 9 60) An auto p s y report of sy nd ro m e o f c o m p ression of s p ir\a l co rel owing to ossifi c a t i o n w i t h i n
1 00 3 - 1 009
i d iop a t h i c ske l e t a l hyperostosis in the
cervical spine. Neuroradiology 33: 427 - 4 3 1 .
5 . , Levin e,
M.S.
( 1 99 1 ) G i a nt th ora C i c
osteo ph y t e c a us ing o e s o p h ag ea l food im p a c t i o n . A J R.
1 57 : 3 1 9 - 3 2 0 . Luschka, I-I. ( 1 8 5 0 ) Die Nerven des menschlichen Wirbelkanales. 1\lbingen: L�llPp and Siebeck . Von Torklus, D . , G e h l e , W ( 1 9 7 2) The Upper Cervical Spine (Michaelis, L. S . , t ra n s ! . ) Lond o n : Bu tte rwor rhs , p p .
von
64 - 6 7 . Wa ck e nh ei m , A . ( 1 974 ) Ro e ntge n Diagnosis of the Crania
New York : Springer-Verlag, p . 360. " U ' , Bann ister, G.c. ( 1 99 1 ) Prog soft tissue i n j u r i e s of the cervical spi n e .
vertebral Region.
Wa tkinson,
A. , G a rga n ,
nostic factors in
Injury 2 2 : 307 - 3 1 0 .
Whitec loud , T S . II I , Seago , R . A . ( 1 987) Cervi c a l di scogenic syndrome: results of s u rgical i nterve n t i o n in pa t i e n t s with
p os i tive d i sc ogra p h y. Sp i n e 1 2 : 3 1 3 - 3 1 6.
Wilson, D.W , Pez Zll t i , R . T. , P l a ce , ) . N . ( 99 1 ) M agne ti C reson ance imaging i n t h e p re ope ra tive evaluation of c e rvic a l radi c ul o p a thy. Neurosurgery 28: 1 7 5 - 1 79 . R . , Karl i n s , N . ( 1 9 86) Qu a d ri p l egia in d iffuse i d iopathic s ke le tal hyperostosis afte r m i n o r tra u m a . A J R. 147: 8 5 8 - 8 5 9 Yosh i n o , M .T. , Seeger, ) . F. , C a rm od y, R.F. ( 1 99 1 ) M RI
Yaga n ,
d i agnosis o f thoracic ossification of po ste r io r
S t ratford , ]. ( 1 9 5 7) Myelopathy caused by atlan to-axial dislocatio n . } Neurosurg. 14: 97- 1 0 2 . S l I l ro , C .) . ( 1 9 6 7) Calcitkarion o f t h e anter i or atlanto-axial l ig a m e n t as the ca use fo r pa i nful swal l ow ing and for p a i nful neck. Bull. HOsp. jo int Dis. 28: 1 - 8. S u zuki , K, Ishida, Y, O h m o r i , K. ( 1 99 1 ) Long te r m fol low of diffuse
cervical
S . , M iyashita , R. et al. ( 1 964 ) t h e posterior longitudinal l igam e n t in the
Maruya m a ,
Ossifica t i o n of
Underberg-Davis,
Russe l l , E.). ( 1 9 9 5 ) Com p u ted tom ogra p hy a n d mye lo gra phy
lip
K.,
cervical spin e 1 1 1
the sp i n a l canal of c e rv i ca l spin e . A rch. jpn Ch ir. 29:
Clin.
mass osteoa rth r i t i s.
Teraya m a ,
of the
Tere s i , L.M , Lufkin, R. B . ,
Assoc. 1 8 : 55 - 5 6 .
fracture . } A ust. Chiro. A ssoc.
degenerative syndro mes
liga ment
with
concomitant
disc
longitudinal
he rni a tio n .
Neuro
33: 4 5 5 - 4 5 8 . S t eve n s , ). 1'v1 . , Ken d a U ,
radiology
Yu , Y L . , B . , d u Boulay, G . H . ( L 983) Corel sh ape and m ea s u re m e n ts in cerv i c a l spondylotic myelopa thy A J N. R. 4 : 607- 608. Yu ,
S.,
Sether,
L .A . ,
Haughton ,
V M . ( 1 98 7 )
Facet joint
menisci o f [ h e cerv i c a l s p in e : correla tive M R i maging and c ryo m i c ro tomy stUdy. Radiology 1 6 4 : 79 - 8 2 .
Copyrighted Material
Medical management of neck pain of mechanical origin R. Cailliet
Examination
The following soft tissues are palpable:
When a patient presents with a complaint of neck pain, or pain considered to evolve from the neck, a meaningful history and examination are mandatory. The examination is the attempt of the examiner to determine the structural, physiological (neurological, orthopaedic, vascular and psychological) aspects of the be
impairment. ascertained
The
by
disability
determining
claimed
the
must
impairment
responsible. Observation of the patient determines the limita
1. Mus cles - accomplished by the active participation of the patient in initiating specific mov eme nts while the examiner palpates the involved muscles. 2. Ligaments. 3. Nerves. Subjectivity of impaired nerve function is elicited fro m the history with symptoms such as tingling, pain and/or numbness alluding to their dermatomal area. Sensitivity is noted from direct pressure upon the
precise nerve root dermatome.
tions of motion in activities of daily l iv in g such as posture,
movement,
grimacing
and
restrictions.
Observations also denote the malaiign ment of the
body structures in stance, assuming Sitting and lying. These are the major components elicited in evaluat ing the postural components of motion.
Nerve function 1. Motor: testing by participation of the patient in performing specific motion and determining appropriate muscular activity, thereby ascertain ing the mu scl es appropriate nerve supply. The maximum effort expended by the pat ie n t must be '
Active and passive methods of examination
ascertained.
2.
Bony and soft-tissue palpation
determining the dermatomal areas sub jectively and confu'ming obje ctivity by various modalities such as touch, cotton swab, pin prick or scratch, tuning fork and position sense test. This is
Sensory:
subjective and the examiner must determine its organic basis.
The patient's neck can be palpated in the supine,
seated or standing position . In the su p in e pOSition the
3. Reflexes: including the triceps, biceps, brachialis and brachioraelialis. Hoffmann's test may indicate
neck muscles and the effects of gravity are eliminated (McKeever, 1968). The following major bony struc tures are palpable:
1. Spinous processes: t ran sv e rse and posterior. 2. Zygapophysial joints. 3. Mastoid processes.
upper motor neuron pathology.
Range of motion Range
of motion
testing reveals
the integrity of
anatomical joint structures anel [unction; this is tested
Copyrighted Material
Medical management oj neck pain oj mechanical origin 113 Flexion Left
Right
lateral
lateral
bend
bend
Left rotation
Right
-------"'fL-- rotation
Extension
Severe Slight
Limited motion
Moderate
@
Painful limitation
Fig. 7.1 Recording range of motion. The upper drawing is the composite record of range of motion . (I) X indicates mere limitation of range of motion in extension ·without pain; (2) slight pain and limitation in extension; (3) m o derate pain and extension limitation; (4) severe pain and limitation in left rotation. actively
and
passive l y.
motions performed
Active ly
implies
actively by the patient
te sting upo n
observation and from instructions. In testing ranges of motion of the cervical spine the following motions are requested and observed (F ig . 7.1). Pas sively testing range of motion measures motion perfo rm ed by the exami ner on the pa tien t by move ment of t h e head and neck involving each in dividual vertebral segment (Fig. 7.2).
Upper cervical examination Upper cervical motion tests flexion of the head, e xten sion ,
lateral tlexion and rotation upon the
t
cervical spine (occiput atlas-Cl axis-C2; Fig. 7.3).
DP
Fig.7.2
Lower cervical examination Lower cervical motion is tested by having the pa tient flex, extend, laterally flex and rotat e the entire lower cervical spine (C3 -7) without movement of the head
Method of move me nt ofrhe vertebral segment from
direct pressure. Direct pressure COP) upon the posterior superior sp i n e localizes the specific vertebra. RL and LL is righ t and left lateral pressure upon the posterior superior
spinous (PSS) process. (F) face t . From permission.
Copyrighted Material
CaiUiet (J 995)
with
114 Clinical Anatomy and Management of Cervical Spine Pain
25 10'
Extension Occiput-atlas
�::> �
No rotation
�
�
Atlas-axIs
Rotation 90' Extension 0"_10° FleXion 0'-5'
�
C,-C,
� � U,
Fig. 7.3
Flexion
Gliding fleXion - extension rotates only after C, has rotated on
C, T, 00
C2
="m,",
and lower segments. Left figure indicates that l a t e ra l flex.ion is always some rotation. The right figure i ndic a tes the degree of motion at each vertebral segment. From Cailliet (1995) w i th permission. Motion of cervical spine: upper
accompanied by
upon the spine. This is performed actively and pas sive ly, Range of motion is estim at ed by noting the difference of the end-point of on e direction versus the op posite e nd-p oin t . Mechanicai limitation is noted when motion stops, or when s ymptoms (unpleasant sensations) are produced. The site (seg mental level) of sensation produced (i.e. local or referred) is determined. As it is kno wn through which foramen a s pecific nerve root emerges, and which foramina open and close upon specific motion (Fig. 7.4), the effects of specific neck mo veme nts are noted which determine the precise level of involvement. As it has been generally accepted that the zyg apo phys i al j o ints are a major source of neck pain, their identification is clin ic ally tested using manual pr oce d ures. The accuracy has been co nfirmed Gull et aI" 1988) as to location and source of pain. The tec hn iques are numerous (Maigne, 1972; Maitland, 1977; Grieve, 1981; Bourdillon, 1982; Stoddard, 1983) and will no t be elaborated on here. Whether the manual diagnos is as to s ite and so urce of pain is
accurate remains controversial but when c o m pared
to nerve root blocks t h ey prov ed accurate Gull et al., 1988). The neurological examination of the head a nd neck involves sensory, motor and autonomic testing. The upper cervical nerves (C 1- 3) are m ostly sensory to the head. Motor testing of the upper cervical (occ ip ital) nerve involve s the muscles moving the head upon the neck. The neurological examination, sens ory and mo to r, of the lower cervical spine (C3-8) in vo lv es the ne ur ologica l examination of the upper extremities - musculoskeletal, axillary and median nerve (Fig. 7.5), ulnar nerve (Fig. 7.6) and r adia l nerve (Fig. 7.7). The sensory (dermatomal) e x a min atio n of the lower cerv ical segments is mos tl y limited to examina· tion of the hand (Fig. 7.8). The details of the clinical examination are adequately summa rized in the lit erature to whic h the reader is referred (Dwyer et ai., 1990; Cailliet, 1994b) Confirmation is clinically possible with the per, formance of el ec tromyograp hy of nerve conduction velocity studies.
Copyrighted Material
Medical management of neck pain of mechanical origin 115
Lateral bending Fig. 7.4 Fo ra m in al
Forward
Head turn
of the head and neck. With the head in an e re ct posrure (centre figure) the foramina a re open equaUy. In right lateral fl exi o n (left fi g ure) the foramina are narrow on the co nca ve side and open on the c o n vex side. In ro t ati on (right figure) the foramina are narrow on the side towards which the head turns and wider on the contralateral side. From CaiUiet (1995) with permission. closure in lateral flexion and rotation
Copyrighted Material
II6 Clinical Anatomy and Management of Cervical Spine Pain
IS] [§] @!I . b-....-[§J �
Pronator teres Flexor
(Posterior
digitorum sublimis
interosseous
(anterior interosseous nerve)
nerve)
Flexor dig itorum profundus
Ext. carpi rad. brev.
Flexor pollicis
Flexor dig itorum
longus
supinator
profundus
ext. digito rum
ext.
Ext. carpi ulnaris
abductor pol licis longus
digiti quinti
:r-l1"'T7'"1,----- -- - - - Wrist
ext.
Abductor
p ollici s
longus-brevis
ext. indicis
pollicis brevis Flexor pollicis brevis Lumbrical 1
Fig. 7.5
& 2
Median nerve. From Cailliet
(1995)
with permis
sion.
Fig. 7.7 Radial sion.
nerve. From
Cailliet (l99"ib) with permis
Ulnar nerve
� �
Roots
Flexor digitorum profundus
]
pollicis
Interossei
Fig. 7.6 sian.
Lumbricals 3 &
Ulnar nerve.
From
Palmar Digiti quinti
4
Caillier
Cl994b) with pennis
Dorsal
Fig. 7.8 Sensory mapping of peripheral nerves of the hanei. The schematic areas of sensory innervation of the median nerve (M), radial nerve (R) and ulnar nerve (lI). The dermatomes of the dorsum of the hand vary as (he radial nerve may have no sensory area or merely a small area over the first dorsal interosseous. From Cailliet (1994b) with permission.
Copyrighted Material
11'Jedicai management of neck pain of mechanical origin 117
Clinical entities
Atlas·axis
Vertebral artery
C2
Upper cervical segment (occiput-atlas-axis)
dorsal root ganglion
The symptoms are headache with hypersensitiviry of the scalp in the CI, C2 and C3 dermatomes. Tender ness with reproduction of the headache is deter m i n ed by d ig ita l pressure upon the emergence site of the greater OCCipital nerve (Fig. 7.9). Diagnosis is confirmed by relief from local injection of an a nalgesic agent into the nerve or into the dorsal root ganglion of C2 (Fig. 7.10).
Ventral root Dorsal root
Fig.
7.10 Greater su p e r ior OCCipital nerve: its C2 root. The
C2 dorsal root ganglion
!.ies
under the oblique inferior
muscle (not shown), over the lateral atlantoaxia.l joint, being
adherent to the capsule. It emerges l ate ral to the posterior
membrane but does not penetrate it. It proceeds d orsa l and ventrJI root. From Cailliet (1991) with permission. atlas-
laterally to divide in to a
Lower cervical segment pain and impairment Neck pain is a poorly u n der s tood symptom variollsly described as disc disease or soft-tissue injury pain (Bog duk and Marsland, 1988: Taylor a n d Finch, 1993). Pain is subjectively located in the neck, and motion is con siderecl as causative or aggravating. Rest relieves pain.
Cervical zygapophysial joint pain Distension of cervical zygapophysial joints with c on tra s t medium can p rodu c e pain c h a ra c teri sti c of
the pattern complained of by the patient (Aprill et at., 1990). Pain from the C2-3 joint is perceivecl in the upp er neck and the occipital area (Fig. 7.11). Pain from the C3-4 joint extends from the upper neck to the levator scapulae muscle. That from the C4 - 5 j o in t forms an angle between the lower neck and the upper shoulder girdle. From the C5-6 joint the pain extends from the lower neck over the s upra spi n atus area, and that from the C6-7 j oin t over the blade of the scapula. The areas are large an d indistinct but reasonably consistent. Compression upon the head with the head turned and laterally flexed causes radiation of pain down that extremiry (Fig. 7.12). Traction of the head relieves radicular symptoms (Fig. 7.13).
Lesions of the cervical cord t----,'---- Greater superior occipital nerve Sling
-r-I---\�'--'-I--- Odontoid Sternocleidomastoid -,---�-T - rapezius
Fig. 7.9 Emergence of the greater s up er i or occip ital nerve. The greater superior occipital nerve, primarily C2 nerve root, emerges in a graovc medial to the mastoid process of the OCCiput. It leaves in an o pen in g between the insertion of the trapeZius and the sternocleidomastoid muscles. A sm a li fascial sl in g completes rhe opening. In some people the netve emerges through the trape7Jus mu�c\e. From Cailliet (1991) with permission.
Injuries of the cervical cord that result in paraplegia or quadriplegia are clinically discernible with upper motor neuron signs: Babinski, Hoffmann signs, hyper· active deep tendon reflexes, spasticiry, clonus, etc . For more subtle injuries of the cervical spine, clinical tests are less specific and thus often over· looked. For lesions from C4 caudally the nerve root levels are discernible with dermatomal anel myotomal level testing. Above C4, there is a blind zone. The diagnosis of lesions within this zone is suggested from the ShinlizlI retlex (Fig. 7.14). The Shimizu reflex is performed by having the patient seated with the elbow bent to 90° and the forearm supported (Shimizu et ai., 1 993) . The exami ner taps the tip of the spine of the sc apula in a caud al direction with a rubb er reflex hammer. The reflex involves movement of the scapula from an abrupt stretching of the upper portion of the trapezius mus· cleo A positive test occurs with elevation of the scapula and/or abduction of the humerus: this indicates the possibiliry of a cord lesion between C2 and C4.
Copyrighted Material
118 Clinical Anatomy and Management of Cervical Spine Pain
Fig. 7.11
Referred zones of
cervical
levels (dermatomes). The graphic zones d e p i c t the roots C2-7. From Caillier (991) with permission.
root
derm:ltomal zones of cervical joints and
7 I i
.. , ,.... --�
\,
\\
Fig.
7.12
neck me n t
radicular symptoms. head (termed Spurling
Head compression causing
Downwards compression upon the
compression test) incticates probable nerve entrap·
turned and laterally side of the s y m ptom s , the head is forced downwards caUSing ipsilateral symptoms. Reproducrion of radicular sy m pto m s is considered a positive Spurling test. From CaiUiet (I 995) with p e rmi ssio n . at
the
foramen. With th e head
flexed to the
Copyrighted Material
to.. ",
\
Medical management of neck pain of mechanical origin 119 Fig. 7.13 Relief of radicular symptoms with manual t raction . In a pa t ien t with cervical radicular sym p tom s , manual tra c tion may relieve the sy m ptom s if the source of pain is forami n a l entrapment. Relief of radicular pain from elevation and traction of the upper extrem i ty may indicate brachial plexu s aeti
Pull
/
ology. From Cailliet (1995) with permission.
I,.
�� ,.
1:".
-.,,1----'-_ " BI i nd" zone
Fig. 7.14 Neurological test for cord injury in the blind z one : Shimizu reflex. R reflex hammer; X elevation of the sca p ula; A abduction of the humeru s . From Cailliet (1995) with permission. =
=
Copyrighted Material
=
120 Clinical Anatomy and Management of Cervical Spine Pain
Treatment protocols for cervical pain
Spasm is frequently initiated by localized pain from inflammation which can also become a tissue site of pain.
This
can
be
addressed
by
local ice,
heat,
massage, gentle stretching and isometric muscular Cervical pain may be related to an acute injury or be
contractions. Local injection of an analgesic agent
an exacerbation of a chronic process. Pain is vaguely
into the painful muscle can be considered when local
localized in a general area and may be related to
tenderness is significant.
specific motions. As an example, radicular cervical
Immobilization has been standard treatment for an
pain can radiate to the top of the shoulder without
acute musculoskeletal injury but its value over early
necessarily being considered a radiculopathy if there
mobilization is being questioned (Mealy et al., 1986).
,
If immobilization is conSidered, a cervical collar or
is no radiation into the arm, hand or fingers. In the acute phase of pain rest, immobilization and
splint has been the traditional modality. The purpose
local ice, followed by heat and gentle stretching, have
of a collar is to hold the head in a comfortable gravity
benefits. Oral anti-inflammatory medication, if tol
aligned
erated, is beneficial.
motion.
,
pOSition
to
and
prevent
or
minimize
A standard collar (Fig. 7. 15) is cllstom-made of felt
Reassurance is provided by a meaningful explana tion and failure to lise frightening words such as
that is 1-1.5 em thick and ellt to mould around the
degenerative disc disease, arthritis or slipped disc. It is
neck and jaw of the patient. No known orthosis or
well-accepted that the significance of the symptoms
collar completely eliminates motion, so it must be
assumed by the patient intensifies the severity of the
assumed that it merely restricts motion, supports the
pain and leads to possible chronicity and exaggeration
head in a gravity-aligned posture and reminds the
of disability over imp a irment (Cailliet, 1994a).
patient of excessive motion. By being under the chin
High enough to reach
�
___
One l aye r
occiput
Tongue blade reinforcement
of stockinet around chin
,
..... _--"'<.''"'', { �
�' ''
Felt to reach CUNe to conform -"'-to shoulder muscles
only to side of trachea - no felt in front Fell inserted into
5
of size to fit under m andi ble
em wide
stockinet
Tongue
and hold head - chin neck slightly flexed
blades
Felt
1.25
5 em
Slit cut for wrap-around insert
reinforcement
Fig. 7.15 Felt cervical collar. From Cailliet (1995) with permission.
Copyrighted Material
em
stockinet
Medical management of neck pain of mechanical origin 121 it minimizes the need for muscular contraction to
overcome
the
effects
of
graVity
and
also
limits
flexion. T he elevation behind the head limits exten sion. There are now available plastic coUars that are easily applied, easy to ke ep dean and cosmetically accep tab l e (Fig.
7.16).
OnLy when there are neurological signs and symp toms, and a need for significant restriction of motion, should a brace be fitted (Fig. As
a
general
constantly
the
for
decreased
as
rule ,
flIst
tolerated.
7.17). week,
Most
occurs w ithin 2 weeks.
sho uld
collar
a
be
then
soft-tissue
worn
graduaUy recovery
Prolonged immobilization
encourages soft-tissue contracture, muscular atrop hy and psychological dependence. Traction modality
subjective
Fig. 7.16
Preformed plastic collars. A standard plexiglass
cervical collar.
The
fibreglass preformed collar comes in
several sizes that need ro be tltted to the patient. They are
held
by a Velcro strap
in
the front. From Cailliet
(1995)
with
has
with
and
remained varied
popular
medical
as
a beneficial
opinions.
objective radiculitis,
the
Wit hout vaLue
of
traction as compared to a cervical collar and analge siCS produces no difference in ou tco m es (McKinney
et aI., 1989). In
acute
cervical
injuries,
continuous
cervical
traction for several days is valuable. In subacute or
permission.
®
Fig. 7.17
This brace immobilizes the cervical spine with (1) and an OCCipital pad (7). A chest pad (2) is connected to an anterior bar (3) that elevates the chin and connects by a strap (6) to the thoraCic portion which, by a vertical bar (4), attaches to the OCCipital pad. The shoulder straps (5) secure the chest pad. All parts adjust to make tl1e brace customized to the specU1c patient. From Cailliet (1995) with permission. Guildford cervical brace.
a rest positioned under the chin
Copyrighted Material
122 Clinical Anatomy und Mmwgement
Cervical Viine Pain
chronic problems, traction for 20 min several times
and
dailv
added
beneficial. Manual traction hefore instituting
mechanical traction will indicate the tolerance and
Range of motion has been advocated but rarely
!'vl:mipulation or mob ili zation ha� been prnalent in today's society hut its physiologK:!1. benefit has not proven
nor
have
indications
the
for
defined
quantitated. A fiJllctional
ill
of motion
range
is
increase to
desirable
acqllire
this
complete and extreme range of motion, albeit physio
the
as m:IIlV soft
approach been clarified. are
incre:bc strength and
en d u rance.
benefit gained from that modality.
been
of motion. UltilTlately, resi�la!lce should be the exercise regirnc
logical , is not necessary. In fact, it should be Jvoidect,
several possible concepts
accomplishment of manjpulation as follows:
damaged
thm have been struclura II)'
will
not
tolerate
excessive
elongalion
.
?-ainfree and functionally adequate should be the
1. IJnlocking hasi'd on a
'jammed': zvgapopb'sial joint. This is
guideline. with gradual restoration
possible entrapment of a meniscus of
from normal daily I be acC("pred at a
told.
synovial
Restoration
of
movement
to
mandatory
in
is
post ulated
minimize tissue which
neurogenic reaction from manipulation.
stage
Restoration or institution of physiological posture
subl u xed zygapophysia\ j Oint facets has also been
2.
greater range
effort
alJ
of
activities
daily
living
to
and lmphy siologkal muscuhr
forwards head posture, ahead of the
the force alters the spindle systems' effect upon the
of gravity, places excessive stress upon alJ the cervical
muscle, alters the mechanoreceptors in the zygapo
spine tissues (Fig, 7.18).
physial joints or has
central rClCtion on reflexes.
Physiological posture
3. Elongation of the contracted zygapophysial joint
trained
Gll!
and practised by the patient
,
a therapist
at first with as",iMive
capsule or periarticular ligaments which may have adhesions
4. ReeentraJiz:llion of
nucJeus within
inter-
fC"\):
vertebral disc. �tandard
procedures.
applie d in the
force
direction that appears limited bm the Maigne tech nique differs in that it is applied in the opposite unrestricted a n d painless direction (Maigne, 1973). as icc, heat,
Modalities
rasound. massage
/ · � 1/(45-5.5 head)
Forward head posture
and electrical stimulation have their proponents out they should be considered as merely palliative and anci!l::!ry to a more active approach, None of these modal1ties are "pecific, curative
precise.
they
extend the costs of treatments without benefit. Exercise remains the most accepted modality. If there
limited range of motion,
exercise is indicated.
gradual active
is stressed, as exercises
performed by the patient are preferable to those exercises being done to the patient weakness is found frorn
ination, are important
.
Strengthening
muscles where
exercises, addreSSing J
specific
meaningfu l clinical exam
.
Isometric exercises should be initiaterl initiaUy
,
followed by kinetic exercises. Isometric contractions with no
joint motion
decrease
spasm,
pain and
atrophy. Isometric exercises should be initiated early
in
management of
spite
of
pain
indications.
.
as
acute cervical injury, in
there
are
few.
exercises
Isometric
if an\'
stretch
.
eontra
the
jo i nt
arm, hand and fingers
capsules to a slight but definite degree, benefiCially compress the cartil age strengthen ,
tendons,
and extrude toxic
ligaments and
(ischacmic) materials
from the muscles reflexly contracted by pain and inflammation. They are active and initiate the involve men! of the patient towards recovcn. isometric exercise should be followed by active assisted exercises that increase strength , endurance
posture. ;10 (approximately 4.5 5.5 kg) is maintained directly above the centre of gravity th e forward. approxiJll:ltely 7.5 m front oi of centre graVity, il ;,!lds an e.,llIll"ted 13 weight lip on the cervical spine. From Cailliet (1995) with
fig. 7. erect
Gravity
posture
-
permission.
Copyrighted Material
the
of forw.Hds head
Weight
of
the
head
Medical management
2.5 - 4.5 kg
of neck pain of mechanical origin 123
occurs as s ome d egree of rotation is usually pres e nt . This force caus e s rotation before extension takes place, resu lting in stress up on the ca ps ule s of the zygapophysial jo ints, the intervertebral di sc s and the alar ligament complex of the upper cervical segment. This fo rce is ap pli ed first at the occipitocervical joint as the head is heavy (4.5-5.5kg a ve rage weight). The force is then exp e n de d at the c6 joint. Th e head rotates fOlward s , followed by fl exi on of the neck which e xte nds t h e po st e rior neck tissues w hi c h are e l ong a te d excessively, w it hou t muscular reCOil, as the proprioceptOrs and spindle system do not react rapidly enough. C linically there are no external s i gns such as bmising, swelling or haem orr hage . Sympto m s are subj ect iv e, wit h obje ctiv e signs being minimal Or non -s pe ci fic . The most common lesions noted in the cervi cal s pine after an acceleration -deceleration cervical injury are soft tissue: muscle, lig am ent, j oin t capsu le and disc (Clemens and Burow, 1972; Dvorak et al., 1987).
Cardinal symptoms of whiplash
Fig. 7.19 Distraction exercise device. A device to assist in posture training. With a sandbag weighing 2. 5 -4.5 kg on the head, erect posture is maintai.ned and the cervical lordosis decreased. This is a proprioceptive concept that is imp.le· menrecl as long as the device is worn e1uring activities of e1aily living. From Cailliet (1995) with permission.
devices (Fig. 7.19) if ne cess a r y, until it becomes a life and ensures aut o mat ic uncon scious implementation. All co ntri but ing factors such as occupati o na l demands, emotional and phys io logi c a l aspects, must be u ne arth ed and addressed.
normal way of
Hyperextension-hyperflexion cervical inj uries: the whiplash syndrome
The
promin ent symptom is n eck pain w hich is
consistent: a dull achi n g sen s a t io n i n itia lly noted at base of the head which is ag g ravat ed by movement. Usually ther e is also an associated neck stiffness with rest ri cte d movement. Pain m ay radiate to the head, sh o u l d er , arm and in ters cap u lar region . Headaches frequently result from a wh ip las h inj ur y and typically are occ ipi ta l , radi at ing a nteri orly into t h e te mp ora l or OCCipital regi o n s which are sub served by nerve roots C1- 3. The examination of the wh iplas h pati en t is as for any ce rvic al injury. Treatment is also similar but with the exce ption that c a re fu l e xpla nat ion and reassur ance are m an d at or y because of all the lay publicity that has be en given to th is type of injury. th e
Conclusion
Th i s syndrom e is so co mmo n, and so controversial, me nt ion ( B arns ley et aI., 1993). By c o mm on definition, it is an injury th at results fro m a motor ve h i cle accident ca us i ng acceleration forces to be imp ose d upon the head and neck. At the time of im pa ct the vehicle is accelerated fOlwards, followed i m med i a tely (l00 ms) with for· wards acceleration of t he trunk and shoulders of the occupant (Fig. 7.20). n1e s h o u lde rs tr'dvel forwards under the head cau s ing extension of the neck . Assuming that t h e heael is facin g di re ctly fOlwards, all fo rces are linear (s a gitt al ) ; however, this ra rely
Tn 1 995 a Quebec Task Force on Whiplash-Associated Disorders (Spitzer et aI., 1995) reached these con clusions:
that it merits se parate
Pain
. cannot be seen on radiographs,
comp u t er tomography or magnetic r esonanc e imaging. Pain can be pursued us in g diagnostic
block s . . . it has been shown that zygap op hy s ial j oint pain is the most common basis for chronic neck pain after whiplash. The tas k force studied thousands of m edi c al articles regarding t re a tmen t and reached the follow ing conclusions:
Copyrighted Material
Clinical
of Cervical
and Managenwllt
Pain
:
,..) : , ..... '" I � I t-\ 1./ � ,/ I I' '\, I J , I !
flo\
""
,. .1..,./ . I / I
I J
I
/
---- Neck
>......
- -- Head
4
............ Shoulder ---
3
/"\
Seat
§
I r '\.. I' i'
,/
1/. I,:'
I
\
. ••
•
.,,,( .\ '
2
\�'.
:
\
dl
I' .-
�. .
.
'Ii
I. :'
'/ :' //, ./ "
(ms)
Time
Fig.
7.20 Upper-body-neck deformations from rear-end collisions. From the effecr of a linear force [he rear, the shoulder, head and neck deform at different rimes measured in milliseconds. The major forces (g) arc expended within the time under 0.5 s. From Caillier (1995) with from
perOll,";"'lI(Jll
1. Collars
(immobilization):
soft
collars
do
not
restrict the range of motion of the ce rvical s pine
stmlJes, it must be stated, reg a rded cervical pain without objective radicular changes.
yet may promote inact ivity and delay recovery.
2. R est : cumulative evidence suggests that p rolonged uctrimental to per i ods of re,,[ Manipulation:
equivalent
immediate
(less
be
undertaken
pro
mu scl e
week s ,
contractions are
combination with activating inter
-
immobili zation with a moul d e u onhosis for
than
min) imp rovemen t in pain anel
MobiIization
In the presence of nerve root impairment, more aggressive treatment must
su bj ectively
beneficial, is accc [l tai ) ic . Manipulatio[1�
mon-
ventions appear to be beneficial in the short term
itored with re p eated neurolo gical exalrunations. may
but lo ng-te rm benefit remains to be established. 5. Exercise : cumulative evidence s uggests that active
be valuable. Gradual isometric exercises, g ra du ati n g
exercise may be beneficial in the short and long
Ergonomic evaluation and correction of daily activ-
to
are a valid part
term. Traction: there
Ch apter 5 is de voted on the neck
benefi t
[l:l in.
regarding range --r
isokinetic exercises,
Passive modalities, posture trainin g an d electrical
an import ant and
should then be initiated
re habilitation the effect brain as thi�
injury is
cause of llluch suffering .
the rapy remain unproven.
8. Epidural or intr'.lthecal steroid injecti ons are of unproven long-term value. that tim(�. medication and rernedial and all
activities modalities
References use of
living are placebo. Their
Copyrighted Material
C, Bogduk 7.)'1-::1poph)'seal jOUlI 747.
The
prevlti,,"u'
flfst approxl!11111
cervical
Spine 17:
Medical management of neck pain of mechanical origin 1 25 Ap ril l ,
seal
C,
Dwyer, A , Bogd u k , N. ( 1 990) Cervical zygapophy· J o i n t p a i n patterns. n. A clin i c a l evaluati o n . Spine 1 5 :
458-46 1 . Barnsley, L . , Lord ,
5.,
of wrupl a s h . Spin e
Bogd u k ,
N. ,
Marslan d ,
j oints a s a s o u rc e BOLII'd i l l o n , J , E
G r i eve,
G,P' ( 1 98 1 )
cervical zygapophysial j o i n t
7: 2 3 9 - 3 5 3 .
1 4 8 : 233 - 236.
A t l a n to ·a x o i d inst:l b i l i lY, Surg.
zygapophysial
610-617, 3 rd
ed n .
edn.
Phil-
1 390 . l a . , R ya n , M, ( 1 989) Th ,
London : H e i n e m a llfl Ca i l l ie t ,
R. ( 1 9 9 1 )
m anageme n t of a c u t e neck 3 rd
a d e l p h i a : EA. DaVIS.
Cailliet, R ( 1 99 5 ) Soft Tissue Pain and Disability, 3 rcl e d n . P h i l a d e l p h ia EA. Davi s , C a i l l iet, R ( 1 9 9 4 a) Pain: Mechanisms a n d lvlanagement, 1 st e d n , Philadelph i a : F.A. D a v i s . CalLi icr, R ( l 994b) Ne rve c o n trol o f t h e hand. In: Hand Pain and fmpairmenl, 4 t h e cl n (Ca i l l i e r , R , ed ) , P h i l a d e l p h i a : F A . Davis, Pl'. 69 - 1 3 1 . Cle m e ns , H j , Bu row, K , ( 1 972) Exp e ri men ta l investigation o f i n j u r y mech a n i s m s fron ta l veh i c l e i m p"ch
STAPP Car
Crasb
accidents.
27-33. Mai gn e , R . ( 1 972) Douleurs R, ( 1 973)
Lo ndo n : Buttelwort h . M ealy,
K"
B re nn a n ,
H ..
Fenelon,
wh i p i :" h
or the Sixteenth
Springfi e l d ,
Vertebral Man ipulation,
M a i t l a nd , G . D . ( 1 977)
rro n L� 1 a n d rea r-
G . c . ( 1 986) Early 8r. Med.
IL:
4 t h edn, roobiJiza
i n j u r ies,
Shira lmra ,
K . ( J 993) Sp in e 18: 2 1 82 - 2 1 90 . \i. L , Sa Lm i , LR. e t at.
W" r re n d aie : Society of
of
I.
12: 1 97 - 2 0 5 A , Apri l l , C , Bogd uk, N, ( 1 990) Ce rvica l zygapop hy seal j o i n t p a t t e r n s , I. A c l inical eva l u a t io n , Spine 1 5 : 57 4 5 3 -4
Vertebrate et Traite Paris: Exp an s i o n
edn .
Orthopedic Medicine,
Charles C. T h o m a s ,
CTfu n c t i o n a l d iagnoc;ticc; SjJine
2nd
Emerg
S c i e n tific , Maigne,
Dvora k , j, Pa n j a b i ,
D wye r,
A rch,
d 'Origine
ments par Manipulation,
Auto m o t i ve Enginn'ls,
cervica l spine.
Problems,
\1:trsian d , A. ( 1 988) T h e a c c llracy
Ju l l , pathophysiology
( 1 91-);,»
Vertebral Joint
Common
Ed i n bu rgh : Ch u rc h ill Livi ngsto ne .
the
Quebec
d isorders, Spine
Stodd a r d ,
Ma n ual of
Lo n d o n : Hutchinso n ,
task
fonT
20: 8 5 - 7 3 S
OsteojJathic Teclmitlll�
Tayl o r, J R . , Fin c h , P. M . ( 1 993) Neck sprain . A us!. Fam. Phys,
22: 1 62 3 - 1 629,
Copyrighted Material
Surgical nlanagement of neck jJain �r mechanical origin N.
Axial pain
Introduction
This is almost al ways present to some degree and the Mechanical neck
ex tr emely
patholog )
but o nly
surgical intervention .. The less c omrnon ca uses
:Ire more likelv
t u mou r s
,
respond to
ar thri
such as
muscle s
,
all contribute The resul tant
·
specific, but
than the
single most i m portan t c ause, dege nerative disease. The usual indications for surge ry in
debatable.
zygapo pl1ysia l l oints l i gament,
f ai rly
co mmonly
on one
side and tends to involve the muscles. This is often
degenerative
desc ribed as an ache in the shoulder, ra di ating to the
cervical spondylosis are ncrve root or spi n al cord
in tersc apular area and often to the head, leading to
involvement rather than neck pain.
tensio n type headaches. The diffuse nature of this
Recent advanccs significal1l
enablmg immediate
-
spinal instrmnclltJrion have on cervical
surgery,
fIXation,
without
the requirement for external orthoses, but as yet
cervical
it from an
will usuaUy pain blll
absence always easy.
abnormalities this
Axial pai n that is worse at nigh t , espec i ally in an
this has not translated into an improvement in the
elde rly
surgical treatment of neck pain due to degenerative
u nd er l ying malign ancy.
pati ent
,
should
arouse
suspicions
of
an
disease. T hh c hapter
,Ind selec-
pa tients
surg ic al
availahle.
Radicular pain Cervical radicular pain is often equa ted with arm pain, and alt hough this is usu all y the case, not aU cervical radi cu l a r pain is felt in the arm and not all
History
arm pa i n is radicular i n nature. Diffuse arm pain
Presenting
be caused
as a Pancoa � l reflex
The history is often �kewed by medic olegal concerns
when pain follows a motor vehicle accident or work i njur y hut it rema ins of paramount importance. The ,
I umour
dystrophy,
conditions and
diverse
in
of the Joint or
is often a co rnponcnt of a
functional problem. True rad icul ar arm pain is due to cerv i cal
irritation or
pain may be either axial or radicular and in many
compression of
cases there are elements of both. From a surgeon's
commonly affected lIre C(l, C7 and C5. aU of which
of view it
!":I d i cular
that is
a
nerve root. The
and fourth
useful in
neck pain
plac e of surgery
in
Copyrighted Material
s p ondylo ...,i...,
most
nerve rarely eighth
Surgical management of neck pain of mechanical origin 127 Table 8.1 S(�ns of cen'ieal radiculojJatiJy
at one level with little or no ev idence of generalized spondylosis
Nerve rool
Motor signs
deltoid
Shoulder abduction EI bow flexion
None
Elbow extension
Triceps
with mechanical neck pain is rheumatoid arthritis.
Finger flexion and extension Hand intrinsics
Finger
This chronic infl a mmat or y d is order has a p re d iJ ec
Over
C5 C6
Thumb and index
fingers IYUddie finger Fourth and fifth fingers AxiUa
C7 C8 TI
suggesting that previOUS traum a may
,
have been relevant.
SenSOJ]l loss
Reflex
Other medical conditions
Biceps
One of the most imp o rtant conditions associated
Horner's
tion for the upper cen'ical spine , part i cu l arly the atlantoaxial level. Atlantoaxial su b lux a ti o n is found in a lm ost 50% of rheumatoid patients at postmortem (Lipson, 1984). Ankylosing spon dylit is and osteoporo siS are also important general medical proble m s to be A full history and systems review may
cervical nerve root is a lso only rarely affected but
cons idered
does produce arm symptoms.
reveal symptoms consistent with other sig n itlcant
Radicular pain is felt in a my otoma l as well as a
.
underlying conditions, particularly
malignancy. An
dermatomal distribution. Often the p a in is maximal in
elderly person presenting for the first time with neck
the myotome with p a raesthes i a e in the dermatom e . A
pain sh o uld be assumed to have metastatic disease
C5 ra dic ulop athy prod uces pain in the shoulder and
until proven otherwise (Fig. 8.1).
in the deltoid muscle. Compression of C6 causes pain which rad iates into the b iceps muscle and in to the thumb anel index tlnger; C7 pa in involves the triceps muscle and the mi dd le finger, and C8 involves the medial aspect of the fo re ar m anel the fifth fUlger
Examination
(Table 8.1).
General physical examination
\Myelopathy � evere
A c omplete general phy sical examination is imp or tant in the assessmen t of the patient presenting with
·
degenerative
there
disease
may
be
neck pain. One should look for signs of conditions
compression of the sp inal cord from osteophyte s or
wi th a kn own association with neck pain, such as
disc material. The pain associated with myelop athy is
oste oarthrit i s or rhe u matoid arthritis. Signs of wei gh t
usuaUy
more
chronic
and
less
severe
than that
loss, organomegaly or lymphadenopathy s hould make
associated with radiculopathy. Cervical myel opathy
one suspicious of underlying malign an cy.
often causes quite vague sympto m s The spasticiry
with diabetes mellitus are more prone to infections
and weakness it pro duces in the lower limbs may be
and brachial neuritis.
.
reflected in
Patients
mild g a it disturbances, a decrea se in
exerc i se tolerance or frequent tripping due to mild d o rs iflexi o n weakness. U pper cervical cord compres
Cervical spine examination
sion may pro duce the syndrome of' numb, cl umsy
hands', m a n i f es ted by diffuse numbness in the hand s
Inspection
and an inabiliry to perform fine motor tasks, such as do i ng up buttons or picking up coins. Any of these
The patient is observed while at rest during the
symptoms should alert the practitioner to the p ossi
taking of the histor y The range and freedom of neck
b ili ty of spinal cord compromise
movements are noted. The neck is then in s pected
may
,
a
c on dition which
progress rapielly to quadriplegia after
minor
.
after removal of the upper clothing. The webbed neck and low h a irline of KJippel-Feil sy ndrome are indica
trauma or manipulation.
tors
of
an
underlying
abn or maliry
.
Past history
Si m i l arly
,
c onge nital
cervical
the tilted head
and
spine
oc ular
imbalanc e res ulting from atlantoaxial rotatory sub· luxation are obvious.
Most patients with neck pain will be able to recaU some injury, often dating back to childhood faUs or school
sp orting injuries.
It
is
often
difficult
to
Active movement
determine the significance of these compared with the normal effects of day·to·day life. O cc asi onally a
The patie n t is
patient will present with severe degenerative ch anges
l ate raUy flex the neck '''hile attenti o n is paid to t he
,
Copyrighted Material
a sked to flex, extend
,
rot a te a n d
] 28 Clinical Anatomy ana Management of Cervical Spine Pain
B
A
c Fig. 8.1
(A) A cervical myelogram and
(B)
computed tomogr:aphic scan showing metastases
range of each movement, the rhyth m of the move ment and any apparent discomfort.
from (C)
a
breast
primary.
Passive movement TIle
passive
range
of
neck
m ovements
can
be
assessed but generally adds little to the information already gleaned from active movements.
Palpation
The cervical spin e is palpated gently, starting from the craniocervical
j unction
and progressing caudally,
Other manoeuvres
one segment at a time. It is rare to elicit any sign other
C ompre ssion
than local tenderness. Marked superficial tender ness
cervical spine with consequent wo rsening or allevia
may be an indicator of a funct i onal component to the
tion of nerve root compression symptoms respec
1980).
or
traction
can
be
applied
to
the
is then
tive ly Spurling's manoeuvre inv o l ves hyperextension
palp ated more firmly if the gentle palpation did not
of the neck and rotation away from the p a inful arm.
illness (Wadde ll et aI., any
produce
tenderness.
The
The sp in e muscles
are
then
.
This is sai ci
to
narr ow the intervertebral foramen on
pal pat ed starting with the insertions of the trapeZi us
the side and repro duc e radicular
muscles, which is a c ommon site for focal tenderness. This is cont i nu e d across the shoulder and a long the
L'Hermitte's sign is pain sho ot ing down the legs after flexion of the neck. This is an indicator of either
medial border of the scapula.
cervical spi n al cord compression or demyelination.
,
Copyrighted Material
arm
pain.
Surgical management of neck pain of mechanical origin 129 Neurological examination
Other
Radiculopathy
A complet e neurological examination may reveal rarer causes of neck pain. Cranial nerve abnor malities may point to a lesion of the skull base or an intrinsic brainstem abnormality. Supratentorial neu rological abnormalities mi ght suggest disseminated malignancy.
Usually the history will have given a strong indica tion of which sign s to t;xpect on examination. Pain, paraesthesiae, numbness or weakness in the dis tribution
of
particular
a
nerve
root
should
be
supp orted by the appropr iate motor and se n sory si gn s
.
panied
Given tim e ,
the weakness wilJ be accom
by was ting and
may even
troph i c
be
fasciculations
in
changes
and
there
the areas
of
numbness. Involvement of C5 will cause weakness of the deltoid and supra sp inatu s muscles whic h abduct
Investigation Blood tests
the shoulder and the infraspi natus whi c h ex ternally Blood
biceps reflex which may be re d u c ed but should still
associated patho l ogy. A raised e rythrocyte sedimen
tests
are
most
in
rotates the shoulder. There is so m e C5 i n pu t to the
useful
the
search
for
be present. Numbness is fo u n d over the upper
tation rate may suggest infection or rheu m atoid
lateral arm.
arthritis; anaemia or hy p erca lcae mi a may be associ
Compress i on of C6 causes weakness of elbow flexion and supin a tion and depression or absence of biceps reflex. Numbness affects the lateral forearm and the thum b and index fmger. A C7 rad ic u lopathy will produce weakness of elbow extension and wrist flexion and extension. The triceps reflex is d ep ressed or absent. The re is sensory loss affecting the middle fin ger and often the posterior forearm. Weakness of finger f lexion and extension and a loss of the finger jerk follow C8 nerve root compression. There is associated numbness in the fifth finger and me dial f o rearm Although Tl lesions are rare, they may imply sinister pathology yet be mistaken for a functional problem. When severe, they will cause weakness of the intrinsic muscles of the hand. A useful sign to look for is a Horner's syndrome, compris ing ptosis, meiosis and anhidrosis, clue to involvement of the sympathetic cha i n There is no accompanying reflex, and sensory loss is in the axilla.
ated with myeloma and elevated prostate-specific antigen with prosta tic carcinoma.
the
,
.
.
Plain radiographs Considerable d iagn ostic information can be glean ed from plain ra d iographs. These should include lateral and anteroposterior projection s
,
as
well as an open
mouth view of the craniocervical junction. Oblique views are sometimes h el pfu l but foraminal stenosis is
much better appreciated with computed tom ogra phy
(CT). If instability is suspected, careful flexion and
extension views can be obtained. In rheumatoid arthritis, particular attention should be paid
Cl- 2 level for atlantoaxial subluxation.
to the
Degenerative changes on pla in radiographs are almost universal and their presence does not neces sarily expla in symptoms. Clinical correlation is of paramount importance. Plain
radiographs may
also detect changes of
rheumatoid arthritiS, metastases, trauma, osteoporo sis and infection. Con genital anomalies such as os
odontoideum and KJ ippel - Feil syn drome will also be
Myelopathy
apparent. Neurological examination of the patient with neck pain is not limited to the upper limbs. If the cord is involved there will be abnormalities at and below the level of involvement. lower motor neuron signs predomin ate at the level of compression and these
CT scan
will be similar to those described under radiculop
CT gives the best detail of the bony structures in the
athy though often bilateral. Below this level there
cervical spine The resolution of the cord is usuall y
will be upper motor neuron signs. The tone is increased and there may be clonus in the knees or ankles. Reflexes are brisk and there may be abnormal reflexes (Hoffmann's s ign in the hand and Babinski'S sign in the foot). The abdominal reflexes are lost in cases of spinal cord compression.
inadequate and shoulder artefacts often obscure the
,
.
lower levels
(C6 7 -
and C7 - Tl). Pa rticularly in thin
individuals at levels above
sufficient to confirm
C6-7, plain CT c an be
diagnosis of disc prolapse or foraminal stenosis (Fig. 8.2), although the degree of a
confidence is usually less than in the lumbar spine .
Copyrighted Material
130 Clinical Anatomy and Management of Cervical SjAne Pain (MRl), a lthough it is still the best investigation for d e ge ne ra t ive llisease when MRI is unavailable or is not t olera ted by rhe parient. O cca sional l y CT myelography is still used wh en MRl gives equiv ocal
results
and is particularly
useful
when
there are large or widespread osteophytes. In such
cases, the superior bone re s olution of the CT and the
presence
or
absence
of nerve
root
sheath
o pa c ifi cati on with elye can p rov i de strong ev idence for or against nerve root compression (Fig. 8.3).
MRI A MRl has rapidly become the investigation of choice for most problems in the neck. It is non·invasive and
produ c es ima ges of the c ervical spine unobtainable wi th any other modality. Shoulder artefact is not a
probl.em,
cervicothoracic junction. The soft tissues of the neck, the s p in al cord and the nerve roots are seen pa rt i c ul a rly well (Fig. 8.2b). I m ages can be o btain e d in a v ar iety of formats. D isa d vant ages of MRl i n c l u de claustrophobia, wh ich is a common cause of failed exam ina t i on, movement artefacts during the relatively long exam
ination times and me ta l artefacts due to even tiny metallic fragments. Cost and availability also neeel to
be considered.
Nuclear bone scan This is
a
relatively simple i n ves tigati on with reason
able sensitivi ty but poor specificity. It is usually used
B Fig. 8.2 (A) Plain
computed romograph.ic scan showing a
left posterolateral disc prolapse at prolapse demonstrated
with
C5-6. (B) A C6-7
disc
magnetic resonance imaging.
In metastatic disease, the degree of bone destruc· tion will be more obvious than on pl ai n radiogra ph s.
Soft-tissue abnormalities may also be seen and some a pprec iation of the incursion into the spinal canal can
be made. The addition of reconstruction techniqu es, partic ularly with spiral CT scanning, can add considerably to the deflllition and diagnOStic capability of this investigation.
Myelography Myelography with concomitant CT has now been
Fig. 8.3
l a rg ely
oradiculopathy
r epl ace d
by
ma gnet i c
resonance
imaging
Copyrighted Material
A cervical
myelog(�(m of
a
patient with myel
Surgical management
oj neck pain oj mechanical
origin 131
as a screening test for metastatic disease or i nfection ,
anteriorly. Fusion for degenerative disease is more
but it has largely been supplanted by computer i ze d imagin g techniques.
commonly carried out anteriorly (Fig. 8.4d).
Radiculopathy
This is the most conunon indication for cervical spine
Nerve conduction studies
surgery.
Electromyography and nerve conduction studies are rarely
used
in Australia
for
the
investigation
of
radiculopat hy. Overlap of myotomes and delay in the
development of ch a nges make the results re latively
non-specific in most cases. Some authors advocate examination
electromyographic
of
the
paraspinal
muscles as a way of increasing specifiCity Qohnson
and Melvin, 1971), but the combination of clinical assessment and imag ing is easier and gives superior results.
Treatment
There
is
almost
always
an
element
of
mechanical neck pai n but the arm symptoms and signs are the reasons for surgery. Tn a younger patient it is usually due to an acute disc prol apse but in an
elderly patient the nerve root is
frequently
injured
in
a stenotic foramen, often after a minor injury or repetitive or unusual neck movements (painting the ceiling is a common ante ce dent to such a radiculop athy). Most often, a bout of radic ulopat hy will settle with conservative treatment alone and surgery will
nor be required. The indications for surgery are essentially threefold and are described below. In all c a ses it is imperative that the pain, numbness, weakness and radiological abnormalities are con sistent with each other. There is no point removing a
C7 - T1 disc for a C6 radiculopathy.
Indications for surgery
1. If there is significant neurological compromise in
the
Atlantoaxial instability
In an adult, a gap of greater then 3 mm betwee n the arch of Cl and the odonto i d process is indicative of instability.
Anterior
10-12 mm im plies
subluxation destruction
of
greater
of the entire
mentous complex ( Fielding et al.,
than liga
1974). A gap of
6 mm or more is considered an indication for surgery. In rheumatoid disease, subluxation is often associated with cranial settling. The degree of brainstem com pression arising from this can be determined most effectively with MRI. Unlike subaxial
dege nerative disease,
the most
common indication for surgery at C 1- 2 is neck pain, which is present
in the majority of
rheumatoid
patients with atlantoaxial subl lL"'(a tion (pellici et al.,
1981; Menezes and VanGilder, 1988). A prime con sideration is also prevention of neurological com promise due to progressive slip .
form
of
weakness
or
numbness,
surgical
decomp ressi o n is indicated as a matter of urgency. The definition of significant is relative and the degree of deficit that worries one individual may not concern an o ther. Reflex changes alone are unimportant, other than as an indicator to the affected nerve root. Sensory changes, including paraesthesiae,
vary
in
Significance
with
their
l o cat ion or intenSity. Numbness of the thumb and index finger of the dominant hand is more serious then num bness over the deltoid. The most impor tant neurological deficit is weakness and again the relevance varies with the individual, the particular muscles in volved and the degree of weakness. A glob al weakness is often seen in someone with arm pain and this needs to be distinguished from a true radicular weakness due to nerve root com pression. Reflex changes can help in this regard .
2. If the pain is in the distribution of a nerve root but there
are
no
neurological
signs
and,
despite
conservative treatment, it persists beyond a rea sonable period (usually 6 weeks), surgery may be
Subaxial instability
indicated. This is referred to as irritative brachalgia
This
may be severe in trauma and rheumatoid arthritiS, but in degenerative spondylosis there is usually o nly a relative instability. Loss of disc space
height will allow some movement but significant displacement implies damage to the anulus and/or
facet joints. Some move m ent is normal in flexion
(as opposed to compressive brachalgia, described above, where there is
a
neurological deficit).
3. In cases of irritative brachalgia, surgery may sometimes be in d icated prior to 6 weeks when the pain is severe and unremitting with usual con servative mea s ures .
extension radiographs but this should not exceed
3.5 mm (White et al., 1975). Surgery for rheumatoid subaxial subluxation involves either anterior or pos terior
fusion.
Zygapophysial
joint
IIlJufles
are
usually treated posteriorly and vertebral body injuries
Myelopathy Surgical decompression is almost al ways indicated in cervical myelopathy. This is a slow l y
Copyrighted Material
p rogressive
132 Clinical A natomy and Management oj Cervical Spine Pain
A
c
B
D
Fig. 8.4 Progressive instability due to degenerative disease. (A) 1988; (B) 1993; (C) 1994; (D) after fusion and t'xatio.n with an anterior plate.
Copyrighted Material
Surgical management of neck pain of mechanical origin 133 disorder which can usually be st a bi lized by surge ry
unco mmon .
of choice. Su rge ry is indi c a te d ,,,,hen radiotherapy h as
The
failed or if there is bony compre ssion of the spinal
longe r surgery is d elaye d, the gre a ter the long-term
cord. Surgical excision of a single affected vertebral
deficit is likely to be.
body
but
significant
improvement
is
with
fIXation
and
stabilization
will
usual l y
improve pain control significantly. When metastases
Tumour Metastatic tumours are a re latively frequent cause of mechanical insta bility a nd nec k rai.n , often without
are widespread in the spine, su rgery becomes much more difficult and is rarely indicated. Be nign tumours such as sch wannoma are much rarer and cause radicular pain rather than mechanical neck pain (Fig. 8.5).
neurological deficit. They may also cause neck pain without
instabiLity. Treatment depends
to a
large
extent on the clinical state and prognosis of the individual patient. If th e re is no neurological defic it and the spine is stable, radioth erapy is the treatment
Trauma Although acute spinal injury is an important cause of instability and mechanic al neck pain, the indications
A
B Fig_ 8_5 (A) Axial pain.
�nd (13) coronal magnetic resonance images ofa right C2 schwannoma presenting
Copyrighted Material
with neck and occipital
134 Clinical Anatomy and Management of Cervical Spine Pain for surgery are quite controversial and beyond the scope of this chapter.
Smith -Robinson This techniqu e involves excision of the disc and any osteophytes throug h the disc space, usual ly using a disc space spreader to widen the gap. A bone graft is
Non-surgical treatment
taken from the iliac crest and impacted into the disc
A variety of non-surgical treatment options are available for mechanical neck pain and these are covered in grea ter detail elsewhere in this book. In most cases, non surg ical treatment will be the most ap propriate form of treatment, with surgery reserved -
for the minority of patients with the specific indica
tions discussed above.
space to effect a fusion of the level. Some surgeons perform the discectomy but do not fuse the level; this would be considered the exception rather than the rule.
Cloward The Cloward technique involves drilling a circular hole centred on the disc space. This is carried down
Surgical treatment
to the posterior
Cervical spine surgery can be divided into operations done from an anterior approach and those done from a
posterior approach
In many centres there is a
.
historical preference for one over the other but, in general, the spine surgeon s hould be fami.liar with both
and
tailor
the
operation
to
the
individual
circlUnstances.
curettes
and
cortex
punches
.
which
Any
is
removed
osteo phyt es
with
are
also
removed. The posterior longitudinal ligament may also be removed to expose the dura and allow access to any disc fragments that may have penet rated this Ligament. A bone dowel
slightly
larger than the hole
drilled is taken from the iliac crest and impacted into the hole (Fig. 8.6). R a t h e r than autogenous bone, some surgeons use allograft,
xenograft or arti icial f
bone substitutes.
Anterior cervical spine surgery
Corpectomy
C1-2
This is particularly useful when there are degen
(Fig. 8.7)
erative ch ange s causin g spinal cord compression at
The most common indication for anterior surgery at this level is rheumatoid arthritis with cranial settling. Al though this is associated with mechanical neck pain,
the greater concern
is usu ally
neurological
compromise. The odontoid process may be removed transorally to decompress the cervicomedullary junc tion. This is then followed by a po s terior stabilization procedure.
Subaxial cervical spine
Anterior cervical discectomy is a common neuro surgical operation, done for either radiculopathy or myelopathy. The same approach can be used for f-usion
in
trauma
or
vertebral
body
excision
in
tumour. The approach is usually from the right side with a
skin
crease
incision
platysma is divided
at the affected level. The
and the plane medial to the
sternocleidomastoid muscle is entered. The carotid sheath is
retracted
oesophagus
laterally and
medially.
This
leads
the trachea directly
to
and the
anterior surface of the cervical s pin e . The level is checked radiographically and self-retaining retrac
tors are inserted beneath the longus coll i muscles. The disc is then excised. There are several variations of this operation.
Fig. 8.6
An autogenous iliac crest
Cloward anterior cervical
Copyrighted Material
fusion.
bone
dowel used in a
Surgical management of neck pain of mechanical origin 135
A
c
D Fig. 8.7
B
C5 vertebral body metastasis; (B) magnetic resonance imaging of th e same case; (C) a corpecromy has been performed and the body replaced with autogenous iliac crest. Internal fixation has been achieved with an anterior Orion plate; (D) an operative photograph of a similar case. (A) Plain radiograph showing a
Copyrighted Material
J 36 Clinical Anatomy ana Management of Cervical Spine Pain two adjacent levels. Rather than making two separate holes at the disc levels, the intervening vertebral body is drilled away, exposing the posterior longitudi Dal ligament which is usually also removed to expose the dura. The decompression is completed by remov ing the anterior part of the inferior margin of the upper vertebral body and the superior margin of the lower vertebral body. This allows for a very thorough decompression of the
cord in
cases of cervical
myelopathy and is also useful in isolated metastases in a single vertebral body. The most common graft material is autogenous iliac crest but substitutes may be used. Vertebral body replacements can be made from titanium and other
A
materials. Corpectomy can be used over longer lengths but it then becomes impossible to maintain the normal cervical lordosis and there is considerable stress on the two ends of a long strut graft (usually fibula).
Internal fixation
A wide variety of anterior plating devices is now available to supplement anterior fusion. The most commonly used are made of titanium, which allows postoperative MRl. The screws are usually of
a
ty pe
that locks into the plate, allowing adequate rigidity without having to penetrate the posterior cortex of the vertebral body. These plates are extremely useful i.n surgery for trauma and also provide immediate stability in multilevel fusions. The fusion rate for
B
single-level anterior cervical fusion is
Fig. 8.8 Two methods used to treat rheumatoid atlantoaxial instability. (A) Halifax c l am ps and bone graft; (B) titanium transfacet C 1 - 2 screws
very good
without fIXation (Robinson et al., 1962), and in non traumatic cases the use of a plate at one level may not add significant benefit.
Posterior cervical spine surgery
preSSion extends over several levels in
a
patient who
still has a lordotic cervical spine. This is much simpler
C/-2
than an anterior approach over multiple segments
Various methods of fusion at the Cl- 2 level have been devised.
Gallie and Brook's
fusions involve
wiring the posterior arch of the atlas to the axis with
interposing bone graft. Halifax interlaminar clamps are also used to achieve the same result. Magerl's technique of direct screw fIXation provides excellent results, including stability in rotation which is some what lacking with the other techniques. This can be combined with wiring techniques and braided cables are now often used in place of wires (Fig.
8.8).
and, with due care being taken to preserve the zygapophysial joi.nts, fusion is not necessary. The operation is done through a midline incision posteriorly over the spinous processes. The para spinal muscles are
stripped from the
bone and
retracted laterall y . The spinous processes are then removed and the laminae d rilled away or removed with bone nibblers and punch rongeurs. Great care must be taken when removing the inner cortex as the cord is compromised within a narrow canal and anything else inserted into the canal will further reduce the space available for the spinal cord. It is usually not necessary to remove the laminae of C2
Subaxial cervical spine
and the strong
muscular
attachments to the C2
spinous process can be left intact.
Myelopathy
When sufficient bone has been removed the dura Cervical
laminectomy
is frequently
used for
the
treatment of myelopathy, particularly when the com-
will bulge out of the defect and, unless there is
a
kyphosis, this will aHow the cord to move posteriorly.
Copyrighted Material
Surg ical management of neck pain of mechanical orig in 13 7 A fo ra minotomy c a n be performed t h rough a
Rad i c u l o p a thy
small incision placed in the mid l ine or m o re laterally
Sing le - o r mu l t i p l e-leve l ne rve root compressi on c a n
a t the affected leve l . By u s ing the same retractors as
be treated from a p o s t e r i o r a p p roach . This is most
for
suiteci to l a t e ra l ly p l aced soft disc p rotrusions o r fora mi n a l
na rrow ing,
pa r t icu l a rly
a
microdiscectomy,
lumbar
the
exposure
is
a d e qu a t e with a 2-cm skin incision . The operating
if i t i s due to
m icroscope provides su perior visu a lization and i.I l u
posterior osteop hytes (Fi g . 8 . 9 ) .
min a t i o n . The med i a l part of the zygapophysial joint is d rilled away to reveal the nerve roo t . This is then followed laterally u s ing a drill a n d a smaLl punch rongeur to undercut the bone l a te raUy, lea ving the j o in t in tact.
Pos terior ftxation The most common in d i cation for posterior ftx ation of the subaxial
cervical
i s tra u m a , pa rticula rly
spine
when posterior elements are invo l ved , as in zygapo physial j O in t facet dislocations. Posterior fixa tion c a n al so be used to imp rove sta bility aft e r extensive
or wide
lami nectomy
or
m u l t ip l e-level fo ramin o tomies (Fig . 8. 9). It is possi ble to perform a much wider decom pressio n o f a nerve root if t h e zygap o p hysiaJ j o i n t can be com p romised
but
,
if this
is
done
bilaterally
or
at
mul tiple levels, t h e consequent in s t a b i l i ty m a y be
A
p ro b l e m a ti c . There a re various wiring techniques w hich are quite
suitable
for
tra u m a .
Wires
can
be
passed
tlu'o ugh holes d r i.lled in sp inous processes, a ro und spinous processe s , under l a min a e , o r combinations of these. Ca bles can be substituted fo r wire and Halifax c lamps c a n also be used . After
laminectomy,
w iring
becomes
impractical
and posteri o r fixa tion is best achieved with lateral mass p lates. These plates a re fixed to the spine with screws passed into the lateral masses and provide excell e n t stability. The lateral mass at C7 i s quite thin a n d a screw may be p l aced in the ped icle at this level instead . At C2, a longer screw is used to pene trate the ped icle.
References Fielding, j.W , Cochra n , G . V B . , Lawsing, j. F II I et al. ( 1 974)Tears of the t ra ns v er se l iga ment of the atlas: a cli n i c a l and biomechanical study. ] Bone Joint Surg. A m. 56A 1 683 - 1 6 9 1 . Johnson, E. W. , Melvin, J. L. ( 1 97 1 ) Value o f electromyography in l u mbar radiculopathy. A rch. Phys. Med. Rehabil. 52: ..
2 3 9 - 24 3
Jipso n ,
B
V
Fig. 8.9 (A) Computed tomogra p h ic scan showing severe bilateral fora m inal stenosis at CS - 6 . The appeara nces at C4 - 5 were s i m ilar. (B) Latera l mass pl a t e s were used for sta bil ity after bilate ra l fora m i n otomies at C4 - 5 and C 5 - 6 .
S .). ( 1 984) RJ1 eumatoid a rthritis of the c e rv i c aJ s p i ne . Clin. Orthop. 182: 1 4 3 - 1 49. Me n ezes, A . H . , VanGilder, ).c. ( 1 988) Transo ral-trans p h a ryngeal
junction:
approach
ten-year
Neurosurg.
Copyrighted Material
to
the
ex p e ri en c e
69: 895 - 903 .
ante rior with
craniocervical
72
p a t i ems
.
.f.
Copyrighted Material
Chiropractic management of neck pain of mechanical origin M. I. Gatterman
Introduction Once a diagnosis has been made using conventional ap proaches such as taking a careful history, perform ing a thorough physical examination Cincluding orthopaedic and neurological tests, followed by im aging and laboratory tests as in d icat ed (Chapter 7), a diagnosis of mechanical spinal pain can be made. The mechanical lesion treated by chiropractors is referred to as a s pinal functional lesion - a subluxa tion. This has been defined as a motion segment in which alignment, movement integrity and/or physio logical function are altered (Gatterman and Hansen, 1994). Motion segments are the functional units of the body characterized b y articulat ing surfaces and their connecting structures. The s pinal motion se g ment of Junghanns is made up of two adjacent vertebra and the connecting tissues binding them to each other (Schmorl and J ung ha nns , 1971). The typical motion segment (or functional spinal unit) of the spine is a complex of three joints, the two zyga pophysial (posterior) joi nts and the interverteb ral disc. Movement at any one of these joints has a significant effect on the other two joints in the three-joint complex with degenerative changes affecting the quality and quantity of movement of the motion segment as a w hol e (Gatterman, 1990). In the cervical spine the two m os t cephalad ver tebrae form atyp ical motion segm e nts with no discs separating the anterior portions of these segments. The occipitoatlantal articulation has two paired condyles on the occiput that fit into the concave articular surfaces of the atlas. The body of the atlas in the atlantoaxial (Cl- 2) segment is replac e d by the peg-like odontoid process of the axis which is bounded anteriorly by the arch of the atlas and_,
post e r iorly by the transverse cruciate ligament. These two atypical motion segments allow for a considerable range of movement in the u p per cer vical region. The p ri ma r y motion at occiput-C1 is flexion and extension, while C 1- 2 allows for 50% of the total cervical rotation. Motion in the mid and lower cervical mot.ion and extension, and c oup le d lateral flexion and rotation. Consistent with spinal motion in general, movement in the cervical spine is guided by the morphology and plane of the zygapophysial articular surfaces. The exact mechanisms that cause subluxation of the zygapophysial articulations have not been estab lished. Biomechanical models that have been pro posed are listed in Table 9.1 (Mootz, 1995). Cervical subluxation synd rome s affecting the ce l-vical motion segments are commonly accompaniecl by neck pain and restriction of range of motion and may be localized to a spinal level by p alpation for painful zygapophysial joints and muscle spasm, and possibly b y functional f'J.diogrdphy (Dvorak et al., 1988).
Table 9.1
Il10dels of chiropractic sublu..Yation
Biomechanical models
Vertebral malposition Fixation caused by adhesion Fixation caused by synovial fold entrapment Fixation caused by nuclear fragmentation Disc deformation caused by tissue creep HypermobiIity and ligamentous laxity Mechanical joint locking Modified from Mootz
Copyrighted Material
(1995).
140 Clinical Anatomy and Management of Cervical Spine Pain
Aetiology of mechanical disorders The aetiology of cervical sp ine subluxation is thoug ht
to include progressive deg e nera tion , trauma and aberrant neurological reflex patter ns (Mootz, 1995). In addition to d e generative changes that occur with the ageing process, it has been speculated that frank trauma such as injury from a whiplas h mechanism, or microtrauma produced by faul ty sleeping posture and other h a bitual positions that produce repetitive strain can cause subllL'(ations. D ifferentiation of subluxa tions must include the recognition of subluxation due to overt pathology and the non-ma ni pula ble subluxa tion. A non-manipulable subluxation is a vert eb ral motion segment wit h radiological or cli nical features indicating that an adj us tive force or osseous manip ulation to this motion segment would be harmful or dangerous and is therefore contraindicated (peterson,
1995). T h.i s
extreme
form of subluxat ion has been
referred to as a medical subluxation or surgical subluxation (Sandoz, 1971) and it is imperative that the d.istinction be made on the basis of the magnitude of damage
to
sup p or tin g
structures
and
clinical
fi nd i ngs . Chiropractic treatment for mechanical pain of the cervical
spine is primarily
manipulation but
this
should only be used when it is considered safe in a particular case. Manipul a tion is a manual procedure that involves a carefully directed thrust to move a jOint past the physiological range of motion without the
exceeding
anatomical
limit
(Sandoz,
1976,
198\). In contrast to the non-manipulable subluxation, the subluxation chiropractors treat with ma nipulation is not commonly diagnosed by radiographic findings but rather is d e termin ed by palpatory indications (Haas and Pan z er, 1995) of l oca l i zed pain and muscle spasm (Bryner, 1989). A manipulable subluxation is one in w hi c h restricted function can be improved by manual thrust procedures (Gatterman and Hansen,
1994)
disc degenerates, this intrinsic balance mechanism is disrupted . With
reduced turgi d i ty,
the nucleus
as
pulp osus loses its hydrophilic properties , s egm enta l instability occurs
because
the
inelastic
ligaments
cannot shorten to compensate for the loss of disc height. The
resultant
increase
in
muscle
activity
required to stabUize the dege nera t i ng spine leads to the familiar pain - spas m - p a i n cycle. Hall
(1965) reviewed the pa ttern of degeneration
of the cervical spine. In the early stages, he noted cavities at the later;d margin of the anular fibres of the intervertebral disc that s prea d from one side to the
other with accompanying loss of disc height and ligamentous
laxity.
In
the
final
stage,
the inter
vertebral dist ance is greatly reduced and the bone structure becomes distorted by os te op hyte formation that results in stabilization of the e xcess mobility allowed by intersegmental l ig ame nts . In the following decade Kirkaldy-Willis et al. (1978) documented similar changes in the lumbar sp in e that provide
working model for the
a
diagnosis
and
management of mechanical low back pain (Kirkaldy Willis, 1984; Kirkaldy-WiJl.is and Hill, 1979). In this model, following the ini ti a l stage of dysfunction, loss of the intrinsic e q uili br i um creates an unstable phase of kinesiopathology duri ng which subluxation occurs (Keim and Kirkaldy-Willis, 1980). In the final stage, stabilization occurs, when motion in the z y gapophysial joints and disc becomes restricted by osteophytic proliferation; this stage is characterized by cartilage degeneration, loss of disc substance, soft-tissue fibro sis and the
formation of osteop h yt es
(Kci.m and
Kirkaldy-Willis, 1980). In the cervical spine the j oints of Luschka also exhibit degenerative changes, with the joint between the bodies of the vertebrae altered from a fibro cartil a ginous
amphiarthrosis
diarthrosis (Hall, intermediate
to
a ball-and-socket-shaped
1965). Sandoz (1989) described an
phase
prior
to
stabilization
during
which reversible j o int fixations (manipulable subluxa tions) occur. He noted that the restricted motion typically occurs at the extremes of se g men tal range of motion and may produce acute pa in of mechanical origin . In contrast, he noted that chronic segmental fD(ations enco untere d in the final stage of stabilization most co mmo nly occur at, or near, the
The process and mechanics of spinal degeneration
joint
neutral
pOSition
and
are
not
reversible
(Sandoz,
1989). The intrinsic forces that make the healthy spine a comparatively stable and mobile mechanical unit are vested in the elastic p roperties of some structures of the
spine.
Forces
acting
on the
typ ical
cervical
motion segment include the axial press ure of the head on the nuclei pulposi and the tension exerted
The mechanics of cervical spine injury
by ligamen ts holding each segment together, thus forming muscular
an
intri n s i c
force
is
equilibrium.
required
f ro m
Relatively the
little
contra ctile
elements to maintain erect p os tu re when this intrin sic e quili bri LUTI is preserved. \Vh en the intervertebral
Injuries
to
the
cervical
spine
accord ing to the structures . mechanism
Babcock,
Copyrighted Material
may
involved
be
classified
and by the
of inj u r y (Whitley and Forsyth,
1976).
Stability
is
dependent
on
1960; liga-
•
Chiropractic management of neck pain of mechanical origin J 41
mentous integrity and the absence o f neu rological
damage, loss of swbility and n eu rological da mage
insult. I nsta bi lity has been defined as:
With severe injuries, the anterior longitudinal liga ·
.
ment and intervertebral disc may be disrupted, with Loss of the ability of th e sp ine under ph ysio
logic load s to maintain relationships betw e e n
bilate ral zygapop hysia l join t dislocati o n O bv iousl y such cases require referral for approp riate surgical
vertebrae in such a way tha t there is neither
intervention (Chapter 8).
.
dam age n o r subsequent irritation to t b e spinal
Hyperextension injuries to tbe cervi ca l spine are blow to the foreh ea d or
cord or nerve roots and, in addition, there is no
most likely to occur f rom
development of inc a pa cit ating deformities or
from whi plash i nj ury produced by sudd en accelera
pain due to stmctural changes
(Whi te and
a
tion and are more common than h yp erflexi on in
Panjabi, 1978).
juries Hyperextension injuries frequently involve the .
atlantoaxial
j o in t ; hyperextension c ombined with
If severe i nst ability is suspec t ed based on severe pai n,
com p ressive forces such as occur with di ving acci
signs of neurological compromise or radiographic
de nt s may result in fractures and dislocations le ading
findings (McGregor a nd Mior,
1990), the pat ient
should be refe r red for a surgical opini on.
,
,
to insta bility and cord damage. Violent hyperexten sion with the fracture of the p edicl e s of C2 and forwards movement of C2
on
C3, prod u ces the
hang man s fracture. Burst fractures fro m comp ressive '
forces are rare and may in vol ve explosion of com
Cervical spine injuries
pressed disc material as well as disrupt ion of the
vertebral body.
In g e ne ra l, s pina l injuries are classified acc ording to the mechanism of injury (Table 9.2). Hyperflexion injuries most com m o nly result from blows to the back
of the
example (MVA).
head
-
,
1995). All these conditions require referral for appro· priate surgical in tervention ( C ha pter 8).
by
motor
ve b icle
accidents
of the vertebral body with ligamentous
Whiplash injuries is not a diagnostic term,
Whiplash
Table 9.2 oj injury
fl"'J.gments can prod uce
and forceful decelerations, for
prod uced
Pure flexion trauma may result in wedge
fracture
Displaced
cord injury in otherwise s tab le segments (F itz Ri tson
Classijlcation of spinal injuries by mechan.ism
but rather a
d escr iptive label that implies a mechanism of injury whereby the body comes to a sudden stop followed by a sudden snap of the unsuppor ted neck and head. By far the most c ommon cause of whiplash injury is the
HFperflexion injuries
MVA. The high incidenc e litigi ous nature of personal
syndrome Bilateral zygapophysial joint facet s ubl uxati o n Wedge compression fracture
injury and the freq uency of ongoing compl a ints
Flexion teardrop fl"aclllre
controversial subject which is dealt with in detail in
Anterior subluxation
Lateral flexion and rolation Injuries Rotational s ub l uxa t i on syndrome Unilater,ll zygapophysial joint facet subluxation
,
lo w speed
following
-
impact
ma ke
this
a
highly
Ch ap ter 5. The vu lne rabiH ty of the neck is created by the
3.5-5.5 kg head Qackson, 1977) sitting on top of the cervical spine with its multitude of joints 50 pair s of ,
muscles and a comp l ex ligamentous/capsular net
Hl'pereXlension. injuries Posterior subluxation syndrome
work. From this pe rsp ecti ve we have a ball (the head),
Hyperextension fracture-dislocarion
a flexible chain (the neck) and a rigid base (the upper
Fracture of the posterior arch spondylolisthesis
Traumatic
Laminar fracture
of tbe a tl as
back). It is not surpr ising that this structure is subj ect . to subluxation synd romes acco mpa nied by soft-tissue damage (Hohl, 1983) when a sudden motion whips
Vertical col71jJression injuries Compression fracl'ure Burst fracture Jefferson burst fracture (Cl) j1;Iixed mechanism injuries Atlanto·occipitaJ dislocation Odontoid fracture
the head and neck (most commonly in flexi on and extens i on)
.
Athletic injuries to the cervical spine
Total ligamentous disruption
Inj uries to the cervical sp ine include those from Modified from Fitz·Ritson
(19\)'»).
athletic activities such as football,
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soccer
,
skiing,
142 Clinical Anatomy and Management of Cervical Spine Pain diving, boxing , hockey and gymnastics. The mech anical
vulnerability
increases
the
risk
of of
the
hea d - neck
severe
disr uption
coupling of
the
mot ion segments. Bony elements , lig a men ts , discs and
muscular
supporting
structures
as
Table 9.3 Static and motion palpation procedures used in the manual tbe rojJy
well
as
neurovascular structures can be affected.
STATIC PALPATION
J\
Soft tissue
A clive/passive sefimentClI range of motion
Tenderness
occupational and lifestyle trauma to the cervical spine
Oedema
'fenclerness
Temperature
Quality
Moisture
Quantity
Muscle
tone AccessolJl motions
Hyperaemic response Motility
Trophic
.Joint play
changes
End
A variety of occupational risk factors have been suggested for mechanical disorders of the neck. The intro duction of modern technology has resulted in
Tenderness
monotonous tasks that impose static and repetitive loads. These
tasks
affect the
joints
and
muscles
pia)'
or end feel
Joint challenge/tenderness
Bony
M;,lposirioll Anomalies
which, in turn, can contribute to subluxation syn dromes. Consequently, a rel a tions h ip has been found
J\ofodified from H""s "lid Panzer
(l995).
between time spent working with office machines, including visual display u nits , and the occurrence of musculosk eletal symptoms. Other facto r s contribut
ing to these disorders are mental strain,
lac k of
sitliational control and low job satisfaction . A study of
420
m edical secretaries found that
63% had neck pain
at some time during the previous year due to workin g with
office
machines
(Kamwendo et at.,
for
5 h or more per day
1991).
Examination Palpation remains rhe primary diagnostic procedure
to localize pain in amenable structures, for example muscles
and
zygapophysial
joints,
by
clinicians
whose disciplines practise the art of manua l therapy. and Faye , 1989; Faye and 1992; Haas and Panzer, 1995) alon g with medical p ra ctitioners ( M ennel, 196 5) , osteopaths (Beal, 1989; Greenman, 1989), and phySical ther· apists (Magee, (987) w ho utilize manipulative ther apy acknowledge this essential skiU. Haas and Panzer (1995) recoreled the static and motion palpation procedures used in the manllal the rapy decision making process (Table 9.3).
Chiropractors (Schafer
Wiles,
Clinical features of mechanical neck pain The clinical presentation of neck pain depends on the
Joint play assessment and motion palpation are
under/ying anatomical and functional disturbance. Neck pain and rest r iction of motion are the most common
presenting comp laints and 45% of the
commonly taught ch iropractic procedures (Bryner anel Bruin,
1991); howe ver, re lia bil ity of palpatory
general population are afflicted at some time dur ing
proceelures llas not demonstrated consistent inter
their uves (Kelsey,
exa miner
one-thirel
1982). Furthermore, as many as
of these individuals will continue with
reuability
for motion palpation, muscle
(995).
tension and malpOSition (Haas and Panzer,
chronic moelerate to severe pa in 15 years after the
Pain provocation, however, has been sh own to have
initial onset (Gore et at.,
fair to
1986).
good
p a lp ators
reliability
have
among
demonstrated
palpators. moderate
Motion to
good
intraexaminer reliabil.ity, in el icating their abiuty to be consistent with themselves (Haas an d Panzer, 1995).
History
One remarkable study Gull et CIt.,
1988) demon
strated a high level of accuracy for the eliagnosis of Patients who present with mechanical n eck pain give
symptomatic cervical zygapoph ys ial joint elysfunction
varied histories as to the onset of their affliction. Most
correlating manu al diagnosis with radiologically con
frequent presentations indicate a history of recent
trolled
trauma from MVA, faUs or sports injuries , or cumu
were useel to test the mechanical propert ies of all the
lative trauma from habitual o ccu pational postmes.
cervical joints: abnormal end feel; abnormal quality of
Less frequently there wilJ be a llistory of, for example,
resistance to movement; anel local pain on palpation.
diagnostic blocks. Three palpatory criteria
antecedent viral illness or exposure to blasts of cold
Because
air causing neck stiffness.
exarnination of every joint movement because of t he
Copyrighted Material
some
patients
could
nut tolerate a
fu ll
Chiropractic management of neck pain of mechanical origin
high irr itability of the pa in it was established that, at a minimum, passive accessol-Y intervertebral move ment would be assessed in all subjects. All sympto matic subjects in this study had ex per ienced chronic cervical spine pain for at least 12 months . Nerve blocks were used to determine the s pecific cervical zygap ophysi al sites of p a in and dysnmc tion. The blinded examiner examined the patients 1-4 weeks after the initi al d i agn ostic block procedure to ens ure that the effects of the block had worn off and no trace of any needle-puncture site remained. This examiner was able to ident ify correc tly 15 of 20 patients with ,
143
Cervical extension and rotation
,
The usenllness of screening the patient for risk of cerebrovascular injury by pl acing the neck in exten sion and rotation prior to m anipul at i on has recently been quest ioned ( C ote et at., 1996). N one the less, the
predictive
esta bli shed and
value ,
of this
test
has
not
be en
g iven that some patients will show
signs of discomfort whe n pl aced in this pOSition, the prudent manipulator wiu gently place the pati ent S '
neck in ex tension ancl rotation, loo king fo r signs of blanching, nystagmus or cyanosis around the mOllth
confirmed zygapophysial j oint pain or dysfunction,
before deciding whether
determ ine the correct segmental level in all 15 patients, and identi fy the 5 patients with non zygapophysial joint pain. This study concluded that 'manual diagnosis by a trained manipulative therapist can be as accurate as can radiologically-controlled diagnostic nerve blocks in the diagnosis of cervical zygapophysial syndrome and that the three d i agnostic indicators chosen were h ig hly specific for sympto matic zygapophysial join ts The study demonstrates that, when symptomatic subjects are exa mined an d compared to a known gol d standard for comparison, palpato ry evaluation is an accurate too l for manual d iagnosis of mechanical lesions of the cervical spine.
man ip ula t ion . These signs, or complaints of dizziness
it is safe to use spina l
or nausea, suggest that the patient does not tolerate this pOSition and may be at risk of a cerebrovascular accident. Cerv ical sp ine manipulation using exten sion and rotat ion on such a patient should be avoided (see also Chap ter 12).
'
'
'.
Radiographic evaluation· The primal-Y use of radiography in the evaluation of mecha nical
disorders of the cervical spine is to
identify c ondit io n s that contraindicate or require modification
of
spinal
manipulation
(Gatterman,
1992). At least 31 condit io n s have been identified that
Functional tests
suggest modification of manipulative therapy and, in at least 20 o f these con diti ons radiography is part of ,
In addition to palpatory examination
several nll1c
the stan dard practice for esta blishing the diagno sis
tional tests may hel p to differentiate between pain of
and the other hancl around the occip ut The examiner
(G at ter man 1991). Flexion and extension views of the cervical spine are in clud ed in the Davis series (Davis, 1 94 5 ), the standard views taken following cervical spine trauma. The f lexi on extensi on examination is useful in determining motion and instability. Atlantoaxial instability is recognized radi ographically as an increase in the atlantodental i.nterval measuring more than 3 mm in ad ults and 5 mm in chilclren on the neutral lateral an d f lexion views (yochum and Rowe, 1987). Similarly, hypermobility, hypomobility and aberran t and paradox ical motion (Fig. 9.1 A -C)
traction to the patient s head to
have been described by chiropractic authors (Grice,
deter mine whether there is relief or a decrease in the
1977; Mannen 1980; Henderson anel Dorman, 1985). Overlay studies (Fig. 9.10 and E) are usenll to identify abn ormalities of cervica l flexion-exten sion motion. This procedure is performed most frequen tly in patients after spine trauma an d is used to indicate the presence of any excessive or ab nor mal segmental motion (White anel Panjabi, 1978; Vernon, 1982; McGregor and Mior, 1990). Outlines of the vertebral bodies from flexion, neutral and extension radiographs a re supe rimposed and traced on acetate transparencies with co loured f ine tip pens. Segmental motion between flexion, neutral and extension can then be depicted. Excessive lateral translation of the atlas lateral masses in re lation to the axis, sho wing atlantoaxial instability
,
mechanical or igin arising from the a n terior or pos terior elements and this may provide useful informa tion for the examiner.
,
-
Distraction Traction of the neck with the patient seated or su p ine may relieve mechanical pressure on joints and nenre roots. One hancl is placed uncler the pa tient s chin '
.
slowly
applies
'
patient's pain.
Foraminal compression C onversely with the patient seated and the neck extended and laterally f lexed, axial compression to the neck will compress the zygapophysial j o ints and compromise the lateral canal, pos s ibly in cre asin g mechanical neck pain. With nerve root involvement, pain wiJI radiate into the arm on the s ide to which the neck is later ally flexed. The distribution of the pain and altered sensation can give some indication as to ,
which nerve root is involved.
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,
-
144 Clinical Ancttomy ctnd Management of Cervical Spine Pain
Fig. 9.1 Cervical spine lateral flexion-extension overlay study. (A) E x te nsion ; (5) neut ra l and (C) flexion (C) radiographs can be analysed for intersegmental motion by
tracing the anatomical outlines from the neutral ra diograph (solid line in D and E). These are compared with the extension (D) and flexion (E) tr:lcings (dotted lines in D and E), which are superimposed on the neutral traCings. The procedure is performed most frequently in patients after spinal
trauma
abnormal
Copyrighted Material
and can be
motion.
From
lIsed to· detect excessive Or
Taylor (1995)
with permission.
Chiropractic management of neck pain of mechanical origin 145
�
�.
E
o
FLEXION ...... .
EXTENSION
NEUTRAL -
NEUTRAL
and a bnormal motion in rotary atlantoaxial subluxa
disease. Table 9.4 outlines some of the more com
tion, can be shown with lateral flexion views taken
mon
with an open mouth (R eic h and Dvorak, 1986).
the
mechanical cervical
and
spine
pathological
disorders
in
encountered
of
chiropractic
practice.
Differential diagnosis
Management
T he his tor y and physical examination, with appro priate imaging and laboratory procedures as indi
The fLfst consideration in the treatment of mechan
cated, help to determine whether the neck pain is
ical
mechanical in origin or whether there are other
i n d icat i on is present (Table 9.4). Indications for the
pathological additional
changes
therapeutic
remembered
that
requiring
non-manipulative
procedures.
mechanical
It
neck
shoul d pain
be
rarely
neck pain
type
is
location
and
manipulation of
when
manipulation
no contra
are
primarily
dependent on palpatory fmdings of segmental mus cle
and/or
zygapophysial tenderness and motion
occurs without accompany ing soft-tissue pathology
restriction.
(Chapter 1).
called the adjustment) tends to be applied specifi
In
addition
to
subluxation
of cervical
motion
Chiropractic
manipulation
(commonly
cally to a single vertebra with a short-lever, high
segments producing mechanical neck pain, among
velocity,
the conditions that must be ruled out or confirmed
lever
low-magniulde
arm
thrust
procedures
have
or
Long
impulse.
the
mechanical
are muscle syndrome s , ligamentous sprain, degen
advantage
erative joint disease, cervical disc herniation, torti
expense of specificity and control. The direction of
collis, myofascial pain syndromes and inflammatory
appJied force is along the plane lines of zygapophy -
of
Copyrighted Material
developing
greater
force
at
the
1 4 6 Clinical A natomy and Management of Cervical Sp ine Pain Table 9.4 Difje"ential diagnosis oj some common disorders oj the cervical spine Condition Muscle
History
and symptoms
syndromes HiStory of t ra u m a (whi plash);
C e nric a i s t ra i n
n ec k pai n rad ia tin g in to the Postura l stra in
Diag nosis indicators
Managem ent
Spasm
Trigger poi n t
and trigger points in n e c k
m u s c l e s ; pain o n ac t iv e ROM ±
therapy
(manual),
electrotherapy a n d exercise
h e a d , sho u lders and arms
pa i n on passive ROM
History of forwards head w i t h s t a t i c loa d in g of neck extension
Trigger po in ts in exten so r
Tr i g ge r p oin t therapy (manual),
muscles of t h e neck
e l e c trot he ra p y, exercise and
muscles; pain ra d i at i n g int o
postura l ret ra i n ing
neck, hea d , sho ulde r s and arms H istory o f viral infeClion,
Wry
synO\�a l fo ld pinc hing or
sternocleidomastoid muscle
Acute torticollis
n e ck fro m spasm in the
Trigger po in t thef1l p ),
exposure to a c o l d draught Biomechanical disorders
Zygapophysi a l
joint
subluxation
H i story of u ngu a rded mov e m e n t
w h e n ind icated
Pa lpa t i o n may reveal r e s tri c t cd
or t ra u I n a ; p a i n i n n e c k , h e a d o r
segme n t a l motion and
arm
tenderness
trauma ;
(manual),
e l e c t rotherapy and m anipulation
Man i p u l a t i on
Cerv i c a l
H i story of
M o t io n p al p a tin n may reveal
Restrict excess m o t i o n w i t h
zy g a p o physial j o i n t
st iffness of n e c k , protect ive
a b s e n c e of seg me nta l restriction;
cervical c o l l a r w h e n acure;
spra in
muscle spasm:
s t ress radiogra phs may revea l
exe rcise
pain a nd
pa in
may
radiate
to oc cip u t and into shou l d e rs
hyper mo b iJe vertebral m o t i o n
once lIluscle spasm reduces S p o n d yl osis and spondyloarrhrosis
Neck pain and stiffness; d ec rease in ra n ge of motion; pa i n may
refer
to cervico-shou l d n,
R ad io g ra p hs revea l decreased
Gentle manipu lation
disc h e i ght, osteophytes,
on de gree of degenerative
sc l eros i s of ve r t e b ra l body e n d
d ec reas ed
dep e n d ing
cha nges; r ra c U o n , exercise; restriction of
excesS motion
occip i t a l and in te rsca p ul M
p lates,
region s , dizziness
facet j o i n t a n d u ncnvertebral
cervical c o l l a r may henefit when
joint s pac e s with oste o p hy t e s
:lc u le
zyga pophys i a l
by
a nd scleros i s Ce rvi c " l disc h e rn i a t i on
H is t o ry of t ra u m a ; neck a n d
Refer severe cases fo r s u rg i ca l
reflex and s e nsa t i o n , ± mu sc l e
t h e arm in tile d i st r i b u t i o n of
weakness and was ting; adva nced
res p ond to
involved ne rve roo t ;
imaging
ge n t l e m a n i p u l a t i o n ; restrict
pa raesthesia : numbness, tingli ng ;
sca n)
sensory and
Inflammato ry disease Rhe u m a toi d arthr i t i s
Possible loss of a ppro p r i a te
sho u lder p a i n rad ia t i n g d o w n
Neck
pain,
refl ex defiCits
necessary (MR! ,
CT
excess m o t i o n , exercise
prog ress i ve pain of
Radiographs may reve a l
ma n ifesta tio n t h a t mal'
eas),
be
electrotherapy
M a n i pu l a t ion contraind icated in
osteoporo s i s , hy p ennob i lity, d i slocatioos and s u b luxa t i o n s
in
a t ri a l of specific
and
myelopathy, n e u ro l ogical (i e
eva l uation ; moderate cases may
subtle
fa t iga b ility or d ifficulty
walking, wit h sen sory loss or
gross para lysis)
of
cases of ve rt ehra l segm e n t a l
i nst a b i li ry ; restr iction o f excess
the c e rvical spine ; a tJa n t oax i a I
motion and refe r ral for m e d i c i n a l
d isloca ti o n may occur w i t h lysi s
t rea t m e n t ± s u rgical stabilization
of transverse l igame nt s; flexi o n extens io n views n e cessary fo r
accu ra te evalua tion (3 m m
gap
berween o d on to id a n d atlas
a n te r i o rly;
4-5
m m fo rw a rd
s u b l uxa t ion is sign ificant).
Positive rhe u matoid fa c to r may
be found Ankylosing spo n d yli ti s
Predo m i n a n tly s e e n in Illales:
st iffness,
spinal
pa i n , muscle
pain and loss o f chest expansion
POSSi b ly h i gh ESR a n d pos i tive
H LA-B27
d u r i ng a c tive phase;
Gentle mobilization,
heat, mi ld
exercise , ma_n i p u l a t i o n
radiograp hs demonstrate a
consi d e re d w h e n acu te p h a s e i s
progressive loss of segnl e n t a l
p a s t ; refe r for
m o t ion w i t h ossifica t i o n of
m e d i c a t io n when necessa r y
l igaments - ' b a m b oo sp in e ' ;
disc
anti-inilammatory
spaces a re not na rro wed as in dege n e ra tive jOint d isease;
l i g a m e n tous lax i ty a bo v e rigid
segmen ts may be seen with a tl a ntoax ial OCCi pital d i slocation Ra nge o f m O l i o n ; M RJ magnetic reso n ance imagi ng; C"T computed tomographic; ES R e rythrocy t e seci i m e n , a , i o n ra t e ; leukocyte antigen. Note: I n all c a ses, the c l i n i c i a n must consider ( h e p oss i ble rjsk fac tors o f a c e re h rovasc ular a c c i d e n t occurring due ro injury o f the ve rtebral or caroti d a rrerks. If i n doubt reg a rd i ng risk fa ctors, do not ( rcac by manual the ra p y. M o d i fied and u p da t e d from Gatterman (1 990).
ROM
�
�
�
human
Copyrighted Material
�
H LA
�
Chiropractic management of n eck pain of mechanical origin J 4 7
sial j o i n t facets, w i t h the objective of g a p p i n g t h e
the a bi lity o f t h e c l i n i c i a n . Lack o f d iagnostic and
joint. A s t h e articu l a r su rfa c e s s u d d e n ly m ove a p a r t
m a n i p tl l a tive s k i lls should be c o n s i d e red a d e fi n i te
a n a u d i b l e re l ea s e
to c e rvical m a ni pu l a t i o n .
possi bly from a
sudden l i b e ra t i o n
,"fl ovi al fluid gases. is
fo rce fu l
to cervical
n o t so grea t a s l i mi ts of i ts a n a t 0 l1l1Gl1 the joint must be so
as
to
absorbed
p oint o f ten si o n
preve n t t h e by
the
a p p lied
s u r rO LU1d i n g
force soft
from
being
tissues
(Ha a s ,
1 990) .
This topic is d e a l t with in d e ta i l i n Chapt e r 1 2 so will o n l y be summarized h e re . Contra in d i c a t i o n s to cervi c a l m a n i p ulation range from n o n-i n d i c a t i o n t o lack o f a c l e a r i n dication and from
Complications from cervical manipulation
rel a tive c o ntraind i c a t i o n
i n d i c a t io n .
Fre q u e n t ly,
benefits of
h ave
overshaciowed by
been
with
ce rebrovascul a r a c c i p a t i e n ts w h o
spine
and w i t h o u t o bvious such
as
c e re b rovascu l a r a r terioscl e rosis ,
hyperte n s i o n ,
h e a vy smoki n g o r oral cont ra c e ptive u s c . I n gen e ra l , cervica l m a n i p u l a tion
is a
rel a t i ve l y safe fo rm o f
t h e rapy i n the h a n d s o f s killed p ra c t i t i o n e rs b u t , l ike o th e r precise m a nual ski l l s , requ ires p ro l o nged a n d specillc tra i n i n g fo llowed by persi s te n t p ra cti c e . B o t h benefit a n d r i s k a re i mporta n t c o ns i d e ra t i o n s i n the e v a l u a t i o n o f t re a t m e n t options as, a lthough the exact incidence
of
occ u r
in
1
estimated t o t h re e
per
1 99:n
that
p e rformed c e rviC i I neck
liga m e n t o u s instability
re) a ti\"e
p a in . The
is osteopenia , whether m a n i p u l a t i o n , light mobiliza t i o n
niques fi c ia l .
a d j u s t ments may p rove Lower-extre m i ty
symp toms
a c c o m panying
n e c k p a in may i n d icate d isc p ro t ru s i o n w i t h c o rd invo l v e m e n t requiri n g m e d i c a l referra l . Early rec o gni t i o n of these con d i ti o n s a n d im m e d i a te referra l for n e u rological d e c o mp res s i o n a re essen t i a l to preven t permanent neurological deficits. T h e c o ntraind ica tions to m a n ipul a t i o n are for the most part c o m m o n sense a n d requ ire m o d ifi c a t i o n o f treatm e n t based o n presen ta t io n .
m ill i o n
evidence for mechanical
carefully
treat m e n t for i n c idence
conditions
osteo m a l a c i a . While osteopenia
is p robably
safer t h a n c o m p l i c a t I O n s mechanical
contra
c o n t ra in d i
for t h e i n volved
lhOt�lk and Orelli ,
mani p u l a t i o n s (Guttm ;IIl ,
1 98 5 : C arey,
following
:1C c i cl e n ts
m a nipulation i s
is
((;:mcrman , 1 98 1 ; Stodd a rd , 1 983) p a t ho l og i c a l
i n the past
h a v e received ma n i pu b t i o n a c c ici e n t ,
Unstahlc
m a n i p u la tion of the
d e n t s . Comp l ic a t i o n s
cerv i c a l
a b s o l u te
c a ted in o n e area of the s p i n e , yet benefici a l i n a nothcl'
The
to
m a ni p u l a t i o n
of serious
pain
gastro i n te s t i n a l b l e e d ing fro m p rescripti o n n on-s t e r o i d a l a nti-infl a m matory d rugs h a s been estimated at 1
While the e v i d e n c e s u p p o r t i n g m a n i p u l a t i o n for the
p e r 1 00 0 p a t i e n ts a n d 3 . 2 per 1 000 p a tients age 65
treatm e n t o f mechani c a l neck p a in is not as con
and ove r (Gabriel et at., 1 99 1 ) .
c l u s ive a s t h a t for the treatment o f acute low back
Wltile m o b ili z a t i o n i s c o ns i dered safer than m a nip
pr o b l e m s (Bigos et al. ,
1 994), t h e re i s convincing
u l at i o n , i t h a s b e e n suggested t h a t m a ni p u l a t i o n i s
evi d e nc e that mani p u l a t i o n of the c e rv ic a l spine i s
m o re effective in t h e treatment o f m e c ha n ic a l n e c k
m o re e ffec tive t h a n e i t h e r m o b il i z a ti o n o r muscle
( Ca s sidy et at.,
w i th m in o r cerv i c a l s p o n d y l o s i s
pain t h a n non-thrust
1 992). Most comp lications be avoided by b a s e d o n a good a n a tomy, physiology should a lways be sho rt-lever t h rusts
m ;mi p u l a ti o n c a n
p a i n , m a nip u l a t i o n with
each patient
shown to b e m o re effective
at. , 1 982). I n subjects
o f the relevant Excess force
p a i n from cervical spine
using s p e c ill c Il.igh-force, l ong-
m o t i o n , increased mOl
m a n i p u l a t i o n w i t h m e di c a t i o ll
lever rotational m a n ue uvre s . S o fr-rbsue a n d m o b i liz
m a illLamed a t 1 week a n d 3 weeks when c o m p a re d to
i ng tec h n i q ues m ay also prove benefic i a l . There is n o substitu tion for skill, knowledge a n d
t h o se rece iving m e d i c a t i o n alone (Sloop et ctl., 1 982) . In s u bj e c ts with chro n i c n e c k p a i n , t h e m ani pu l a te d
finesse . L i k e a n y o t h e r skilled p roced ure, the expec
g r o u p demonstrated a 4 0 - 50% r i s e i n p a i n threshold
ted resu l ts a nd n u m b e r of c o m p l i c at i o n s d ep e n d o n
around the m anipu l ated joint c o m p a red to n o change
Copyrighted Material
1 48 Clinical A na tomy and Management of Cervical Spine Pain in the group that received mobil ization (Vernon et at.,
Cassidy, ] . D . , Lopes, A . A . , Yong- l-I ing, ). ( l 99 2 ) T h c i m mediate effect of manipulation versus m o b iliza t i o n o f pain and
1 990) . Patients with lmilateral neck p a in showed a rotational manipulation tha n those receiving mobi Li zation without a thrust (CaSSidy et at. , 1 992) . Greater i mp rovemen t
in
patients
with
non-specific
Cote, of
control
group
receiving
d etuned
short-wave
dia
thermy and those contin uing treatment with general p ractitioners (Koes et al., ] 9 9 2 a , b , 1 993). Management
neck
of
p a in
by
chiropractors
involves m ore than simple manipulation of cervical joint dysfunction . Adjustments in cl u de a variety of osseou s
manual
thrust (Ba rtol,
1 99 5 )
and
reflex
(Bergmann, 1 995) techn ique s . Tra d ition al chi roprac tic
care
1 99 5 ) ,
involves
with
viewed
the
spine
w hole
and
patient
nervous
as integral components
H a rrison,
(Gatterman,
system
function
(Troyanovich and
1 996) . The chiropractor approaches th e
spi ne as a m u l t i l i nked mechanical system that com b ines weight-bea ring with physiological movement (Gatterman,
1 990) .
Restoration of mobility and a
the workplace and other activities of daily l iving are
test
as
a
c li n i c a l
screen ing
Man;p. Physiol. The!". 19: 1 59 - 1 64
1 2 7: 1 49 - 1 5 6 . J., O re l l i , F. ( 1 985)
is m a n i p ulation Med. 2 : 1 - 4 . D. , Pen n i n g , L. e t at. ( 1 988) Fu n c t i o n a l H o w d a n ge ro u s
to the cervic a l sp i n e ' Man.
Dvora k , J, Froehl i c h ,
rad iograp hic
d iagnOSis
of t h e c e rv i c a l s pine :
fl exion/
13: 748 - 7 5 5 . Faye , L.J . , Wiles, M . R . ( 1 992) ,\ilanual exa m im t i o n o f the spine. In: Principles and Practice oj Chirop ractic, 2 n d e d n (H a l d e m a n , S., c d . ) . S a n M a t e o , CA: A p p l e to n & Lange, p p . 30 I - �H 8. Fitz-Ritson , D . ( 1 995) Cervicoge n i c symp a t h e t i c synd romes: e t i ology, t rea t m e n t , and re h a b il i t a t i o n . I n : Founda t ions oj Chiropractic: Sublu_wltion (Ga tterman, M. 1 . , c d . ) . St Louis M osby, p p . 3 1 8 - 339 G a b r i e l , S .E. , Jaakkimain e n , L. , Bomba rd i e r, C ( 1 99 1 ) Risk for s e r i o u s ga st roin tes tin a l c o m p l i c a t ions relate d to use of n o nste ro i d a l a n ti-infl a m m at o ry d ru g s : a meta-a nalysi s . A n n . Intern. Med. 1 1 5 : 787-796. G a rterma n , M . l . ( 1 98 1 ) Contraind ications a n d com p l i c a t i o n o f s p i n a l ma n i p u lative t h e ra py. A CA ] Chiro . 1 5 : exte n s io n . Spine
57 5 - 586. G a t te rm a n ,
M . I . ( 1 990)
Related Disorders.
Chiropractic lv/a nagemel1t of Spine
Ba lti m o re :
&
Willia m s
Wilkins,
pp.
2 2 - 36 G a t terman ,
M.1.
( 1 99 1 ) Sta n d a rds of practice rela tive [0
c o m p li c a t i o n s of and c o n t ra i nd i c a tions to s p i n a l m a n ip
equ aUy i mportant in the management and prevention of neck pain of mech anica l origin .
extension-ro t a tio n
Dvora k ,
the overall objecti ve of improved posture and genera l well-being. Modification of precip itati ng factors in
Kreitz, B ,
the
sis. ]
reduction in p a in are the pri m a ry goals of chi rop rac tic management of mechanical neck p a i n , along with
P,
Davi s , A . G . ( 1 94 5 ) Injuries of the c e rvica l s p i n e . ]A . M.A.
strated in a group receivi n g manipulation an d/or massage and other forms of p hysical therapy, anel a
th e c e rv i c a l
proced ure before neck man i p u l a t i o n : a sec o n d a r y a n aly
nec k
mobilization comp a red to groups receiving exercise,
in
c o n t ro l led tria l . j Man ip. Pbysiol.
mea n improvement in physica l functioning, and pa i n complaints with limited ra nge of motion, was demon
spine: a ran do m i z ed The!". 15: 570 - 57 5 Cassidy, J . D . , The i l , H . ( I 996) The valid i ty
range o f moti o n
greater mean decrease in pain intensity follow i ng
ula tive therapy ] Call. G a t terma n ,
M.1.
Cbiro. A ss oc. 35: 2 3 2 - 236.
( 1 992) S t a n d a rd s of contra i n d i c a t i o n s [ 0
sp i n a l man i p u l ative thera p y. 1 n : Chirop ractic Standa rds
of Practice a nd Quality
Care
(year, ) . 1-1 . , ed . ) . Aspen
G a i thers b u rg, pp. 2 2 1 - 2 3 6 .
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Copyrighted Material
L. J"
eds). B a l t i m o re : William s
&
()steopatbic management
cervical pain
T. McClune, R. Clarke, C. Walker and R. Burtt
Introduction
be contused with the duty to comfort the patIent (Weber and Burton, 1986), always bearing in mind the need to avoid iatrogenic effects or disastrous
Cervical spine disorders are a common source of previous cl
discomforl and disability, this
have attempteci
consequences of inappropriate intervention. In
unravel the
with low
trouble, cervical
dromes
most people,
t:xlent. Chronicity
knowledge ,surrounding pillilology, biomechanics and
stage
the
uncommon, :md the c1inicll challenge is
order to prOVIde
useful framework for
lives, to
clinical management. This chapter aims to set out an
just the
approach to management adopted by the osteopath.
natural
However, as with the other manipulative professions
rather it is the reduction of recurrence rates and the
(and arguably most of clinical medicine), osteopaths
prevention of persistent pain and disabUity.
vary dramatically in wlut
belIefs and melliods,'io
is distilled
praetice anu
mixture of
contemp()rary research findings;
rhe
resolution of immediate
The litcraillre in respect
symptoms (the
cervical
dromes
more fragmented than for lumbar
ordcrs.
there are no
clinical
UK).
intention is to provide a rational framework for the
available (al least in the
Nevertheless, there are
assessment, trcatment and rehabilitation of patients
sufficient clinical similarities between lumbar and
with cervical syndromes, within the setting of an
cervical syndromes to indicate that the principles set
osteopathic clinic. Inevitably there will be consider-
out in the American and British guidelines for low
able
back
with
thc
from
other
tnodes of therapy. and
therapies vvhich use
(Bigos et aI,
general
for
doubtle.)' there will bt" o'iteopaths (and
essentLtl message, once
who
ruled
disagree with
follows.
Clinicians traditionally use three main sources for their choice of treatment (Weber and Burton, 1 986):
I
are appropriate,
cenici!
neck trollble pathology
that the approach "ilould be one
positive
management
promoting
early
return
to
normal activity (including work) along with a reduc
their own experience, what they learn from col
tion of passive (rest and avoidance) approaches.
leagues, and reports from investigations. The fU'st two
However, it would be a mistake to equate cervical
and
but
problem of dissemination
are
most
third, whilst
the
three, suffers
the
it follows that, at best, the
resultant therapy will be suboptimal. In describing the osteopathic approach we are aware that we only offer
a
part of an overall management strategy, a part
that is underdeveloped yet offers the help for
proportion of the
strict scientific proof of the though ab�()ll1tely essential,
of
and
problems;
with
distinct spinal referral of
possibilities
for concomitant diseasf,
serious
careful initial assessmenl j" of particular importance in cases of cervical symptoms. Cervical pain is a common presenting symptom in osteopathic
practice;
tigures
vary
between
20%
(Burton. 1 9R1) and 2 5 % (Rurns Jnd Lyttelton, 1 994) This
compares
with
approximately
patients presenting with
1 981;
Copyrighted Material
and LytteJtol1.
40
back pain
1
The symptom oj'
Copyrighted Material
152 Clinical Anatomy and Management of Cervical Spine Pain ensuring that there are no underlying conditions
Symptom-modifying factors In low back pa in , symptom-modifying factors may function
as
discriminating and
Langworthy
B ree n ,
factors (Burton, 1987; 1992) and can give an
indication of disability and loss of function and hence the degree of severity. It seems reasonable to assume that this is also tme of the cervical spine. General questions are asked as to which factors, if any, increase or decrease the presenting symptom . The answers to such questions will both guide trea tment as well as aid diagnosis . For example , neck extension increasing
separate to or causing the present problem that either need fu rth er referral or are contraindicated to osteo pathic manipulation. When asking questions about the patient's o ccupation , an osteopath is searching for factors which may predispose , calise or maintain the
patient's
activities
problems. Work
often
practices
the
influence
spinal
and daily mecha nics;
advice g iven often needs to address these issues. The p at ie n t ' s general psychOlogical status, including atti tudes to pain and
treatment,
s h ould be assessed.
neck pain, which is relieved by neck flexion, may indicate zygapophysial join t inflamma tion.
Clinical examination
Lifestyle and psychological influences
Table
An osteopath will question the patient on general health and lifestyle to gain a
more
comprehensive
understanding of the patien t's condition, as well as
Table 10.1 O steop a thic
10.1 is a summary of a protocol used by
osteopaths to exclude instability/pathology prior to high velocity thrust (HVT) manipulation of the upper cervical
segments.
screening protOCOL for upp er cervical high-velocity th rust
Rapid osteopathic screening examination for the cephalocervical region p rio ,'
Neurological elements
Tendon reflexes upper and lower l im b s, bilateral plantar Exclude organic neck stiffness, neck flexion test
If
Parts of the protocol
(HVT)
will be
manipulation
to HVT
responses
(Ker n ig ' s s i gn)
the pati ent complainS of sensory changes or we a kn ess
of the
limbs, assessm e n t of sensation and motor power is
necessary Intracranial contents
Pupils should be equal , centrdl, regular and react to light . UniiateraUy dilated pu p il
may
- if pupils
are asymmetrica.l, the larger
be associated with a Hutchinson'S pupi l. UnilateraUy con s tricted pupil - exclude Horner's syndrome
Note that both neck and upper limb pain can be referred from dys fun ct i on of the heart and subdiaphragmatic organs
such as
the gallbladder.
If
symptoms c a n.n o t be produced by musculoskeletal examination, the possibility of visceral
referral from these areas must be considered. Consider also the p os sibili ty of lung apex involvement, and percuss ausc ul t ate these areas
if
Try to elicit oculomotor ataxia (nystagmus).
bra instem compromise,
and a
Vertical nystagmus (j e rky/bobb in g HVT
up
and
down)
is
pathognomonic of
contraindication for
Skeletal elements
Passive
and
necessary
examination of cervical co l umn , with patient supine, neck in neutral pos ition
(a
pillow he l ps
prevent extension)
Note any p ersistent paravertebral sp asm or tenderness Brief palpation of surface of skull, for bu mp s , holes, deformities, local areas of tenderness Palpate
extracranial
circulatio n - exclude arteritis (hard, tender, pulseJess cord), superficial temporal arte ry
Vascular elements
Auscultate and palpate (separately) the transcervical port i on of the common carotid arteries.
HVT
is contraindicated in
the presence of an intrinSiC bruit/audible tl ow murmur, as ymme try of pulse volume, with asymmetrical conduction of ordin ary heart sounds, i.e. one side muffled co mpared to the ot h e r. Auscultate the ve rt ebral triangle, at the
apex
of the posterior triangle of
the
artery in the vertebr�J the su b clavian artery
neck where it arises from the first part of
Trial leverage
Passively put
the cervical sp in e
into a minimum levera ge pOSi tion
disturbance of feelings or perceptions: vertigo (sense of
internal
and sustain for 30 s. I nstru ct
in st a b ility) , anxiety, su b j e c tive
distress, nausea, epigastriC a nywh ere in the body, involuntJ.ry mu sc ul ar resistance.
discomfort, any visual disturbance, i.e. diplopia (double vision) or amblyopia or paraesthesia
especially the face. The patient Dlay superficially cooperate but you palpate an increas ing In the case of any of the
above ,
HVT tech.niques
Copyrighted Material
the patient to report any
Osteopatbic management of cervical pain 153 performed routinely during a clinical examination,
The evaluation of the biomechanical hll1ction of the musculoskeletal system will include examin ing
other parts wiU be used prior to HVT only.
symmetry of motion, movement of complete sections of the spine (regional motion testing) and of single
Observation
spinal h ll1ctional units (intersegmental motion test
Observation begins with general surface anatomy,
ing). The quantitative value given to a
then more specific regions are assessed, followed by palpation, to confirm or rule out visual i mpressions. Spinous processes can be palpated for any devia
movement is subject to error; the judgement is made based on the recognized physiolog ic a l norm al values, which will alter depending primarily on age, disc
tion from the
midline
degeneration, previous injury and sport participation.
depression
prominence
in
the frontal plane,
and
range of
plane.
Instrumentation such as a goniometer can be used,
Deviation of the skull and cervical or thoracolumbar
which would arguably be more accurate (A1 a ra nta et
or
in
the
sagittal
be
al., 1994); however, in a clinical setting thi s accuracy
assessed. A rotational or lateral displacement of the
is not necessary for the evaluation of dyshll1ction. The
spinal curves thoracic spine,
from
the
ribcage
normal
position
can
or scapu lae indicates the
presence of a scoliosis.
qualitative value given to the range of movement is as important, and a combination of the two is
Observation is m a de regarding pelvic tilt, unilateral
our aim.
erector spinae or limb girdle muscle hyper tonicity/ hypertrophy. This assessment of the symmetry to pos ture can guide the clinician to possible areas of over
Active motion
use or biomechanical dysfu nct ion. The transition from
The
the cervical lordosis to thoracic kyphosis should be a
co l um b a r regions may be assessed whilst standing.
overall
motion
of both
cervical
and
thora
smoot h minimal curve, a lthough a promine nce at the
However, active movements of the cervical spine may
C7 spinous process is ex pected . Note the presence of any lateral deviation within the cervical spine (e.g.
be testecl in the seated position to stabilize the trunk, and in elderly patients or those prone to dizziness.
torticollis) which often results from protective mus
The expected range of motion in t he cervical sp ine is
cular spasm associated with trauma, or the possibility
set out below
of bony pathology. If the patient needs to support the
1990).
(Kahn and
1989; M c R ae ,
Monod,
upper limb, this may indicate nerve root compromise.
confirmed with palpation. Noting signs of trauma
1. Ask the patient to bend the head forwards - about 70° should be expected. 2. Ask the patient to tilt the head back wa rds, into extension (exerCising care if the patient is elderly, or there is a history of vertigo or dizziness) - about 70° should be expected. 3. A s k the patient to tilt the head towards each
(scars, bruises, lacerations, abrasions and swelli ng) is
shoulder in turn, without slu·ugging the shoulders
important, and may help identify cause and extent of
- 45° is the normal range. 4. Instruct the patient to look over each shoulder in turn. No rmally the chin stops just short of the coronal plane at the shoulders - about 90° should
In advanced stages of bony pathology or soft-tissue infection the head may be supported by the hands. Inspect for colour changes. Erythema may indicate infection, inflammation or acute somatic dysfunction. Specific muscle bulk, signifying atrophy or hyper trophy, is poss ib le to detect with observation, often
injury. A brief inspection of sup ra clav i cul a r fossae would indicate if any lymph node enlargement is present, which would require fur ther in vestiga tion. If the symptoms are aggravated by sitting, observa
be expected.
tion would continue with the patient in a si tting position. Again, alteration of surface anatomy and morphology f rom the expecte d may help
in the
identification of areas of dyshmct ion .
A note is made of ove ra l l range of movement and at which sp in al segments that moveme nt occur. The next stage is to identify any limitation of movement , and the likely cause. The possibilities are muscle guarding, ligament shortening , b ony apposition or
Musculoskeletal assessment
presence of p a in. The qual ity of movement and the ex acerbatio n
The assessment of spinal somatic dyshmction is the
reproduction
central issue of our clinical practice. Neumann (1989)
presence of protective deformity, deviation, abnor
or
of
symptoms,
the
suggests that diag.nostic signs of somatic dysfunction
mal contours, loss of normal curvature on move
are:
ment
may
help
identify
tissues
co n tri buting
dysfunction (Corrigan and Maitland,
1. Joint movement restriction. 2. Neuroreflexive disturbance man ifest i ng as: (a) local segmental tissue irritation and/or (b) per iphe ra l segmental irritation (segmentally related dermatomes).
to
1991). A note
is made of any paraesthesia and concomitant symp toms,
and
which
movement
or
pOSition affects
them. To demonstrate the cervical origin of arm pain, the neck is moved into extension, rotation and then
Copyrighted Material
J 54 Clinical Anatomy ana Management oj Cervical Spine Pain lateral
flexion
towards
the painful
side together
with gentle but gradually increasing pressure (Spur ling manoeuvre). Pain and/or paraesthesia down the arm
indicates
nerve
compromise,
rather
than
a
thoracic outlet syndrome. This also exerts maximum load on the intervertebral joints and can reproduce musculoskeletal
referred pain of non-root origin,
which tends to be of a more vague distribution, not
normally
below
the
elbow,
and
without
paraesthesia.
Peripheral segmental irritation Patients
commonly
experience
neck
pain
which
radiates to one or both shoulders, elbows or hands. Radicular and peripheral jOint pathology as the cause
of these symptoms should be excluded. Neurological and clinical examination of the relevant peripheral joints will be necessary for this purpose. Referred pain or hyperalgesia of musculoskeletal origin from vertebral
segment,
without
root
involvement
a
by
mechanical irritation or compression, is often found
ill zones related to, but not always confined
to,
Palpation
associated dermatomal areas. This so-called
sclero
Palpation will include the neck, scapula, mid/upper
tome distribution is less distinct than the dermatome,
thoracic areas and ribcage. Muscular state (resting tone, bull<, temperature, abnormal mass) and mus cular symmetry are noted, as is tenderness to pressure. Symmetry of the ribcage and bony landmarks are noted. Variation from the expected normal is the purpose of such examination. When estimating the normal, bear in mind work activities, sports participa tion , previous injury and personality type.
the
and is subject to considerable individual variation. However, musculoskeletal referred pain in the neck, trunk and limb may nor be neurons alone. segments
to
a
matter of somatic
Pain is often referred from spinal
body
parts
which
have
no
nerve
connections other than autonomic nerves (Grieve,
1991). The sympathetic nerve distribution may be an factor in patterns of referreel pain of
in1portant
musculoskeletal origin. Pain conveyed by autonomic nerves is diffuse anel poorly localizeel. Accompanying
Local segmental irritation
the spread
of pain is
often
referred
tenderness,
Facet jOint somatic dysfunction is said to be usually
muscle hypertonus anel sometimes vasoconstriction,
associated with tissue changes around the involved
manifesting
jOint, segmental irritation points (Neumann, 1989), tender nodular areas resulting from increased tension
in the deep musculature of the neck and �welling of connective tissues.
as f lushing or sweating. The effects of segmental somatic dysfunction are listed in Table 10.2 and the effects of cervical musculoskeletal dysfunction are listed in Table 10.3. In oreler to identify surface anatomical landmarks
and
These points change with the direction and extent of passive joint movement, becoming more tender
on
and
ing the inion, mastoid processes, spinolls processes
easier
to palpate as the restricted joint
ap·
the
cervical
and
upper
of C2-7 anel zygapophysial
proaches its end·point.
thoracic
spine
sh01Jider girdle, palpate for bony prominence includ joints below C2
(for
Table 10.2 EJ!ects of speciJtc segmental somatic dysfunction Segmental Level of
Distribution of pain
Museu/ahlre aDected
Occipitoatlanto
SubOCCipital, occiput temporal
Recnls capitiS posterior (major
Atlantoaxial
region, orbit
and minor), oblique capitiS (inferior
C3-4
C5-6
and
C4-5
Possible cOJ2com.ilant
inoo/vernenl
somatic dysfunction
and
From anterior aspect of
Deltoid, supraspinatlls,
infraspinatus,
shoulder,
lateral side
dysfunction
superior)
shoulder to elbow crease Anterior
Temporom:ll1dibular joint
Periarthricis of shoulder
ceres minor
Biceps, brachioradialis
Lateral epicondylicis, radial radial tunnel
C6-7
Posterior aspect and arm;
index,
of
shoulder
Triceps brachii
Medial
aspecc
of arm,
ring
and
Medial
epicondylitis, extensor tendinitis
or flexor
middle and
ring ftngers
C7-8
tendinitiS, syndrome
scyloidicis, bicipital
of the arm and thumb
Hypothenar muscles
little finger
Copyrighted Material
•
Osteopathic management of cervical pain 155 osteophytic lipping and tenderness). In the unim
pathognomonic of somatic dysfunction. Peripheral
paired per�on, c6 moves anteriorly with respect to
segmental irritation is also clinically useful as an
C7
indicator of disturbance in the related cervical joint
WiEh cervical spine extension, allowing local
ization of C7, which is not always the most prominent
(Neumann, 1989).
vertebra. Palpate the neck for altered bony alignment,
Occipitoatlantal, a t l antoax ia l and lower cervical
cervical rib or muscular spasm ( Cor r igan and Mait
joints are tested separately in the sup in e position.
land, 1991). The information gained from this palpa
Whilst guiding th e patient's movements passively,
tion helps to identify alteration from the expected
evaluate quality and end feel range of motion in all
normals. After general identification of surface land
planes of movement at each jOint, in addition to any changes. The main physiological move
marks , using the pads of fmgers, palpate for subtle
soft-tissue
changes
ment is a nodding action (flexion and extension) with
in
the
and
ligaments
texture
of
tendons,
skin,
by
fascia,
gradually
muscle,
increasing
a
potential for a sma ll amount of rotation and lateral
pressure of fi ngert i ps to examine structures layer by
f lexion.
co ntra c ture or fibrous changes of the fascia. Follow
put in both hanels and place the tip s of both index
the directions of muscle fibres to their insertions,
fingers behind the transverse processes of CI. Rock
layer. Feel for abnor m a l tensions which may indicate
To examine flexion and extension, hold the occi
noting their tone, level of contraction, presence of
the occiput to produce a nodding movement and
contracture or spasm, bog giness ( f lui d) or ropiness/
assess the movement between tile mastoid processes
fibrosis (chronic contraction), and diffuse or localized
and
tenderness.
fmgertips, palpate dep th and tissue texture changes in the occipitoatlantal sulcus as you fle x and extend the OCciput. Normal range of motion is 10° of flexion and 25° of extension.
Soft-tissue texture varies according to chronicity. Acute somatic dysfunction gives rise to increased temperature, bogginess and oedema, increased mois
transverse
processes
of
Cl.
With
remaining
ture, tension, tenderness a ncl a rigid end feel. Chronic
To assess lateral f l exion, pl a ce the tip of the left
dysfunction ge nerally does not give rise to increased
index finger between the left transverse process of
Cradle
temperature or oedema; there is a 'ropiness' feel to
Cl
the myofascial structures. Palpate the supraclavicular
OCCiput in both hands. Tilt the head on the upper
and
adjacent
mastoid
processes.
the
fossae for cervical rib with local tenderness, tumour
cervical area fully back and forth and palpate the
masses and enlarged cervical lymph nodes. Palpate
opening and closing of the gap between the trans
the axilla for enlarged lymph nodes. Examine anterior
verse process of CI and the mastoid process, noting
neck structures (thyroid gland). Assess the patient's
cha nges in tissue tension.
hands, forearm and upper arm for intrinsic muscle wasting and temperature changes.
To assess rotation , use tile same positions as with lateral flexion, and rotate the head back and forth. As maximum
rotation
is approa ched,
the transverse
process of Cl is felt to draw nearer to the mastoid
Passive motion testing
process on the contralateral side. Zygapophysial joint
The ob j e cti v e in assessing joint movement p assively
crepitis is common in arthrosis. Most somatic dys
is to identify the range of movement, and the reason
function involves the minor motions of side flexion
for any l i mit a tion of movement. In order to examine
and rotation.
grou p of spinal segments, the patient is asked to lie supine and, using both hands to support the hea d and neck, the clinician guides the patient a
passively through flexion, extenSion, lateral flexion
Segments C 1- 2 The movement affected by somatic dysfunction is
and rotation. Ob serve range and quality of move
rotation. The normal is 25° to each side. Palpating
ment, end feel and reproduction or exacerbation of
the s pinous process of C2 , rotate the head until the
symptoms. The next stage is to identify the precise
spinolls process is felt to move. Normally C2 does
location
of
t he
spin al
segment(s)
involved,
and
not
begin
to rotate
until
the
head
has
rotated
determine whether they are h ypo- or hypermobile.
20 - 30°. However, in the case of somatic dysfunc
Hypomobility can result f rom ruptured disc, trauma,
tion,
degenerative change, processes .
inflammatoll'
Hypermobility
c an
or dest ructive
exist in
the early
stages of elisc degeneration/spondylosis, before any
the
spinous
process
starts
to
move much
earlier (Neumann, 1989). Note the degree of free dom of rotation,
and
changes
in symmetry and
tissue texture.
compensatory mechanism to stabilize the segment occurs.
Determine
the
direction
anel
extent
of
motion restriction and any change in joint pl ay and
Segments C2 - 7
hypomobile
Support the occiput with one hand, and flex and
segment is accompanieel by local segmental irrita
extend whilst palpating with the index fingers of
tion. The presence of hypomobility and segmental
the other hand between sp in ous processes for the
end feel.
irritation
Evaluate
indicates
also
jOint
whether
the
disturbance,
but
is
not
amount
of
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separation.
To
assess
lateral
flexion,
Clinical Anatomy and Management
Pain
Cervical
support the occiput and neck in both palms, whilst
carpal tunnel syndrome, ulnar nerve entrapment at
palpating the lateral aspect of the lateral masses
the elbow, proximal radicular syndrome suprascap
with the pads of inflex fingers. Assess the extent of
ular
nerve problems.
index
assess rot;1! Ion. place the pad on the !l()srcrolateral aspect assessed,
rotating this
the
neck
down
jOint. Assess the
to,
but
not
extent of opening
between two articular processes.
give
a
positive brachial nerve
Therefore,
the
real
benefit
because of the presence of the first rib, this region should be examined as a separate unit, with the parlent in the sicklying position, F:1ce the patient on the deltoid
with
fingers
of the
arm
with your
curling
around
of
the
test
is
to
differentiate between muscular and nerve root irrita condition.
cI ifferentiate
range of
abduc-
girdle fixed.
of the spinal colunm (cervical and thoracic) and,
Support the
tension
bility. A sensitized cervical nerve root can mimic an
between two distinct areas
folded
surgery)
test.
C6-T3
uppermost
extra-
after trauma
shoulder
Gerl'icothoracic
outlet syndromes,
like Pancoast
tissue adheSIons
lateral
masses. Pivot the head away from the Joint being beyond,
thoracic
occupying
gapping.
the
forearm, patient's
lower
the neck
this side,
f lexed to the
which applies tension to the upper roots of the brachial plexus. If the range of active abduction is now decreaseci, this suggests nerve root pathology as the limiting factor. Likewise, if contralateral cerwith the
rotation is compared to that
shoulder
that cervical
roots on
are sensitive to tension.
neck. Flexion, extension, rotation and lateral f lexion are all tested in this pOSition, whilst one finger of the caudal hand palpates movement between adjaspinous processes, [.ateral f lexion repeated to
opposite side,
movement
respiration,
Peripheral joints always
ancl uppC!
examrnmg
rotation also first
the scapulotilOracic, acromiocb\"ieular, sternocI:lvlCular, glenohll!11eraI md upper rib
faults
sites. Wilh
oecur at any
extremity pain, check the integrity of the elbow,
Other tests
forearm, wrist and hand - again a possible site of musculoskeletal dysfunction,
Brachial plexus/upper limb tension test straight leg
test, this
rib
the involvcmcnt of nerve tension.
shoulder
with
the
ischaemia in
for evidence
(cold-
glenohumeral jomt abducted to 90', with elbow
ness,
extended and the forearm supinated. Superimpose
radial pulse and apply traction to the arm. Oblitera·
wrist and finger extension.
tion of pulse is not diagnostiC, but is suggestive if
Normal subjects may
discoloration,
trophic changes).
the
experience stretching over the anterior shoulder,
there is no change on the other side. Ask the patient
cubit:11 fossa and latcr:11 forearm, oftcn accompanied
to turn rhe head to the affected side :md take a deep
tingling llUXlIllUm
in nerve
tralateral cervieti
cause
(and hold
Obliteration of the
pulse is
superimpose con-
suggestive of a
rib causing
vrlsclllar
lateral three tension, flexion
depress the
shoulder girdle (Elvey, 1994).
as is a
"iubclavian
heard over
artery.
The arm abduction stresses both cervical nerve roots and subclavian artery and vein. Addition of contralateral cervical lateral flexion puts additional hut not on
allowing
diffcrentiation bc! ween neural and
tissues .
muscular
neural ten-
on nerve differentiate flex the elbow
Resisted isome tric muscle contraction III ay
be used
muscles and com-
attachments, and of nerve
reduce shoulder abduction.
This reduces tension in peripheral nerves but not in cervical and shoulder girdle musculature (e.g. sca
General medical screening
lenes). Hence, if pain reduces, nerve root tension is
The
indicated. This test may indicate the presence or
presenting condition is of musculosktletal origin. See
of nerve
tfension, but
the pathology. 'rhe response even for
conditions.
nature or be the example,
Copyrighted Material
initial
interview
0.1 for a
may
raise
doubt
that
the
screening protocol designed
identify underlying pathology which
pre-
manipulative treatment. Medical screening is
Osteopathic m anagement of cervical pain 157 important because self-referred patients give only a
bending). If anterior one side, and posterior on the
one-off history; they are already symptomatic and
other, bilateral pain may occur due to rotation.
impatient for treatment. There are two sources of
Trauma to tile head or neck, e.g. from a fall, or
clinical error - to miss a detectable pathology and to
during contact sport or a knock to the vertex, can
hurt the patient by treating a surgically unstable
result in a restriction of the occipitoatlantal joint and
body.
associated pain. The patient is typically a young adult presenting with ipsilateral suboccipital pain, often spreading to the frontal and supraorbital area. He or she will have an accentuated cervical lordosis due to
Classification of musculoskeletal dysfunction
upper cervical
muscle spasm.
Rotation and side
bending towards the affected side w ill be painful and restricted, and away from that side will elicit a pulling
The upper cervical complex (occiput to C2)
sensation in the symptomatic side. The overlying tissues will feel thickened and tender. Any neuro logical symptoms, such as occipital paraesthesia or numbness with weakness on active resisted chin
Both these joints possess articular nociceptors and
movements, may indicate a tearing of the cranio
sensory afferents and hence have the potential to
vertebral
produce upper neck pain. The tissues causing pain
and trespass on the C2 nerve root. ill this case care
ligaments
production are the suboccipital muscles, C1 and C2
should
nerve roots, the upper cervical ligaments and zygapo
contraindicated.
be
taken
with and
subsequent
instability
mobilization/manipulation
physial joints. Referred pain from the occipitoatlantal
Postural strain develops over a period of time,
joint is variable and diffuse but tends to be sub
often with insidious onset. The individual may be
occiptal, temporal or radiating from C5 to the vertex.
asymptomatic for a period of time, with pain only
The atlantoaxial joints produce more localized pain,
experienced when there is an increased load placed
lateral and posterior at the C1- 2 segmental level (Grieve,
1981a; Ehni and Brenner, 1984; Star and
Thorne, 1992; Dreyfuss and Fletcher, 1994).
on the tissues and
a subsequent tissue response
provoking muscular ischaemia or fatigue. This may result from activities such as desk work, producing
The occipitoatlantal joint can become problematic
flexion injuries of the occipitoatlantal joint, or from
as a result of a primary trauma or due to chronic
jobs involving sustained extension of the occipi
postural dysti.mction. A sudden or excessive move
toatlantal jOint, Stich as decorators or car mechanics.
ment of the head will cause the zygapophysial joints
The atlantoaxial joint tends to become restricted in
to move beyond their normal range of movement,
rotation. This can occur, for example, as a result of
resulting in excessive stretching of the capsule and
an uncoordinated movement during sleep or due to
Ligaments with impingement and 'jamming' of the
working in confUled spaces. There may be an acute
facet surfaces. Pain occurs due to the subsequent
or chronic history. The patient can present with a
synovial iHitation and inflammation. The swelling
variety of symptoms, including occipital and hemi
may cause encroachment of the nerve root and other
cnll1ial pain, face pain and occasionally paraesthe
tissues. A protective muscle spasm also occurs, giving
siae and stiffness of the upper neck with diffuse
ischaemic pain. These will all result in restricted joint
headache. Side-bending and rotation are painful and
mobility. Altered neuromuscular activity may contrib
restricted on the symptomatic side. The heael and
ute to a chronic pain situation resulting from an acute
neck may be in a normal pOSition or in some cases
condition, which has no obvious reason for persistent
side-bent to one side and rotated to the other, with
symptoms.
hypertonia of the contralateral sternocleidomastoid
Irritation ments as
a
of
local
result of
myofascial-periosteal acute or
sustained
attach
muscle. Caution is necessary if the onset is trau
muscle
mat ic because excessive rotation can also be associ
contraction also produces local pain or tenderness,
ated with anterior shift of the atlas, especially if
especially at the base of the occiput. The hypertonic
there is a transverse ligament
suboccipital
rheumatoid
muscles
may
cause irritation of the
arthritiS,
which
deficiency,
can
lead
to
e.g. a
in
com
superior occipital nerve in this area, causing pain in
promise of the vertebral arteries with brainstem and
the top and side of the scalp rddiating to the frontal
cerebellar infarction (Chapter 12).
,
area.
the
Arthrotic changes occur most commonly at the
occipitoatlantal joint can become restricted: either
There
anterior atlantoaxial jOint and also at the occipito
anteriorly or posteriorly, unilaterally producing ipsi
atlantal anel lateral atl.antoaxial joints.
lateral
with
commonly mature or middle-aged with a history of
increased movement contralaterally (torsion), either
symptoms for months or years, often initiated by a
pain
are
and
various
positions
resistance
of
in
which
movement,
Patients are
anteriorly or posteriorly bilaterally, giving bilateral
traumatic stress. They may complain of a nagging
pain and resistance (flexion or extension) laterally,
headache in the forehead and eyes, with a feeling of
unilaterally with ipsilateral pain and resistance (side-
retro-orbital pressure. The pain tends to get worse as
Copyrighted Material
158 Clinical A na tomy and Management oj Cervical Spine Pain t h e day goes o n , It is a ggra va ted by p rolo nged flexion or exten s i o n , w h i c h can a l s o c a u se d izziness, N u ch a l
c repitus is c o m m on ly p re sen t , O n palpation t he re i s t h.i c ke nin g and tenderness o f t h e suboccipita l soft tissue s , The re is o ften a variety of accompa nying symp to m s , incl u d ing ve r tigo , m o m e n ta ry vagueness, nausea , dysp hasia , dysp h on i a , b l u r red visi o n , va so and s u d o m o to r c h anges a n d miosi s,
The u p p e r c e rvic al sp i n e i s i nvolved in 4 0% o f rhe u m a to i d art h ritis cases (Sharp a n d Purse r, 196 1 ) , with a tl a n toaxial subluxa tion o c c u rring i n 2 5 % ( Con lon et aI. , 1 9 66 ) due to so fte ni ng a n d wea kening of the
t ra nsve r se ligament .
S y m p to m s a re commonly
upper cerv i c a l and suboccip i ta l pain , spre a d i n g to m a s to i d , te mpora l o r frontal a re a s , Gre a t ca re must be
taken in a l l case s of suspected rhe u m a toid a rthri tis , with spin al m a n i p u l a t i o n a b s o l u tely c o n tra ind icated a n d refe r ra l to a rhe u m a tologist necessary,
Cervicogellic headache This p res e nts as a unilateral d e e p , d ull p a in st a r t i n g in
t h e ne ck or occi p ut an d rad i a ting to fro nta l , temporal and s u pra o rb ital a rea s . There is o ften refe rred p a in into the i p sil ateral u pper ex tre mi ty. A s soci a ted symp toms can i n c l u de nausea, dizziness/ve rtigo, blurred vision a n d dysphas i a . The d u rati on of p a in varies g rea t l y, from hours to wee k s , but u s u a lly l asts a few days. Sy m p to m s a re frequently brought on by awkwa rd n eck move men ts or uncomfortable p osi ti o n s d u r i n g slee p . There may be h i story of a re c e n t neck tra u m a . Pa ti e n ts are commonly y o u ng or middle-aged females (sex ratio
3 : 1; Merskey and Bogd u k , 1 994a), These headaches are thOUgh t to be s tro n gly associated with m u scu l oske l e ta l
d y sfu n c tio n
and
a rthrosi s of the upper
ce rvical spine , an d l ess fre q u e ntly with spond y l osis of the lower cervical segments (Grieve , 198 1 b) ,
The asso c i a ted symptoms are p robably in iti a te d d u e to i rritation of t he sympathetic n e rve component
in the upper cervic a l nerve roots ( M e rskey and
Headaches
Bogdu k , 1 99 4 b) via the superior cerv i c a l ga n gl ion ,
H e a d ache is a c o m m o n sym p to m a n d its c a uses a re too n u me ro u s to be d iscu ssed fully here . We will c o mm e n t on those which re late to t h e m u s c u loskele tal sys te m , A p p rox im a tely 1 0% of consultations to an oste o p a th a re for headaches (Burto n , 198 1 ; B u rns and Lyttelton, 199 4 ).
and d u e to l i n ks w i th the s p i na l tract of cra n i a l n e rve
V, w h ic h is accom panied by p a rasympathetic and sym pa thetic n e u ro n s , D i zziness and vertigo are li kely to be i n iti a te d b y d istorted a fferent imp u l ses from
mechanoreceptors in
the
u p p e r cervical
zygapo
p h ysial j o ints, w h i ch a re i n vo l ved in eq u i l i b rium . Vascular headache
Tension headache
Althou g h migraine is th ought to be d ue to a vas c u l a r
This is c h a rac ter ized by a pers i s te n t low-intens ity,
d isturbance, n o tably d i l a t i on of th e a rteries o f the
n o n -p u lsa tile ache, typically in the fore h e a d , temples,
s c al p and i n c re a sed cerebral blood fl ow, it can be
s u boccipital a re a a nd n e c k . T here is often a fee ling of
accentu a ted by m u s c u l oskel e ta l p ro b l e ms , especially
press u re a t the vertex or a tight band-like se ns a tion .
at the o cci pi to a tla nt a l join t , d u e to va somoto r effects
There is usually a hi story of p roblems over a few
via the sympa thetic nervous syste m , It is o ften fou nd
ye a r s . The p roble m is m o re common in females (3
:
1;
)errett, 1 9 79) and tend s t o o c c u r b etwee n the ages of
to o c c u r in c o nj u n c tio n with te n sion heada ches defi ned as a mixed hea d a che .
3 0 and 40, Pa in
It is a problem freq uen tly encou ntered , a l t h ou gh
occu rs
as
a
resu l t
of s u s tained
musc u l a r
exac t p revale n ce still rem ains unclear, p roba bly d u e
contraction, which i s b ro ught a bo u t b y various l o c a l ,
t o the
cortical a n d t h a lam i c ref lex e s ,
of
fact that there a re several
m igra i ne
c o n Side ra bly
Pain may res u l t fro m :
a nd
he n c e
be tween
d ifferent ty pes
d i a gno s tic
s t u d ies
criteria
( Mo unstephen
va ry
and
Harrison, 1 995). 1 , Irrita tion of the periosti u m d u e t o traction exerted
by the c o n tra c te d muscle a t its s i te of i nserti o n . 2 . A b u i l d-up of metabolites w ith s u bse q uen t ischae
1 , Classical m igraine. T his is a t h r obb ing headache assoc i a ted with a p ro d romal state and p re c e d e d by
mia, a n d increase d intram uscular p ressu re in the
a n aura u s u al ly with visual sym p toms. I t accou n ts
muscle belly.
for a b o u t 1 0% of a ll cases of migra i ne (G rieve ,
3 . Irritation
of
the su p e rior o c c i p i tal nerve as it
1 9 8 1 b) ,
It
is
more
comm on
in fe ma les (2 : 1 ;
passes through the con tra c ted s u b o c c i p ita l mus
Jerrett, 1 979) and te nds to o c c u r from child hood
cles , whi c h refers pain to the top a nd sid e of sca l p
to a b o u t 35 years of age . There is a p remoni tory
and frontal a re a . Also i ts connec tions with th e
p hase, lasting from h o u rs to a fe w d ay s , Pa i n th e n
fi.ft h , nin th and ten t h cranial nerves res u l t i n p a i n
s tarts , u s ua l ly in t h e u nilateral fro n tote m p ora l a rea
perce ption in the c ran ial vault. 4 . Emoti o n a l fa ctors: s o m a tization of anxiety i n the
an d may sp re a d to t h e w h o le hemicra n i u m , l as tin g
from 4 to 72 h , It is aggra va ted by s to o p in g o r
c o n traction;
exerc i s e , Ofte n th e p a tie n t also experiences n a u
m u s c u l oske le tal-type headaches a re o ften worse
sea , vom iting an d p h o topho b i a , Attacks u s u a lly
d ur i ng times o f stre s s ,
occm a b o u t 1 - 4 times a m o n t h ,
form
of increased
s keletal
m u s c le
Copyrighted Material
OsteojJathic management of cervical pain 159
2. Cornmon migraine. This occu rs more often tha n the classic type (2/') : 1 ; Merskey and Bogd u k , 1 994b). They
osteopaths are interested in relate to t h e p la n e of j o i nt m ove m e n t a n d th e expected ran ge o f move beets a re oriented at a
characteristics,
except t h a t t h e
There is a l a rge
no premoni t o l-Y accompanied by
s tage or a u ra
i n d ivid u a l s w i th regards
Attacks a l s o
in the c e rv i c a l s p i n e . rotat i o n t a k e s p l a c e in C:'
lip to 2 days or more. These two
a re tra d i t i o n-
a l ly exp l a i ned
cha nges. We
wou l d however suggest t h a t a m u sc u l oskeletal componen t
is
invaria b ly
prese n t ,
which
Lateral flexio n is a b o u t
,iO°
side,
and
extension
distn b u t i o n of move m e n t i s fai r ly equ a l t h ro u g h o u t
does
the segm e n ts (Ka hn a n d 'VIonod , 1 989). Assess m e n t
respond t o m a n i p u lat ive t re a t m e n t (Pa rker et al. ,
o f the mi d cervica l spine shou ld n o t be lim i te d t o t h e loca l t i s s u e s ; a d j a c e n t structures h a ve a direct i nflu
1 978) .
3. Cluster headache. T hese occ u r as 1 - 3 attacks p e r
e n c e on the biomec h a n i cal function of t h e m id-ne c k .
d a y i n b o u t s o f 4 - 1 2-week duration, with rem i s
T h e upper thoracic a n d s h o u l d e r gird le stru c t u re s a re
sion lasting for 6 - 1 8 months. They a re c h a rac
i n c l u d e d i n t h i s assessm e n t .
terized b y severe
u nil a teral stabbing,
burning,
throbbing p a i n
and temporal
a reas w h i c h
whole
I n c e rv i c a l s o m a t i c dysfunction Chyp o m o b i l i ty synpattern o f restric t i o n i s
d rome) ,
h e mi-
w i t h restriction o f
i s associated
c ra niu m , neck
towards the p a i nfu l sid e .
and rh inor-
ipsi l a t e ra l l a c r i m a t i o n .
supra s c a p u l a r p a in . T h i s i s
rhoea, with
w h i c h i s genera lly
between the common
the p a t t e r n i s
in
d i rection o n ly. Regu l a r p a t t e r n s ineluoe restriction o f m o ve m e n t (rotalion
d rin kers and srll o kers.
4. Temporal arteritis. This is a vasculitis of the
a n d latera l flexion) away from t h e p a i nfu l side, t h e
tempora l arteries . I t i s i n c l u d e d h e re beca use in
p a in b e i n g aggravated b y flexion and relieved by
o n e-th ird of cases it is a ssoci a ted w i t h polymya lgia
extens i o n . Non-trau matic d isorders tend to exh i b i t
rheumatica, a connective tissue d i sorder p resent
t h e s e regul a r patterns, w h e re a s tra u m a tic c o n d i tions
ing as pain and s t iffness i n t h e c e rv i c a l s p i n e a n d
d o not, as d o c o n d i t i o n s involving m o re than o n e
shoulder girdle muscles a n d therefore c o u l d be
compo n e n t , e . g . zygap o p hys i a l jOint, foramina! tis
confused w i t h a simple musculoskeletal p roblem.
sues, d i s e . Wit h in thi s sec t i o n it is assumed t h a t a ll
of o v e r 50 years
The patien t i s of age, c o m p l a inHlg
w hich p rec l u d e spinal
u n ilateral or
re i e c te d . Pain originating
b i l a teral t l"lro b b ing
(zygapophys i a l j o ints,
i n t h e tempora l
is a
on p ro l o n ged various systemic
cation o f temporal is symptoms such
common
symptom
cause of prese n t i n g cond i t i o n v a riable
low g ra d e fever a n d
weight loss .
5 . Headache of organic aetiology. T h i s i s i m portant
l . D i rect muscle strain . 2 . Repetitive/cu m u l a tive muscle s t ra i n .
to bear i n m i n d as i t oft e n p resents w i t h symptoms
3 . Direct j o int/ligame n t s t ra in.
similar to that of m igra i n e a n d there fo re must be
4 . Repetitive/c u m u l a tive j o i n t or ligam e n t strain .
i ncluded in t he d i fferen t i a l d i agnosis. (a) Menin g i t i s .
5 . C o m p lex tissue s t rain (whiplash).
(b)
Subarachnoid haemorrhage .
Dege n e ra t ive
(c) C h ronic s u b d ural h a e m a to m a .
cha nge
w i th i n
the
in tervertebral
discs of the c e rvical spine i s genera lly a n a tura l
(d) Post-concussion
\vll i c h is caused by the
(e) I ntra c ra n i a l
the tissue during d a i l v c h ange will resu l t i n in g
space , w hich in
Typical cervical
j o in t a n d the u ncoyend)!�!1 a p p roxi m a t e . The increased
This
can
be
structure at these segments
C3-7.
Join t
of a symphysis
type a t the intervertebra l discs and synovia l type at
will res u l t i n degencratilc accelerating (Barnsley et al.,
1 99 3 ) . T h e
osteoa rthrosis a t th e uncovertebral j o in t s may res u l t
the zygapophysial surfaces. The d e tailed a n a tomy of
in osteophyte form a t i o n , w i t h the e ffe c t o f protru
soft-tissue a t t a c h ments has been described elsewhere
s i o n i n t o t h e i nterverteb ra l foram e n . This may c o m
in t h i s boo k . The b i o m e c h a n i c a l p rope rties which
promise t h e cervical nerve roots Oackson , 1 977) . A
Copyrighted Material
Clinical A natOiIlY Clnd Management
Cervical
decrease in d i sc height will init i a lly resul t in seg m e n t a l i n s t a b ility (Grieve , 1 99 1 ) . There will b e rel aiive hype r m o h iJ i ty a t t h e affected segment. m ay be at adjacent .segments. for t h e surround i ng w il l t h e n join t interspi n a l hypermobility and capsul e a n d a d j a c e n t m u scu l a t u re wiU shorten and fibrosis wiH o c c u r (co llagen infi ltra tion). The n e t e ffec t wilJ be a sta b i l izatio n . The sh0l1eni ng of t h e i n te r s p i n a l t i s s u e a n d the formation of osteophytes natura l to the disc Howwhich mechanism failure of may from demands exceeding in t h e sympLOmatic picture wc assoc iate w i t h c e rvical spondylosis . T h e change i n biomechani c a l function o f t h e m i d cervical spine as a resu l t o f the degenerat ive p rocess c a u ses i d e nt ifiable c l i n ic a l ch:mge s . O n exam in:ltion , muscle t o n e often c h a no f the chro n i c tissue m uscles red u palpa b l e . i ts lordosis: ces. The cervical spme this may be associated with an increase i n the upper thora c i c kyphosis. The c h a nges a t segme n t a l level may cause n erve roo t compromise. Osteophyte interformation o r a in the sile ne rve I c rtebral foram e n sympi rritation. m ay (paraesthesia . anaesthesia or resu l t . The d istrib u t io n of such s y m p toms will d epend o n the spina l level a ffected (Ta b l e 1 0 . 2).
Cervicothoradc region mobile is t h e t ra n s i t i o n a l a re a b e tw e e n c e r v i c a l s p in e and relahvely i mmobiJ e t h o r a x . The area is vu lnera b l e to overstra i n/overload, in par t i c u l a r i n t h e C 7 T I apophysea l j o in t a n d a d j ac e n t connective tissues, which can have d i rect effects on the i n tegrity related stru c nJ re s (bra chial plexus, sternoclavi c u l ar acromioclavi c u l a r) (see a l so Chapter -
Ti:Joracic outlet sYlldrome
T h i s describes a variety of signs and sy mptoms resul t i ng from compressio n of the neuro m u sc u l a r b u n d l e a s i t p asses through the thoracic o u t l e t . S y m p t o m s rad iate the shou lder girdle a n d There a re whe re and into the is m o s t nilnera ble to neu rovascu l a r compressi o n , hence a c l assifica t i o n o f th ree syn d romes has been proposed:
1.
A t r i a ngle fo rmed by the a n terior and
medial scalene muscles t h e fi rst r i b , o n to wh ich they insert anterio r ,,(alene syndronlc a n d first r i b citlcicu/ocostal Between t h e .\�)Jtldrome. -
3 . Betwe e n pectora l i s minor, [lear its attachment to the coracoid p rocess and the ribcage pectoralis nzinor syndrOJne. -
red u c t i o n in size passageways will s ion can resu l t fro m :
of t hese compre ssio n ,
na rrow compres-
1 . Cervical rib. This is a conge n i ta l bony or fi b rous overdevelopment of the transverse p rocess of C7 . usual ly b i l a teral varies i n s m a ll be a r i b . There p rotrusion to fi b rous band rib. Cunseq u e n t ly, ove r t h i s higher barrier, w h ich may cause it to become stretched . It may also be compressed by t h e fibrous b a n d . 2 . Abnormal fibrous htl!1rls in sca l e n i u s merlius may lower brac h i a l a kin king o r first r i b su b.sequ e n t Fractu re o f the !Tu l u nion or the fo rmation cm ciavicu locostal space . 4 . Alt e red rib mech a n ics, e . g . elevation of the first and second ribs due to trauma o r hypeno n i a of t he sca l e n es , c a n result in chronic p ress u re on the �[ructures in titis posture, saggi ng, proU
tend to b e o f cases:
spnptoms
freq u e n t ,
i n 90%
1 . Pai n , paraesthesia or numbness starting in t h e root of the neck or shoulder, rad i a t i ng down the m e d ia l fOl'C8rm and h a ne! JSflcct of t h e S u bjective WeakJKSS w i th occasion a l wa:Sling of in t r i nsic the h a n d . flexor muscles Cra m p i ng of t h e
Copyrighted Material
Copyrighted Material
1 62 Clinical A natomy and Managemen t Table 10.3
of Cervical
Spine Pa in
Cervical musculoskeletal dysfunction
Significan t disc
Cause
Muscle tone
degeneration
A ctive jOint
Passive jOint
Neurological
mobility
m obility
changes
Possible
Acute muscle
Possibl e
Hy pertonic
1 Mobili ty, o fte n
1
strain
shortening of
cervic a l tissue
all d irections
j o ints a dj a ce n t to
tissue w i t h
Mobili ty o f
t i s s u e in j u ry
subj e c t ive sym p to m s i n the
advanced
arm
dege nera t ion Chro n i c m uscle
Possible
Hype rtonic a nd/
1
p a in
shortenin g o f
or fibrotic
affected t i ssues
1 M o b il i t)' o f j o ints adjacent
muscle tissue,
cervical tiss u e ,
stretched
t h e muscle
l1egeneration i s
predisposing to
a n d often
tlbrosis
advanced
rec urrent
perisc a p u la r
micro trauma
M o b i li ty
if
U n usua l , except
to
if
disc
m u scles
Acute j o int/
Approximation
Hyperto n i c ,
1
ligam e n t strain
of zyga pophysial
p rotective
p a r t i c ularly
Mobili ty,
if
joims, increasing
g u a rd ing of
i n j u red tiss u e is
d egen e ra tive
cervical m u s c l es
stre tched
1
M o b il i ty of
affe c t e d segme nts,
unilateral
often
Possi ble subjective
symptoms in the
arm
cha nges, therefore
s ho rtene d capsule/ l igaments and
i
potential of st rai n Chronic joint/
Ap p ro x i matio n
Fibrotic cha nges
1
l iga m e n t
of zygapophysial
a d j a cent to
affected
affected
degeneration
dysfunction
joints, increasi.ng
affected
segm e n t s ,
segm e n ts
a d vanced ,
degenerative
segments, often
p a r t i c u l arly
possi ble nerve
cha nges ,
fi brotic changes
when affected
root
therefore
in periscapular
segmems are
compression
shortened
muscles
moved
cap sul e/ l igaments and po te n ti a l to
Mobil i ty of
1
Mobi li ty of
If
d isc
is
i
stra in Acute complex
Soft-tissue
Hyperto n i c ,
1
t i ss u e i n j u ry e . g .
shorte ning,
protective
most planes of
a ffec ted
whiplash
zyga pophysiaJ
g u a rd ing/ direct
movement,
segm e n ts , often
possi ble if disc
j o i n ts
tra u m a o f
parti c u l a rly in
involving m a ny
h e rniation
a p p rOXi m a te d ,
cervical muscles
the a c u te phase
i . e . vul n era ble t o
a n d often
,
strain/
M obility i n
1
M ob i l i ty a t
co m pressio n
cervical
p resent o r
segm e n t s
ad vanced disc degeneration
. hypertonic
i nflammation
N e rve root
periscap u l a r
present p r i o r t o
m u scles
i n j ury
Clu-onic complex
Possible increase
Chronic
1
tissue i n j ury
i n d isc
hypertoni c/
i nvolvi n g > one
involving > o n e
compression
dege n e ra tio n ;
fi b rotic
p l a n e of
segmental level
possi b le
degenera tio n
a n d periscapuJ a r
may be
muscles
c ervical
Mobility often
mo veme n t
J,
Mobility ofte n
Nerve root
if there
is l l llresolved
(USC
herniation
a ccompanied by
o r advanced d i s c
herniatio n ,
d e generation
par t i c u l arly
if
tra u m a a ffec t e d the in tervert e b ra l d isc
Copyrighted Material
J 63
Osteopathic ma nagement Of cervical pain
as
which l i e s free in the s k u l l , i m pacted i ts
p hase
ex te ns i on
the s k u l l e n d s
1 986) .
D u ring
t i o n shou l d be used i n a limi ted way, rest is s e l d o m
the
n e c e ssa ry and reass urance of a good p rognos i s i s
extension p hase of whiplash the ante r i o r structures of the cervical ve rtebral c ol u m n are strained and the
e n c o u rage d . Fa i l u re t o resolve with in a p p rox i m a tely 3 m o nth s , p rogress ive n e uro logic a l signs o r pe rsi st
p o ste r ior structures a re co mp resse d Anterior struc
e n t severe arm p a i n s h o u l d in i t i a t e fu rther referral
(Bogd u k ,
.
subject
t u res
to stra i n a re i n tervertebra l d i sc s , an
terior lo ngi tud ina l
l iga m e n t ,
( S p i tz e r et at. , 1 995)
muscles,
preverte bral
oesop hagu s and pha rynx . Po s terio r s tructu res su b j ec t to com p ression a re the cervical zygapo p h ys i a l joints ancl the s p in o us p rocesses. The fo rce tra ns
Management of cervical p ain
m itted at t h e c ra n iocervical j unction will c a u se the odo nto i d process to com p ress the a nterio r arch of
Aims
the atlas; the fo rwards movement of the a tla s wi ll b e tra n s m i tted to the head thro ug h t h e atl a nt o occi p ital -
j o i n ts . The dropping of t h e mandible would cause the anterior
capsu l e
to
be
s trained
(Bogd uk,
1 986) .
During the flex i o n p ha se th e p o sterio r lon gi tud inal l igame nt
the i n te rsp i na l l igaments, the l iga m e n tum
,
The p rinc ipal a i m of o steo pa th iC tre a t m ent when a pp lie d to mec h ani cal neck p a in i s the rest o rati o n of optimal
fu nction
the
to
cerv i c a l
spin e
and
its
s u r ro u nd i ng tissues for that ind i vi d ua l . Th is is ach ieved wi t h a variety of m a nll a l tech n i q u e s d i rected a t
n u ch a e , t h e pos teri o r neck m uscles and t h e ca p s u les
j o i n t s a n d s urro u nd ing s o ft tissu e .
The com p re ssed a n terior structu res would be the
rega rd i ng
i n tervertebra l d i scs and the vertebra l bodies.
b ody, tho ugh trad i tiona Uy t reatment i s ap p lied w it h
o f the zygapophysia l j o i n ts wou ld b e s u bject to stra ill .
T h e re i s m u c h d isc u ssio n i n o s teopat h i c c irc l es natura l
hea li ng
mechani s m s
the
w i t h in
The l i a b ility to i nj ury would be greater in the
t h e i n te nti on of e nh anc i ng s u c h re p a i r a nd reco very
exten s io n s t rain because there is no thi ng to preve n t
fl ex io n the chi n wil l m a k e c o n tact w i t h the sternum
All h u m a n b o d ily fu nctions rely on a h o m eos tati c balance w i t h i n the p hys io logy of the tissues; if th i s situa tion a l ters th e n p a thologic a l c h a n ge m a y take
a n d t h u s p reve n t excessive flex ion (Bogd u k , 1 986).
p l a c e in t h e tissues. I t therefore fol.lows that a bno rma l
the head ex tend ing be yond t h e n a t u ra l range . In
.
fu nction i s a s te p towards p a t ho l o gica l Cha nge w i t hin
tissues, such a s fibrotic i nfi l t ra ti o n of m u s c l e , liga
effects
Pathophysiological
.
m e n t , fa s c i a , s y novium and j o in t capsules or degen ca r tilage .
T h e most l ikely pat hological effects of whi p lash , as
e rative
demonstrated fro m c l i n ic a l a n el ex p erime nta l s t u d i e s ,
and s urge ry w i l l often be i n co mp a ti b l e w i th such
stra in
include
herniati o n ,
l ongi tu d i n a l
of the
vertebra l
en d p l a te -
l igame nt,
avu lsion,
disc
muscular
s t ra i n or ru pture (p a rticu la rly t h e sternocleid omas to id a n d l ongus col l i ) and
c a ps u l a r
(B o gd u k
zygap o phys i a l j o int fractures
,
d a mage , a n d a variety of b ra i n inju ries
1 986) . Odontoid fra c t u res a re m o re com
,
mon
than vertebral body fra c tures. Zygapophys ial
joint
pain
is
the
single
most common
basis
for
is
that
somatic
p resen t as mob i li ty
,
ciysfu nc tion
hyp e rto n i c
p ai n
wil l
resu l t . This
musc u l a t ur e ,
ex p e r i enced
at
wiU
in
hya l i ne
l eaving p h ysic al
c ha nges ,
M edication
approach es a s
a n a lter
n a tive; m a nip u l a tive trea tment is one such a p p roach
.
If no tre a t ment is offered in t h ese c ircu mstances, does the fun c ti o na l state of c e rvic a l spine c o n t i n u e to
d e teriora t e , Ieaeling to i rreve rsible structura l c h a nges and
chronic
and
pain
d i s a b i l i ty? The
a n sw e r
is:
p rob a bly - sometimes. I t m a y d e p e n d on the i n d ivid u a l s m ake up ( b oth phys i c a l a nd psyc ho logical) '
p ersis te n t pain after whi p l as h ( B a rn sle y et al. , 1 995). T h e cli n ic a l i m p l i ca t i o n o f th e musculoskeletal effects
ch a nges
-
.
Tissues which may influence neck move m e n t are
the ta rge t for treatment; a ttempts may be made to reci u c e
muscle
tone,
stretch
fi bro t i c
a reas
and
re duc ed j oin t
i n c rease e l asticity of j oin t ca p s ule s and i nte rsegmen
sp i nal
tal l igaments . If move m e n t , and t h e refore fu n c ti o n , is
t h e a ffected
segme nts, a n d p a i n ex p e r ienced in ass oc ia te d d e rma
im proved
tomes or sclero tomes
ensu e . The notion p roposed by os teopa ths is that the
.
,
then n o rmal rep a ir mechanisms should
correction of s u btle i m pai rmen ts of movement a t a segme n tal
Guidelines
level
is
of paramount
impo rtanc e
for
c orrect func tio n .
G u i d e l ines, based on the Quebec Task Force and its
The
app ro a ch will g o b e yon d
os teop a th s '
the
recomme n da ti o n s , which have implications fo r p rac
mechanical co n se q uenc e s of impaired mobili ty. It is
t i s i ng osteo p a t h s are 'given below.
sugges ted that fea r of p a in and negative attitu des m a y
The
Quebec Tas k
Force
stud i e d
the
l i te ra ture
prolong an e p i sod e of low back pain a n d may a l s o be
regard in g whip l a s h i nj u rie s a n d p rod uced guidelines
a
for clinica l p ra c t i c e . Ma n i p u l a t i on was re commended
1 989 ; Bu r ton et al. , 1995). TIlis m a y a l so be true o f
,
fac to r in the progreSSion to chroni c i ty (Lee et al.,
in the early stages of a w h i p l a s h-associated disord e r
t h e c e rvi c a l sp ine
g ra des I - I l l . Early re turn to usual activities s h o u l d be
ma n age m e n t
emphasized , soft col.lars should be avoided , me d ica
a ppropria te a ttitudes and beliefs . Chronic pain is a
-
Copyrighted Material
,
t h u s a v i tal component o f t h e
p rocess
is
to
h e lp
a d d ress
a ny
in
Cervical
Clinical A natonlY and Managelnl!J1 t c o m p lex d am a ge
phenomenon but
invo l v i n g
a t t i t u des
to
pain,
not
tissue
brought to a point of tension lIs i n g a combin a t i o n of
strategies,
move m e n ts - flex i o n - rotation and s i d e- b e n d i n g with
o n ly
coping
exp e r i e n c e o f p a in a n d a l tera t i o n of c e ntral p rocess i n g m e c h a n i s m s
shou l d be
c o m p res s i o n/tra c ti o n . I f a patient's t o t h e righ t
without
p a ra m o u n t
i n t h e m a n a ge m e n t o f a c u t e p a t ie n t s to a v o i d
is
and s i d e-be n t
would be rotated to the
p rogre s s i o n to chro n i c i ty,
thrust
inte n ti o n
to a
s i n gl e spinal l evel ; c a refu l p a l p a t i o n is llsed to gu i d e t h e l everage a n d b ring the j o i n t concerned to t h a t
Classification
p o i n t o f t e n s i o n w here the soft tissues b e g i n t o l im i t m o t io n ; stated aims,
to a c h i e ve nerds
the
pa t i e n t .
will
a lways
applied eit her
o r less
be
w i th i n
the
joint. At this
normal
o f tension
ro tation l eft o r sid" -belld ing b u t a very sm"JI a m p J lrude ,
with a high
broad
of m a n u a l p rocedures a re used
th.is
p l lysiologi cal range
be u tilizec L d e p e n d i n g o n
a p p ro a c h e s i n d ivid u a l
variety of
gap ping the l e ft zygapophysia l j o int a n d p roduc
u nive rsally, b u t there are o t h e r t echni q u e s , beyond
ing cavitation (To m li n s o n , 1 97 1 ) . It i s emph a s i zed that
the scope o f this c h a p te r, that a re used b y some
the j oint should not b e moved o u ts i d e i ts normal
osteopath s , Advice, in its various for m s , s h ould be
physio logica l ra nge . The p rocess of cavitation pro
considered a pan of the t h e ra p e u t i c p rocess: this i s a
duces
p ro c e d u re
l env back pa i n
et
::l
te mporary sep:Jr:l t i o n o f the j o i n t s urfaces,
at ,
an
increase
[he
ra nge
1 97 1 ). A
(Unswor t h
b e for c e rv i c a l
a nd a rg u a b l v
t h o u g h t to
a b o u t by
mput
a l tering the fee d b a c k in t h e n e u romuscul a r re flex arc ,
Soft tissue
t h u s c h a n g i n g the effe r e n t message to the m uscle
T h i s term refe r s to d i re c t-co n G. c t tec h n i q u e s applied
s p ind l e s , resul ti ng in a red u c t i o n o r muscle tone. TIlis
t o muscle and ligam e n t o u s tiss u e , TIlfee type s of
tech n i q u e a p p l i e s to the middle and lower zygapophy-
c ross-fibn"
techn i q u e s s t re t c h a n d
The
l o n g i-
a re s u b t l y
for
p ressure , Cross-fib re stretch
a p p l i e d al
a ngles to t h e
fi b res in
to re l a x the
o r i n c rease
dastl.City o f
t h e m u sc l e fi b res . The m e c h a n i s m by which muscle
Upper cervical spine
t o n e i s red u c e d i s not fu lly u n derstood , b u t i t is
The o c c i p u t - a t l a s - axis form a specific fu n c t i o n i n t h e
tho u g h t t h a t the Golgi t e n d o n a p p a ratus has a ro l e to
cervical s p i n e : t h ese j o i n ts com b i n e to fo rm a versa tile
p l ay i n a d j u s t i n g m u s c l e tone , Lon g i tu d i n a l stretch i s
c o m p l ex which
applied along
I
i n c rease elasti c i ty
l e n g t h of the
l arge
range of f1exion -
Soft-tissue
is
s l l b o c ci p i ta l m u s c l e s .. Artjcu l a t-
h re a k i n g c ross- l i n k:i ges a n d Oeep p ressure
s t re t c hi n g fi b rous
a l l ows a
and
o rd e r a p p li e d to
out with
tec hni q u e s a re
t o the
so-ca lled t r igger POifllS, LO s p e c ifi c m uscles a n d to
nonnal v a l u e s o f j o i ll l m o b i lity. The o c c i p iLOat l a n t a l
areas of fi b ro s i s to i n c rease local c i rc ulati o n and alter
j oin t c a n be m a n i p u l a ted a s a d il'ect thrust t h rough t h e
neuro mu s c u lar reflex.
Liga
j o i n t , w i t h s l i g h t Side-b e n d i n g a n d rota t i o n , o r a s a
m e n t o u s t issue can b e also be stretched a c ross the
c o m b i n e d l e v e ra ge u s i ng s i d e-be n d i n g a n d ro ta t i o n ,
affe r e n t inp u t
to
the
l o n g i t u d inalh'
lanma n , 1 985)
s l ight exte n s i o n
w i th deep p ress u re
j o i n t i s m a n ip u l a ted
; n l a nto-
rot a t i o n .
Arlil:u/£ltion This term refers to p assive j oint m o ve m e n t . The j o i n ts involved
Czyg a p o p h ys i a l)
a re
moved
within
thei r
/.lid cervical spine The mid cerv i c a l spine consists o f typ i c a l c e rvica l
n ormal p hysiological range; in p rac t i c e , a rt i c ulation
ve rte b ra e ,
m ay b e combined with soft-t issue techniques, I f t h e
techniq u e s
c a p s u l e o r i n l e rsegm e n t a l l i g a m e n t s s t re t c h e d t h e n the ces i s!:m c e . Joi n t
mea n i ng that t h e s t a n d a rd osteopathic fo r
the
cervical
spine
can
be
used
1 985).
to be
c a n be moved heyond its is n o r m a lly cl rned o u t
w i th t h e patient lying s u pi n e .
Frequency How o ften should a p a t i e n t be treat e d ? Th is va r i es q u i te considerably betwe e n pra c t i t i o ners , b u t the
High-velocit)! thrust T h i s term refe r s to
c o n d ition b e ing treated must inll u e n c e the d e c i s i o n , n o reH a bk
The
zyg a p o p hysial j O i m
i n d iv i d u a l
tec h n iques a ngl e s to the
base for
Itu rn b e r o f and for
osteo p ; H h i c pra c t i c e ,
Copyrighted Material
average o f s ix trea! rn e n ts
Osteop a thic management of cervical pa in 1 65 b e i n g typ i c a l (Bu rton et al. , 1 99 5 ) . [n cases with acute week se e m s
treat m e n t
tiss u e
support
pat i e n t
for
a n d c o n c e rn s .
t i o n p rocessing a n d n e rvousness: Radanov
1 994).
esse n t i al
Some cons itkra b k
e n c o u ragClll e n l will be
l i o n s (sleep d i s t u rba n c e , red u c e d speed of i nfo r m a persisting neck
the arm
fu rther i nves tigation. There
help the
with ra d i a t i o n
i n d i c ative of d i s c p ro t nl s i o n , and requ i res cn
re turn to n o r m a l a c t i v i t i e s a s quic kly as possible.
d isc p ro t ru s i o n resp o n d s weU to s urgical m a nage
Mai n te n a n c e visits, p a r t i c uJ a rly i n c h ro ni c o r recu r
m e n t (Bar nsley et aI., 1 995),
re nt cases, are lI seci by many osteopaths to m o ni t o r a patient ove r t i m e . The i nt e rva l may be 2 - 4 m o n t h s , and t h e
consist of
Osteopathic treatment of beatlaches
i n volve
of pathoiogic i l
t h e headache
is unknown
onglll ,
to
mech a n i c a l
dysfu n c t i o n ,
I
m an ip ul a t i o n of the n e c k bas been shown to decrease the p a i n and improve the range of m ovement o f t h e
sp i n e (Stodo lny a n d C hmi e lews k i , 1 989) . M a n i p u l a
Osteopathic treatment oj whiplash As w i t h any presenting condi t i o n , m u s t take
tured
is a h igh
reS U l t i n g fru m
type 01
d etailed s t nlC-
a
beJDre a ny d c c b i o n s that a
.
i n terview
is
necessary,
fol lowed
by
the
physical exa m i na tion a n d appropriate investiga tions; then
a
manage m e n t p l a n c a n be fo r m e d .
the thoracic a n d th o ra c o c ervi c al j u nctio n . Marupula
tion of the t h o racic spi ne wiU i nc l u d e HVT,
articu la
tion a n d soft-tissue techniques. T h e a i m b e hind the t h o racic wi t h i n
t rea t m e n t ,
is
to
t rapezi u s ; a rti cu la tio n of the i n d ividu a l zyga pophys i a l joi n ts as wel l as those gross articulations of t h e neck
m e n t is focllsed
in i t k l l
cervic a l
m u s c l e s as well as the upper a nd lower fi bres of
t o be
of the proced ure . O ften with
im ponant
e n c o u ra ge
fu l l
Efficacy and outcome of cervical treatment
m o b i l i ty
vc r t e b ra l zyga p o p ilV:'la i a n d c o s tover !
osteop a t hi c
Wit h
j oi n t s Appro p riate soft- t iSSllF l re:wnen t i s n e e d e ci complcmem increase m obili ty. Cl earl y any b o n y fra c t u res, j o i n t i nstability, b rd i n d a m age o r progressi ve n eu ro l og i cal signs p re c l u d e o s teopa t h i c treatme n t . Tre a t m e n t a p p l ied d irec t l y to the c e rv i c a l spine i s aimed a t redu c i ng dysfu n c tion, rhls would
muscles, art i c u l ating zyga p o p hysi :t l j o ints,
HVT exercbcs
!vgapnphysial
a r e simi l a r
t h a t of t re a t m e n t
(Howe e t (./t., 1 983 ; Koes et at"
the lumbar
1 99 2 ) . I t m u s t be saId
th a t more res e a rc h has been reported with respe c t to low back p a in. In one o f the ea rly trials investigating m a n i p ulation of the cervical spi n e , it was fOlU1d t h a t spin a l
stretc h i ng
ma ni p u l at i o n
s t u d i e s h ave d emonstrated t h a t
.
In the
to the
c ross-fibre
longitudinal
j oin t m a n ip u l a t i o n s to a reas d e t e r m i n e d b y p a l p a t i o n
t horacic spin e
c o n d i t i o n s , assessme n t of
et al., EnS) . techn i q u e s ,
in a U r;lngf'S o f moveme n t bar f'xten s i o n ; sp f'cific
osteop a t h i c m a nageme n t o f
As
in frequency
i n d uced di sa b ility
d u ration
Tre a t me n t consists o f
road traffi c
will i n c l u d e l i ti ga tio n With this in m i n d , a p a rt i c ul a rly d e t a iled
t ion h a s a l s o been s h o w n to d e c rease the symptoms of migraille leadin g to a
p ro d uced
imp rove m e n t
sym p t o m s
significant i mme d iate
tliose p a t i e n ts
pa i n/p a ra est h e si a in t h e s h o u lder and some im p rove,
advice
w i th p a in/paraesthesia i n the h a n d (Howe e t a t 1 98 3 ) . M a n i p ul a t i o n a lso p ro d u c e d a s ignific a n t i n c re a s e in meas u red rot a t i o n t h a t was m a in ta i n e d fo r 3 weeks, together with a n
worki n g
m e n t in
.,
EYjJected recovery There
immed iate improve m e n t i n l a t e ral flex i o n ; however
heen a n u m b e r
studies carried
expected
of recovery
looking whipla.s h
The o u tcmnc
m o n t h s SCUllS
c a l spi n(
a c t as a good p redictor for [he n e x t 2 y e a rs (liargan and Bannister,
not m a i n t a i n e d (I lowe et at. ,
this i n c rease Exercises
1 994). Over 90% of asymp tomat i c
b e n efi t
often recomm e n d e d to m a intain
'
require s
it h a s b e e n s h own t h a t long term u s e (McCarthy e t at. ,
c o n t i nu a l
1 996)
c a s e s at 3 m o n t h s after the road traffic a c c i d e n t
Ch ronic neck p rob l e m s , in c ommon w i t h ctlfon i c
re mai ned asymptomatic o v e r the n e x t 2 ye a rs N e a r l y
l o w b a c k p ro b le m s , prove to follow a fl uc tu a ting
.
90% of
who were syrnptornatic a t 3 2 years.
,Indy fou n d
rema i n ed w11l ptom a t i c for w ruch
to
poor
i n i t ia l
no
subjects treated favOll ra b l e
et al., 1 98 2 ) ,
in c l u d e
irr i ta t i o n , intensity of neck bead t ra u m a a n d
showed
increased
p revio u s history
inj u ry-re l a ted cerebral reac-
another p a raspin a l
t hresh o l d l eveJs (Ve rnon et ai" � 1 990) .
Copyrighted Material
1 66 Clinical A natomy and Management of Cervical Spine Pain
Complications to manipulation
ma n i p u l a t i ng the cervi c a l sp i n e . Ass u m i n g that a l l note d ,
c o m p li c at i o n s
have still been rep o rted fo ll ow i ng HVT.
to w h i p l a sh . Spine ogy o f w h i plash .
a fter whiplash. B igos, S . , Bowyer,
ra m u s
c o mm u n i c ans
between
more
worrying
c o mplic at io ns
are
cerebrovascular accide n ts and , a l t h o ugh u n common ,
they h ave been rep o rted . The genera l consensus of
evidence
h a s suggested
that
th es e
tests a r e n o t
rel i a bl e (Th i e l et ai. , 1 994). S i n c e verteb ra l a rtery occlusion
occ u rs
in
extremes
o f ex ten s i o n
be taken with the patient at s u bsequent treatment.
A. K . ( 1 98 1 )
Rbeumatol.
p a in
osteopathic
in
and
Patterns of lumbar sagittal mobility Iytlue in the nalUra/ history of back pain. Doctora l t h e s i s : H uddersfi eld Po l y
and sciatic
tech n i c/CNAA . Bur t o n , A . K . , Ti l l otso n , K M , M a i n , C j. , H o ll is , S. ( 1 995)
and s u b t ro u b l e . Spine 20: 7 22 -728. C l i ni c a l Stand ards Advi sory G r o u p ( 1 994) Back Pa in R ppo rt of a CSA G committee o n Back Pain . Lon d o n : HMSO. Conlon, PW, Isd a l e , I . e . , Rose B . S ( 1 96(,) IUl e u m a t o i d a rt h r i t i s o f t h e c e rv i c a l s pine. A n n. Rh e u m . Dis. 25: Psychosoc i a l p re d ictors o f o u tcome i n a c u te
c h ro n i c low back
1 20 . B . , M a i tl a n d G . D . ( I 99 1 ) Pra c tica l Orthopaedic MediCine. Oxford : B u t terwort h - H e i n e m ann.
Corriga n ,
V ( 1 989)
H a e m ocil'namic
t i o n s o f the head . Man.
n eck pain
is a
l a t e ra l
common
p rese ntin g symp tom , often of m ec h a n i c a l origi n . T h e o ste o p a th w i l l assess the i nd i v i d u a l a n d a tte m p t t o exclude the p ossibili ty of a serious pathology. Assum
d i sorciers
(treatment) pla n . Th e re is reas o n a bl e evidence to support t he use of spinal mani pu l a t i o n with cervica l
c o n d i tions of m ec h a n ic a l origin . However, fur t he r c l i n i cal tri a l s a re absolutely necessary to i n ves tigate the effects o n acute and chronic neck co nd i t i o n s . As the duty of care for our pa tients i s of
p a ramou n t i mp o r t anc e : treatment and ad vice should be give n , based on sOllnd biomechanical p r in c i p l e s a n d all av a ila ble researc h li terature .
References I-J . ,
F l exi b i l i ty
Heliova a ra ,
of
the
M.,
spine:
Soukka, A . , H a rj u , R . n o r m a tive
gon io metric a n d t a p e m e a s ure m e n ts . Scand.
!Heel. 26: 1 4 7 - 1 5 4 .
values
of
PM.M.,
F l e tc h e r
a t l a n to-ax i a l
within
the
ext reme posi
Med. 4 : 1 27 - 1 2 9 .
D. ( 1 994)
joint
pain
Atla n to-occ i p i ta l a n d patterns.
Spine
19:
1 1 25 - 1 1 3 1 . Elln i , G. , B re nner, B . ( 1 984) O c c i p i t a l n e ur a l g i a a n d the C l - 2 a rt h rosis sy n d ro m e .
j Neurosurg. 61: 96 1 - 96 5 .
E l vey, R . ( 1 994) The investiga t i o n o f
arm
pa i n : signs o f
adverse resp o n se s [ 0 t h e physic a l exam inatio n of t b e
ing no ' red flags ' a re appare n t , a detailed musc ulo skeletal a sses s m ent w ill c o n clude with a m a nagemen t
p ra c t i c e .
their predictille
ve rtebro b a s i la r arterial syste m fo l l ow i ng
o s te o p athic p ra c tice ,
( I 994)
Back
Rehabil. 20: 2 39 - 24 6 .
B u r t o n , A . K . ( 1 987)
D re y fu s s ,
Al a ra n t a , H . , H u rr i ,
Spine 2 0 : 20 - 2 5 .
0. ,
200 - 203 B u r to n ,
Suounary
cl i nic i a n s ,
N. ( 1 99 5 ) T h e zyga pophys ial j o i n t pa i n
Wa l l i s , B j. , Bogd u k ,
N. ( 1 986) T h e anatomy and p a t h o p hysiology of Clin. Biom ech. 1: 9 2 - 1 0 1 . B u rn s , K . and Lytt e l to n , L . K . ( 1 994) Osteopathy o n the N H S : o n e pra c t i c e ·, expe r i e n c e . Complement. Ther. Med. 2:
Danek,
In
S.M.,
whiplash .
ro ta t i o n , it is p ro b a b ly safe r to ma n i p u l a t e the neck i n I t m ust be noted t h a t i t i s n o t u n c o mm o n fo r the p a t i e n t to feel s l ig h tly li ght-he aded, dizzy or nauseous afte r t re a tm e n t . These sy m p t o m s c a n occur after soft tissue techniques, passive join t a r t i c u l a t i o n s or HVTs ; it is p ro p o se d t h a t stimulation of arterial reflex or a l t e red symp at h eti c a c tivity is re s p o n s ible . This i s u s u a l ly shor t-lived, a l th o ug h if reported, care should
19: 1 28 5 - 1 28 9. N. ( 1 993) The p a th o p hysiol !,pine: State of the A r/ Rel 'iews 7:
Bogd u k ,
and
flexion ( D a n e k , 1 989; Th i e l , 1 99 1 ; Chapter 1 2) .
( 1 994)
C a re Pol i cy a n d Resea rc h .
o p i n i o n is that verte brobasilar competence s h o u ld be assessed befo re HVTs are p er fo r med ; however, rec e n t
al.
comparison
H u m a n Services, P u b l i c H e a l t h S e rv i c e , Age n c y o f Heal t h
son, 1 987) . The a u t h o r states tha t , although mishaps The second,
a
refe re n c e gu ide n u m b e r 1 4 . AI-J CPR p u b l ication no. 95 - 0(,·4 3 . Rockvi l l e , MD: US Depa r t m e n t of Health a n d
the
thoracic n e rve and the s ympa thet i c ga ngl io n (Gray occ ur, manip u la tion sh o u l d not be dis c o uraged .
et
Breen , G . e t al. ( 1 994) A cu t e Low-back Problems in A dults. Clinical Practice Guideline. Q u ick
the base of the n e c k led to a traction/avulsio n i n j ury white
D. R .
daily l i v i n g :
preva l e nce of c h r o n i c c e rvi c a l
One re po rted co m p l i cation is Horner's synd ro me .
the
of
329- 353 Bar n s l e y, L . , Lord ,
T h e pr o p o sed t h e o ry is that l o c al forceful thrusts to to
Motiuk,
B a r nsley, L. , Lord , S . , 13ogd u k ,
pathological c o nd i t i o n s have been eliminated, i.e. all have been
I.,
Weir:lo n e s ,
A ccel era t i o n pert u r b a t i o n s
There a re some i n h e re n t da ngers associated with
contrain d i cations
M.E.,
Al len ,
b ra c h i a l p l ex u s a n d re l a ted n e u ra l tissues. I n : Griel'e 's
Modern Manual 1beretj)Y (Boy l i n g , J. D. , Pa lastanga, N , eds). Ed inburgh : C h u rc h i l l Li v i ngstone , p p . 577- 586. Ga rga n , M . E , B a n n i s t e r, c e . ( 1 994) The rate of recove ry
Em: Sp in e j 3: 1 62 - 1 64 . M . E ( 1 987) Horner's syn d ro m e after m a n i p u la t i o n o f t h e n e c k . B1: Med. j 295: 1 3 8 1 - 1 3 82. G rieve , G P ( l 98 1 a) Common p a t t e rns o f c l in i c a l p resenta t io n . In: Common Vertebra/Joint Problems (Grieve, G. P , follow i n g w h i p la s h inj u r y
Grayson,
e d ) Lo n d o n : C h u rc h i ll Li vi ngston e , p p . 206 - 208.
G rieve , G. P ( 1 98 I b) C l i n i c a l fea t ures. I n : Common Verteb ra/ Joint Problems ( G rieve , G . P , c d . ) . Lo n d o n : C h u rc h i ll livingsto n e , p. 1 8 2 . Grieve, G.P ( 1 99 1 ) Mobilisation of the Spine - A Primary Handbook of Clinical Medicine , 5th ed n . Lo n d on: C h u rc h i l l Livingst o n e .
H a rtman, L.S. ( 1 985)
j Rehabi!.
flandbook of Osteopathic
2 n d e d n . Lond o n : C h a p m a n
&
Technique ,
Hall.
Howe , D . H . , N e w c o m b e , R . G . , Wa d e , M .T. ( 1 98 3 ) Man i pula-
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Osteopath ic management of cervical pain 1 67 tion of the cervical spine - a pilot s t u d y. } R. Coll. Gell.
Pmc!. 33: 574 - ')79. J a c k so n , R. ( l 97 'J Spri ngfi e l d , [L: .I e rf ett W ( 1 979) 222: 549 - 5 5 5 . K a h n , ]. E , Monod , Ergo nomics 32: cn·c - oCt u . Koes, B . W , Bouter
589 - 59 3 .
in I n d uced by static wo r k .
a
for non-specific
ra n d o mised
c l in i c a l
back tria l .
and
neck
Spine . 1 7 :
28 - 3 5
0/ Case
History VClI'iables for Back Pain Classification. Lon d o n : Society for Back Pa i n Research. Lee , PWH , Chow, S . P , Lieh-Ma k, E, C h a n K.C. , Wong. ,
( 1 989) Ps y cho s oci a l fa ctors influ e n c ing o u tco m e p a t i e nts w i t h l ow·bac k p a i n . Spine 14: 838 - 84 3 .
!
PW,
Stretching !:1"xercise.\' in the Cen'ical
M c Rae,
R.
p a t i e n ts su ffe r i n g
in
( 1 996) Effects oj
an d
E.,
Sloop, P.R., Smith, D. S . , G o l d e n b e rg ,
Dore , C . ( 1 982)
Mani p u l a t i o n for c h ro n i c neck pain. Spine 7: 5 3 2 - 5 3 5 . S p itzer,
W O . , Skovro n , M. L , Salmi, L R . et al. ( 1 995)
S c i e ntific
m o n ogra p h of
the
Q u e b e c Task
Force
on
whiplash-associ a ted d i s o rd e rs : rede fi ning " w h i pl a s h " and its m a na ge m e n t . Spine S t a r, M .],
C u rd ].G., ,
mass osteoa r t h r itis:
severe
20 (Suppl) 85 - 7 3 S . R . P ( 1 99 2 ) Atl a n t o a x.ia l lateral
Thorne
a frequently overlooked c a u se of
o c c i p i to c e rvical
pa in
.
Spine
17
(s"ppi)'
H . ( 1 989) Manual therap"
oj Motion (ROM) I lorser: A ECC.
( l 990l
33: 442 ·
( 1 9 6 1 ) S p o n taneous
H . et at. ( 1 992)
La ngworthy, J , Breen , A. ( 1 992) The Gmt/ping
McCart],y,
1 17
} Rheumatol.
treat m e n t b y the
practil ioner
G., S c lmiti r i g .
d e Stefa n o ,
psych osoc i a l findings a n d o u tcorl1�
pLlCtic e . Pretet. lHed.
The effectiveness
general
M.,
e dn .
b e tween ea rly s o m a t i c , rad i o l ogicili .
,
complaints:
4th
\'Flldrome,
8:
of c e rv i c a l m a n i p u l a t i o n for m igra i n e . A ust. NZ } Med.
w i t h cervi c a l m igra ine . }
Examination.
Edin b u rgh : Churc i l tl l for whi p l a s h . }
Marti n e z , ]. l . , G a rc :" ,
Biomech. 1: 2 3 - 3 2
M e r s ke y,
H . , Bogd nk,
(I
Su\)()cc i p i ta l a n d cervi c a l
muscu loskelcta l disorders. I n : Classification oJ Chm n ic
Pain, 2 n d edn (Merskey, H . , Bogd u k ,
N. , eds). Seattle :
LAS P Press , p p . 9 3 - 97 .
M e rs k ey, I I . , Bogd uk, N . ( l 994 b) Plimary headache s y n · d romes, vascu l a r disord e r s , a n d cerebrosp i n a l tlu i d syn
d romes. In: (Mc rskey,
H.,
Classification Bogd u k ,
oj Chronic Pain,
77-89 Mounst e p h e n , A . H , m i...llfai n e an d i ts Med. 45: 3 1 1 - 3 1 Neuma n n , H . D. ( 1 9R9 ) IIv m,ClII.( III" Berlin : Springer Parker, G. B . , Tu p l i n g ,
2nd e d n
N . , eds) . Seattle: LAS P Press, p p .
( 1 995) A s tu d y o f p o p u l a t i o n . Occup.
D o n a t,
j. , Yon g·H ing K. ( 1 99 4 ) ,
of va riou s head a n d n e c k pOSitions o n vertebra l a rtery
blood flow. Cli n BiomeciJ. 9: ! O s I I O. To nlinso n , A . M . D . ( 1 97 1 ) Osteop a th i c technique - a new a pproa c h . 8r. Osteopath. } 5: 20 - 2 5 . U nswort h , A . , Dowso n , D . , Wrigh t , V ( 1 97 1 ) Cracking j o i n t s : a b i o e nginee ring s t u d y o f cavi ta t i o n i n t h e metaca rpo· .
-
Rhe um . Dis. 30: 3 4 8 - 3 5 8 . H T. , Aker, P , B u r n s , S . , Viljakatl,UHo a x i a l n e n , 5 . , t ( 1 990') Press u re p a i n t h re shold eva l u a tion o f the
p h a l agea[ joint. A nn. Ver n o n ,
m a n i pul a t i o n in the trea t m e n t
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Ma n ip Physiol. .
.J.1anual Medicine.
( 1 986) R a t i o n a l t rea t m t lll A contro l led trial
Copyrighted Material
liiom ech.
1: 1 6 0 - 1 67 .
Physiotherapy management of neck pain of mechanical origin G. A.
Jull
cervical spine dis
are analysed to determine first of all whether or not
orders aims to care for patients by address ing their
their complain t is arising from m uscu loskeletal dys
Physiotherapy
management
of
pain and pathology, which is manifested in local and
function and, if so, whether it is suitable for and
regional
amenable to, phys ical
movement
dysfunctions
in
the
articular,
,
treatment.
The model high
muscular and neural systems. The global aims of
lights the importance of a precise physical examina
physiotherapy management are to alleviate patients'
tion to elicit the dysfu nct ions in the neuromuscular
pain, reverse the dysfunc tion and restore optimal
articular systems which are linked to the pa tient s
muscle
recurrent
pai n and disability. The treatment methods selected
episodes. With.in this management, patients ar e pro
are precise and dysfunction-based, add ressing both
and
function
joint
to
prevent
'
vided with precise and relevant exercise and lifestyle
the unique as well as interrelated dysfunction in the
strategies to assist them with effective, preventive
three majo r sy stems. Imp rovement in the patient's
self-management.
pain and disability should par.lllel the ch anges in the
and
nature
The
of the musculoskeletal
scope
dysfunctions in the cervical region are vast, ranging from
acute
degenerative
minor
sprains
to
chronic
compromising
advanced
.
In this way
,
treatment out
and function
as
well as in the physical impairments.
spinal
Continued development of the understanding of the
cord. The cervical spine, throu gh physiological and
relationships between pain, physical impairment and
pathology
the
physical dysfunctions
comes are judged on im p r o veme n t in both symptoms
mechanical links, reflects and imposes postures on
response to
the whole spinal region. Likewise, dysfunction in
practice
ce rvical
structures
may
secondarily
affect
or
a
treatmen t method advances clinical
.
be
affected by the structures of the upper limb. The neck's involvement in some shoulder pain syndromes and its possible role in various forearm and hand disorders have been described (Upton and McComas,
Examination of the neck pain patient
1973; Schneider, 1989; Hawkins et at., 1990; Yaxley and Jull, 1993). Furthermore, a neck condition may
Examination of patients with neck pain syndromes
directly involve the vascular system in the thoracic
encompasses the clinical examination which includes
inlet
or
via
the
vertebral
artery. The
neck
and
a comprehensive histor y of the na tu re, behaviour and
shoulder region may also be the site for pain refe rral
onset of symptoms and a physical exa m ination
from
addition any of
non-musculoskeletal
1988). The dysfunctions
variety
and
underlie
pathologies
poten tia l
the
need
(Grieve,
complexity
for
careful
of and
specil1c differential diagnosis in the first instance followed
by
a
c omprehensive
yet
,
ind ividualized
management programme.
,
a
l a borator y tests can be perfo r med as required. The clinical examination is of primary importance. It is
conducted with a background knowledge steeped in the physical, behavioural and medical sciences. The
reasoni.ng lIsed by the physio
t he rapist in decision-making during the examination
thera pists encompasses a problem-solving approach.
involve a combination
The patient s present ing signs, symptoms and history
pat tern recognition Oones et at., 1995).
'
In
.
methods of clinical
The model of clinical p ractice followed by p hysio
.
variety of radiological i maging and
Copyrighted Material
of
hypothesis testing
and
Physiotherapy management of neck pain of mechanical origin 169
Subjective examination Patie m ,; with
f re quently complaint of prJin
for management pain with ache, p:lIl1 alone or arm pai n broad cluster s of patients' disorders. [n taking a systematic his tor y from the patient , the clinician seeks pa tterns that are characteristic of cervical disorders and notes features which are o ut of pattern. :111 alte rnative These evoke the creation hy potheses diagnose d iffe renti aUy the wil[ be placed emphasis complain l physical dbon.ler, it is necessar y for the cliniCian to understand any psychosocial aspect of the patient's disorder. D ecision-m ak ing from the s ubje ctive examination revolvt'5 around four basic q uestions:
headaches CBo quet ct at., 1989; Vern on et al., 1992a; Kidd and Nelson, 1993), The history of a presentmg headache good ex am ple and pattern rec ogn ition in clinical ing cervical involvement in p atient 's head ach e To predict a role for ce rvic al dysfunction in the pathogenesis of a p a tient 's headache, the clinician would expect to hear a p atter n incorpo ra ting many of the f o U owing features. The head ache described is clas sically unilateral headache (Slaastad et al., Wa tson and bilate ral OuU, but it Gill 199 3) . Ce n icogenic headaclJe side cons is tency and will n ot change sides withul or between heau ache attacks as can occ ur with migraine or cluster h eadaches C Sjaastad et at., 1989a; D'Amico et a l. , 1994) It is associated with s u boccipital or neck pain (Bogduk and Marsland, 1986; Jull, 1986a) with of pain
1. Is
spine dyshmction the o ri gin
patient's pain? 2. What is the like ly nature and location of the structural compromise' :1 Are there factors provok i ng and perpetuating the c ond i tion ? 4. Art' features in patient's histo ry general medical condition which either restrai nt d i rec t p articu lar rnan agement ? Discussion of each question will hi gh lig ht aspects of clinical reasoning.
The
the patient's
The p henomenon of
pain
requires
alterna liy !' sources of ot herwi se cOlllmon ccrvicallllusculoskeletal distribu tions. It is well known t hat the neck, the upper thoracic region and the upper limbs can be the site of referred pain fr om , for example , the diaphragm , the heart U1Il10urs in the the lung tenet in examination of musculoskeletal 1988). a re l ati onship us ually exis ts lnechanical fluctu:.Ilions pain and ti on of t he re gion . This should be lacking when, for ex am p le , heart disease is responsible for the neck and arm pain as, conv e rsely, signs of heart disease are abse nt in patients with cervical angina or, as it is ot herwise known, pseudoangina (Jacobs, 1990). These relatively overt examples of non-rnLisculoskeletal referred pain am enable t o the raplc;;,. lhe s ym ptom 01 headac he is, in the main, more benign in nature yet differential diagnosis is equally important to de ter m i n e a pr im ary, partial or no role for cervical dysfunction in a p atient ' s head ache There is considerable sy mptomatic overla p hetwe en the benign head: lclw te nsion migra ine wit ho u t forms 1994) . Pe opl e and cervicogenic headac he suffer mixed headache forms or two concurrent clinician', alertness to
commonly
and tem poral areas. The o n set
of pain in the s u bse quent head. This is in contrast to the more classical migraine which has been shown to sta rt most fre quently in the h ead with subsequent sprea d to the neck CSjaastad et at. , 1989b) The intensity of cervicogenic head ache can be moderate or Its in tenslty fluctuate.
is differem
uncontrollecl. will inevitably to a severe ach e w ith at ta ck . C ervical d y s function does produce the excruciating pain s characteristic of c l uster headaches or truc neuralgias (Lance, 1993). There may be other symptoms associated with the h eadache snch as v is u al distllrhances, nausea, dizziness, Jightlwacledness, b ut not a dominant feature.
migraine with
CSjaastad
Bilvim, 1991)
cluster headaehe
The temporal pattern of headache is often diag nostic of a p a rticu lar headache form, as is readily evident in migr ain e with aura and cluster headache (lance, 1 993 ). A feature of cervicogenic headaches is the lack regular pattern 1992). typical l , p recip i tated m ec hanic ally hy sustained postures movements, but provocative factors sometimes diflkult to identify (S j allstad et al .. ]uU, 1986a; Pf affe nrath et al., 1987). Equally, the patient may h ave d ifficu lty identifyin g relievi ng f ac to r s , although the headache's lack of response to medications used for other headache forms may add to the cervicogenie headache (Bovlm Sjaastau . 1 Sj aasta d et The history onset or c'enicogenic headache commonly relates trauma, pos[Ural strain to the neck or degenerative joint disease (Braaf and Rosne r, 1975; Bogduk, 1994 ; Lord et at" 1994) a l th o ugh an in c ident is not alw ay s identified by the pati ent . Age of onset is variable and there is Lllnilial tendencv Ihis headachc a5 is uSllal This
probabilitv
to confirm
cervical
is a major,
sole, cause of the pat ien t ' S h ead ache sy n dr ome . T he
Copyrighted Material
170 Clinical Anatomy and Managemen t of Cervical Spine Pain clinician listens for such patterns in the differential
While structures with the same nerve supply will
diagnosis of all neck pain syndromes. If patterns are
have similar segmental reference, mher factors may
of
not clear.
potheses are proposed
continue
source
I
of
symptom�
for
be able to pinpoint the
process of the clinic:iI
examination.
tlngertip, localizing
The nature compromi.'ie
the
joint. They may report
lo,ca,tio'll of the structural
medial
border
with the areas of referred
(19'19) recorded with cerviGI] has been an acceleration
Over the
p:,in is referred into a
in research into the natme of the pathology causing
level may become more apparent and the quality,
the cervical dysfunction relating to both degenerative
nature and intensity of pain may suggest whether or
and
not the pain has a neuropathic source.
traumatic
causes.
In
vivo and postmortem
studies in particular have revealed a host of lesions. These have ranged
from ligamentous strains and
Conversely, thc pain may not have a clear anatom ical pattern but have characteristics which might
contusions, to disc disruptions and zygapophysial
suggest a particular syndrome or structural com
joint
promise. For example, Smythe (1994) documented a
fractures,
to
very
chronic
venous
changes
around the cervical ner;('s Oonsson el al., 1991,
1994; Barnsln Finch, 1
I rauma,
dysfunction. PhYSiotherapist;;
patients often haH
with the array of neurop;nhlc
.levels (Bogduk and Aprill.
multiple
1993;
patterns that can be
However, it seems that
d),I1;tlllics of the nervous sys\(:rn
')H9; Butler, 1991, 1994)
yet advanced to the stagl'
of neural structures
pathoanatomical diagnosis can made in
presenting with nel'k
pain Oonsson el al., 1991). Furthermore, the relation
with
pattern of tender poin . ts
(for review); Taylor and
lines of pain along path of nerves, areas of pain at sites where nerves are example,
the
inter
ship between imaged stmctural lesions and clinical
vulnerable
signs and symptoms can be poor (Barton et ai., 1993;
vertebral foramen or the path through the scalenes
Pettersson et ai., 1994). Positional observations, such
(Butler, 1991). A pattern where proximal and distal
to
irritation,
for
as a straightened cervical spine, or a rotated C2
symptoms link up could suggest a double crush
vertebra, also have a very tenuous association with
phenomenon, so well-demonstrated by the associa
cervical
dysfunction
(Boquet
et at.,
1989; Mac
pherson and Campbell. 1991; Nagasawa et ai., 1993;
tion
of
cervical
rhe current state indicates
Borchgrevink tance, with
examination being
adjunct
means that a precise
or
clinician.,
rather than a proven
fact. Whal
gained, however, is a clinical
pattern of symptoms wh.ich can incrinlinate certain
carpal
tunnel
widespread
when
sy'il em sensitization (Quinl ner and Cohen, 1994; .1'1:111
for many patients,
pathoanatc>mical
with
from any origin may
is of primary impor-
that the
spondylosis
syndrom<e (Opton and McComas, 1973). Pain patkrns
the phenomenon 01 p:lin Oanig, 1990). analYSis of symptom responses ments or postures can also contribute important information to clinical patterns. Based on a knowl
structural compromise. Pain is a multidimensional experience and, while
edge of cervical mechanics and kinematiCS, neck
the clinician must be cognizant of the psychological
movements producing pain are analysed for their
aspects and the central pain phenomenon , peripheral
structural compromise of the zygapciphysial joint,
nociception still seems to be a major factor in the
disc complex and i.ntel'Vertebral canal and nerve root
pain syndromes of patients presenting to general
complex. When patients present with neck and arm
physiotherapy practices. All structures of the cervical
paill; differentiation is made between intrinsic cervi
spine are
sources. Neck movements
studies of experimentally
induced
suggesting local CeJ'ViGll
and neural structure, of segmental reference
upper limb movements
initial directions in clinical
This could still reflect
1954; Cloward,
diagnosis
1959:
tension or traction (Quintner,
structures supplied
Dwyer et the upper 1
1990). ConvClsely.
ariSing from the shoulder
nerves cause neck pain with
referral into the head. 'fhe segmental reference for
dysfunction
pain
cervical disorder. Schneider (1989) obsel'Ved that in
from
the
mid
and
lower
cervical
regions
may be
primary
or
secondary
to
a
includes the shoulder, scapular area, anterior chest
patients with neck and arm pain, with restricted arm
and upper limb.
movement,
Copyrighted Material
those with disproportionately limited
PhysiotherajJy management of neck jJain of mecbanical origin 171 external rotation responded to treatment of the C5 6 segment. Those with proportional movement loss in required specific the conventional glenohumeral joint The patterns :;trucrural hypo thesis proposed nature and be clarified with haviour of symptoms deraiJed movement the physical examination -
Factors provoking or perpetuatinf.!, the condition
Recurrent chi·onie pain is a burden to society in terms of personal suffering, lost work productivity and health care costs. Hasvold and Johnson (1 993) determined that over 50% of the female and 35% of the male popuLltlon shoulder pain on monrhly. Half of weekly or daily basis. worker is not in symptomatic in the chronic and headache. and recurrent pattern There is complexity in causal and provocative factors both in neck pain syndromes of both insidious and traumatic onset. Intrinsic, environmental and psychosocial factors variously have their roles and the physiotherapist seeks a clear and complete picture of patients and their environment in understanding what provokes and aggravates their pain syndrome. Intrinsically, contributing factors may arise in the nervous, muscular wstems. A fixed cervicothoracic adjacent cervideficit in neural cal segments. A normal move· tissue elasticity (Butler, 1991). It ments and postures is believed that poor neuromotor perpetuation of . Richardson and .lull, control (lancia, 1 1994: W hite and Salu·mann, 1994; Hodges anel Richardson, 1996). Evidence is accumulating that lack of stability function of the deep spinal and postural muscles is a key deficit in chronic back and neck pain (Beeton and Jull, 1994; Richardson and.lull, 1995a,b: Hides et al., 1996; Hodges and Richardson, 1996) and a precise physieal examination can reveal is growing to these problems. of the muscle suggest that precise dysfunction can pain state. Work sites and piKe provocative on cervicobracyclic or fatigue chial neuromusClllar-articular structures (La Ban and Meerschaert, 19K9) of ergonom ically designed work stations and changes in work practices has contributed to reducing these stressors (Grancljean, 1988). However, they have not elimi nated the problem and the physiotherapist carefully
analyses the movement anel motor patterns the patient uses in performing tasks. Here often lies the key �[ructural overload. injllry may also have a iiJ,e\ihood of progression Sturzenegger and 199�: Sturzenegger et at.. consecutive patients wil Ii to identify which factors be associated with long term and chronic problems. At the I-year follOW-Up, 24% of subjects had persist· ent symptoms. The initial symptomatic and accident mechanisms which predicted longer-term problems included a higher intensity of neck pain, the presence of headache, not being prepared for the acciclent, an inclined or rotated head pOSition, and a stationary car Such information helps identify patients at problems. For such directed towards support to substimte osseoligamentous integrity is 1992}
Fealures
caution, restraint or
particular direction in treatment
There can be features presenting in patients' sympto matology, in the history of their neck disorders, or in their medical history, which alert the physiotherapist to pathologies which may give definitive directions in management. Care is always warranted when patients present syrnp[()ms of physical compromise Wilh the SllCh syndromes can range of the spinal nerve compromise of the spinal cord. IlIlIcllable to carefully applied the presence of cord medical investigation and There are a host of symptoms which can accom pany cervical musculoskeletal disorders. These include dizziness, lightheadedness, nausea, visual, auditory, senSOL)' and balance disturbances and poor concentration (Hinoki and Niki, 1975; Barnsley et al., 1993). The basis of these symptoms is not always certain, although many are likely to relate to con Ilw central nervous system eXAmple, the trigeminal (Dieterich et al., 1993; 1995). Cervical propfloceprive influence on posUlre and eye movement and cervico-ocular and rellcxcs. When the origin of symptoms such as lightheaded ness, or visual disturbances, lies in cervical muscu loskeletal dysfunction, thcy can be alleviated by treatment of the neck. However, such symptoms can
Copyrighted Material
172 Clinical Anatomy and Management of Cervical Spine Pain have other causes and the crucial factor in examina
Similarly, mechanosensitivity of neural str u ctu res
tion is to differentiate a cervical cause of these
will induc e protective muscle activity (Hall
symptoms from other causes. For ex ample, dizziness
1993). If muscle control is poor, joint strain and
is
pain may res ult (Panjabi, 1992a). In consequence,
a
symptom
of
which
all
practitio ners
using
manipulative therapy to treat neck dysfunction are
examination
highly mindful. Differentiation between cerv ic a l ver
one
tigo and dizziness of vertebro bas ilar or vestibular,
treatment
to
the
which
focuses
of others,
exclusion
on is
misdirected.
,
origin is necessary. As head and neck movements can
or
system,
et al.,
invoke symptoms from any system, cervical vertigo is
2. There is considerable variability in cerv ic al struc ture and function within the a sym pto matic normal
often provisi ona lly diagnosed through exclusion o f
p o pulation. Ranges of movement are highly vari
neu ro l o gical and labyrinthine signs (Coman ,
a ble and hypomobility, segmentally and regionally,
1986;
Dieterich et at , 1993; Bogduk, 1994).
will increase with age
.
Ou ll ,
1986b; Hole et at.,
1995). Neural tissues have variable flexiblity (Yax
The info rmation
gained
from all
.lull,
ley and
Conclusion of subjective examination
1991; Edgar et at.,
1994). Slight
tigh t ness in cervical axios capular muscles is prob
aspects
ably as common in a symptomat iC as in sympto
of the
s ubj ective examination provides an evolvin g clinical
matic subjects (Treleaven
pattern T he cl inical reasoning process continues in
muscle stren gth varies across subjects with and
.
the
et
al.,
1994). Neck
physical
without symptoms (Vernon et al., 1992b; Watson
diagnosis on which to base selection of physio
and T rott, 1993). Th e refore the implications of any
physical examination to gain
a wo rking
therapy treatment techniques.
variation
from
an
ideal
must
be
questioned.
Variations become relevant when they ha ve a direct link to th e pain state
Physical examination
.
neural and muscul ar systems and performs tests of
3. The sensitivity and specifiCity of any physical test to discr im i n ate releva nt dys function must be appreciated to make me aningful decisions. 4. Any movement of the head and nec k will stress
other systems as appropri ate to the patient s condi
each and every structure of the neuromllscular
T he physiotherapist tests the function of th e articular,
'
tion. The aims are to diagnose differe ntially both the
articular system. Any structure can be involve d in
immediate source of pain and factors contribu ting to
a
and perpenlating the cervic al syndr ome. The dysfunc
examination
tions linked to the condition are identified and these
promisee! structure accurately.
guide the selection of specific and preCise t reatment
pa infully limited movement. Careful differential
is required
to id ent ify the com
5. Any physical ex a mina tio n of the cervical region should consider the muscu loskeleta l system as a
pro cedures.
whole. There is an int erdependence in cervical,
The physical examination encompasses several procedures. The assessments of posture and active
thoracic and lumbar postural form, as well as an
movements can reflect dysfuncti on in any or all of the
interd ep ende n ce between upper limb and spinal
neuromuscular-articular systems. T he articular sys
movement (Crawford and .lull, 1993; Stewart et at.,
examination of the spinal segments. Two functions of
track and movement distal to the cervical region
the nervous systems are tested,
can affect local neural tissue structures (Brieg,
tem receives more specific attenti on via a manual
1995). The nelvous system is a continuous tissue
n a mely tests of
n ormal conduction aJld tests of free movement and
1978).
extensibili ty (neuromechanics). The muscle system is
more widespread problems Oanda, 1994).
examined through a v a riety of tests , including tests
Loca l muscle dysfunctions may reflect
highlight
specific to particular muscl es through to patterns of
To
mu scl e activity and kinesthetic awareness.
the description of th e physical examina t ion in this
belies the potential complexity of musculoskeletal
testing rather th311 repeat physical examination pro
A checkJist of physical examination procedures
dys funct io n and the level of problem-solving required to reach
an
accurate phySical diagnosis. T here are
several facto rs which should be co n sidered co n
the in tegrated nature of the dysfunction,
text will h ig hlig ht some examples of differential
formas which can be found in standard physiotherapy
texts (Maitland, Palastanga,
1986; Grieve,
1994;
to
1988; Boyling and
1994a). An emphasis is
current ly in decis i on making both for diagnosis and
deliberately
treatment.
muscular system as it is believed that this is an area
-
given
Grdnt,
assessment
of
the
neuro
of considerable change in current therapeutics. 1. Cervical pain syndromes represent multi system dysfu n ction. Joint p ain and dys funct i on
occur in
cannot
isol ation and w ill induce reactions in the
Postural assessment
neuromuscular system (Stokes and Young, 1984;
Posturdl form provides information in both the acute
Watson
and chronic pain states. Acute pain from joints, neural
and Trot t
,
1993;
Hides
et at.,
1994).
Copyrighted Material
Physiotherapy management
of neck pain of mechanical
origin J 73
tissues or muscles can be reflected in familiar antalgic
upper limb function and proper transfer of loads from
postures such as the acute wry neck , or the raised
the upper limb to the trunk (Johnson et al., 1994).
shoulder, which relieves tension from the neuro
Clinically, imbalances in levels of activity of the axioscapu l a r muscles are not Wlcommonly observed (Janda, 1994; White and Sahrmann, 1994). Most
vascular bund l e .
In patients able to assume their normal s ta nd in g and sitti ng positions, posture is analysed for basic
particularly, muscles such as levator scapulae can
structural form, the i nterrelationship of spinal curves
become overactive, the overact i vity creating poor
et at., 1993; Janda, 1994;
scapular mechanics as weU as resolving into unneces
Whi t e and Sahrmann, 1994). There is an assumption
sary compressive loads through the upper cervical joints (Be hrsin and Maguire, 1986). Such overac tiv ity can be rec ognized by viewing hypertrophy of the levator scapulae in its bulk towards i ts insertion into the superomedial border of the scapula (Janda, 1994). A l ack of supporting function of i mportant shou lder girdle musc l es , such a s se rratus anterior and the mid and lower portions of the trapezius, can be in evidence during observation of postural form. An a bd ucted and winged pos i tion of the scapula may be observed, accompanied by a lack of muscle bulk in the intersc a pular region (Ja nd a, 1994). The shape of the shoulder region is also of interest. Some unevenness in shoul t1 er height may refl ec t the very common occurrence of a slight scoliosis, thereby having little, if any, dysfu n c tional Significance (Vercauteren et at., 1982). An acutely sloping shoul der may indicate poor upper trapezius a ctivity in co n c e r t with an overactive levator scapulae. Con versely, the upper trape Zius may appear hypertonic. This may be part of a problem of poor neuromotor control and a poor pattern of muscle activity (Jan da, 1994). Alternatively, the hypertonicity of the upper trapezius accompanied by a subtle elevation of the
and muscle form (Kendall
that a deviation from an ideal or neutral posture, in which there is minimal stress or strain, is capable of c a using adverse strain and subsequently pai n in spinal structures (Kendall et al., 1993). There have been
stud ies revea l ing a wid e
numerous
human postural shape , indica ting
variation
in
that there is a
certain painfree tolerance when postural form alone
is considered. Other variables may have to be considered along with postural form. The specific links betwee n postural factors and pain need to be identified to dep i ct the aspects of posture, pOSition and control that require rehabilitation. These links are also necessary to justify any emphasis on postural re-education
in
management
and
pre ven tive
programmes. On a regio nal level the forward heael posture, associated with an increased kyphosis in the upper thoracic or thoracic region, is regarded as the most common poor postural form in neck pain syndromes (Sweeney et at., 1990; KendaU et at., 1993; Janda, 199 4; Raine and Twomey, 1994; White and Sah rmann, 1994). Nevertheless, Dalton a nd Coutts (1994) found tha t it was also a factor of age, indicating some painfree a d aptat i o n . This would be consistent with the findings of Griegel-Morris et al. (1992) th a t it was those of their popu l a ti on with a more exaggerated forward head poslllre that had the greater incidence
shoulder girdle could be protective of mechanosensi tive cervica l nerve trunks. This warrants an inspec tion of the scalenes which may also be reactive. Considerable
information
can
be
gained
from
analysing pos tural relationships and muscle form.
of headache and cervicothoracic pain.
An i mpo rt ant link between the forward
head
There are multipl e factors influencing posture and
posture and muscle dysfunction was reported by
the clinician seeks those which have a link to the
Watson and Trott (1993) in their study of cervico
patient's pain syn d rome .
genic headache patients. They found th a t a lac k of endurance ca pac i ty of the upper c ervical and deep neck flexors was correlated w it h a forward head posture. Longus coUi has been shown to h ave an important supporting and postural function on the
Tests of neuromotor control There are a variety of tests which can be used in a clinical setting
to gain an insight into a patient's
cervical curve, working with the cervical extensors
kinesthetic awareness and pattern of
to stabilize the cervical segments in aU positions of
a n d control. These
the head (Mayoux-Benhamou et aI., 1994). This link
repositioning sense
between
a
pa in
state,
poor
postural
form
and
can
include
head
(Revel et al., 1991),
muscle use and
neck
pat te rns of
muscle recruitment (Janda, 1994) and postural and
dysfunction in a muscle with a pr imar y support ing
movement contro l . Examination of movement pat
role
specific
ter n s can reveal i n approp ria te use of some muscles
rehabilitation direction. The direction is to i mprove the supporting capacity of this deep musc l e in the quest for improvement in postu ral form and active
of control by muscles with a prime stability fimc tion. Conversely, patients may a d opt i na pprop riate
joint support for alleviation of joint strain and pain
regional movement strategies, again ref lecting poor
of
the
cervical
segments
gUides
a
(Jull, 1994; Richardson and Jull, 1995a)
substi tuting for others, which usually reflects a lack
muscle stability capacity and control.
The well-coordinated activity of the muscles of the
Such poor
muscle and movement environments are conducive
upper thora cic and scapular region is vital for well
to perpetua ting strains and recurrent and chronic
supported cervicothoracic posture,
pain.
as well as for
Copyrighted Material
J 74 Clinical Anatomy and Management of Cervical Spine Pain One set of tests assesses the efficiency of the axioscapular
muscles
to
control
proximal
girdle
the neck is brought into neutra l (Fig.
11.1). This
indicates dominant a ctivity in the sternocleidomas
stability. The p a ttern of glenohumeral a bduction for
toid (which is a neck
1994), can reveal in appropriate overuse of scapular elevators crea t ing an environ
extensor), rather than a ba l a n ced a ctivity in the neck flexor synergy. Testing the patient s ability to assume
ment for local muscle pain as well as exposing the
a neu t ra l spinal postural position in eit her
cervical spine to unnecessary and rep etit ive com
four-point k n eeling position can alert the clinician to
pressi ve and
the spine can be assessed through movement and
a patient's in ad eq u a t e d eep and postural muscle control and joint position sense. The patient will be observed to use inappropriate muscle and movement st ra tegi es in attempting to assume a balanced pos tural position (Fig. J 1.2). The post ural analysiS and these preliminary tests of neuromotor control begin to point to the dysfunction in the pati ent s muscle syste m and direct the clinician to more precise an d
postural patterns. The in teraction between the cervi
exacting tests of muscle function
,
example
Oanda,
,
tensile loads (Behrsin and Maguire, 1986) . Forwards arm elevation can reveal not only poor axioscapular control but also a loss of deep cervical flexor control as the pat ient shows su btle to marked signs of forward head and ne ck displacement ,
during the full arm movement. The pattern of control of the muscles intrinsic to
flexor,
but upper cervical
'
a
sitting or ,
,
'
.
cal t1exor synergists for example, is gauged from the ,
p attern of control during neck flexion from extension to neutral . Insufficiency of the upper cervical and deep neck flexors, so important to cervical segmental
Examination of active cervical movements
eviden ce when the head remain s in extension and as
An appreciation of the patient's basic flexibility is gained before sp ecific examination of the cervical region
A
B
control CMayoux-8enhamou et al., 1994), is readily in
.
Fig. 11.1 Return from extension ro the upright position. (A) The movement is dominated by sternocleidomastoid and the upper cervical reg ion remains in extension. (B) A good pattern of movement is demonstrated, ill which the upper cervical and deep neck flexors initiate the return from extension and control and protect the cr:miocervical region.
Copyrighted Material
Pbysiotberapy
management
of neck
pain of nzechan ical orig in 1 75
B
A Fig. 1 1 . 2 An a ." cSSIDCIlt of the pa t i e n t ' s l u m b a r pelv i c reg ion i s flexe d , with the indicative o f poor n e u ro m o t o r control.
a b il i ty to assume a n e u t ra l s p i n e postu re .
(A) A
patient ex tendi ng i n t h e lower thoracic a rea to
well·bala nced posture . (B)
achieve
Note
the
a n u p ri g h t posture . T h i s
is
Act ive move ments o f the cervica l reg i o n stress
u p p e r c e rvical anc! ce rvicothora c i c regions, i s exa m ·
articu lar, muscle and n e u r a l tiss u e s of the reg ion as
ined . Severa l p rin c i p l e s and p ra c ti c e s are followed in
well as giving i n d i c a t i o n s of muscle control . Inter· pretation of ex a min a tion fmdi ngs is built on an ever· increa s i n g u n d e rstanding of t h e a n a to my, mecha n i c s and ki nematics o f the regio n . New knowledge contin ues to mou ld and d eve l o p c l i n ical c on ce pt s leading c l i n i c i a n s towards better pathoanatom ical hypotheses (Merc e r a n d Jull, 1 996) . U s i n g s u c h knowledge, t h e p hysio therapist exa m i nes move· ments in single a n d c o m b ined p l a ne s , continuing to foc u s on gaining a pattern of dy s fu n ct io n which is ' l i n ked t o the p a t i e n t ' s s y m p t o m a t i c c o m p l a ints an d fu n c t i on a l imp a i r m e n t . The fu nctional cervical s p i n e in corporates the region from the a t l a n to-occ i p i t a l articulations to th e u p p e r thoracic region. Moveme nt is exa mined in each of th e th ree primary pl anes of motion. There i s both i n tercl epe nt1ence and independence i n t h e segmental m o ve m e n t of the cerv ical regi'o n s . Total movement, a s we ll a s movement focused to the
examination of active movement which apply to each d i rection of m ovement and which a re i n line w i t h t h e gl obal p r in c i p l e s of exa m in a t i o n . Observation and measurement
of movement
In ex amin a t i on of ce rvic a l mo ve m e n t the clinician assesses the pa ttern and distribution of move m e n t , th e gross ra nge o f motion and its rela tionship to the patient'S sympto m s . A symptoma t i c segmen tal block to m ovement may be rec o g nize d via a d i stortion of an oth erwise smooth cu rve of the neck . Excessive movement may be o bserved in the C4 - 6 region d u ring sagittal plane motion as the patient p ivots the head and neck ove r a hypo m o b ile and ftxed cervico thoracic region. Restoration o f some mobility in thi s reg ion wo uld be par t of a trea tment programme des i gn e d to relieve stress from the C4 - 6 segments. Likewis e observation of th i s poor pattern and ,
,
Copyrighted Material
J 76 Clinical A natomy and Managemen t oj Cervical Spine Pain con trol of m o ti o n wo u ld si g n a l p o o r s u pp o rting capacity o f neck musc u l a tu re (Fig . 1 1 .1) . There a re n o w clin ica l ly a p p l i c a bl e a n d a fford a b l e
measurement tools to p rovi d e repe a ta ble , although gros s , measures of cervi c a l motion (H ol e et al. , 1 995). Al t h o ugh th e re is u n d ou b ted merit in a ims to h av e qu a ntification of p hysica l factors, m eas u re s of gross movement often p rovi d e very poor l inks b e tween dysfu n c tion and fu nc t ion a l outcome. C lini cians have not e m b ra ced th es e too l s w i d ely a nd ofte n c o n t i n u e to rely more on visual a n a lysi s . I ndeed, H ind l e et al. ( 1 990) e nd o r sed the clinic i a n s ' senti m e n ts when they fou n d that it was not a bsolu t e ra nge of motion which disti ng uis h ed back p a i n fro m non back pain subjec t s , b u t rather the abe rra n t patterns of movement thro ug h range .
Reg ionalization oj active movement examination R e a c t io n s of pain and a b normal o r lim i t ed motion contri b u te
more
to a c l i n ic a l pa ttern when they ca n
be l oc a l ize d to a segm e n t or reg i on of the sp i n e .
Sagitta l p l a ne motion is foc u s ed to the craniove rte bral region by t est i ng flexion and extension of the h ea d
A Fig. 1 1 . 3
rat h e r t h a n the h ea d - n ec k c o m plex . A s u b t l e neck retract i o n a c t i o n w i l l b e tter i n d u c e exte nsion i n the ce rv i co t h o ra c ic
a rea . The regi onal
l ocati o n of a
limitation of axial ro t a t ion c a n be ga u ge d by the
pa t i e nt performing head ro tation with a fully flexed cervical s p in e (C l - 2), with the u pp e r cervical spine in flex i o n (C2 - 3), as comp a re d w i t h rot a tion per fo rmed in a neu tra l s a gi t ta l position (Fig. 1 l . 3) .
Examination oj movements i n combination Normal fu nc tio n involves comp l e x loading, ra ther t h an move m e n t s in a p u re pl a ne , s u ggesting tha t a p a tt ern or posi t i o n of co mb i n ed movement m ay be more co m prom i s e d in a dysfunc t io n a l segment. The j oin t s o f the c e rvi c al reg i o n a re therefore also exa mined with a combination of m ovem e n ts . The combination of added move m ents is d eri ve d from the j o int ' s movement and pain as we l l a s kin e m a t i c re l a t i o nsh ip s (Edward s , 1 99 2 ) . F o r examp l e , t here is re l ated zygapophys i a l joint and u n c overtebra l j oint motion in l a t e ra l flex ion and ipsi lateral axi a l rotation of the mid and l o wer cervical spine (Penn ing and Wilm i n k , 1 987). Added exte nsion wi l l take the
B Ex a m i na t i o n
of cervica l axial rotation (A) foclIsed to
t h e C l - 2 segme n t ; (8) foc l I sed
Copyrighted Material
to the C 2 - 3 segment.
Physiotherapy management of neck pain of mechanical origin J 7 7 zyg apo p hys ia.1 j o i n t towa rd s i ts c lose-pac ked po si t i o n . The concept o f combined move m e n t ex a mination is guided by kn ow l edge of ki n e m a t ic s d e rived pr inci pally fro m in vit1"O resea rch (White a n d Pan j a b i , 1 990) . Nevertheless, cl i n i ca l p rese nta t io n m ust always override the theoretical sta t e . T h i s was well ill ustrated
in
rece n t
in vivo
studies
whe re ,
for
ex a mple , l a teral flexion a n d axial ro ta ti o n d i sp l aye d a contra l a teral cou p l e i n some su bj e c ts at bo th C2 - 3
ancl in the upper t h o ra c i c reg i o n , rather than the expec t ed ipsilateral couple (Penning a n d Wilmink,
1987 ; M i m u ra et at., 1 989; Wil.l ems et at. , 1 996) .
The application of ovetpressure There is a d iffere nce i n m agn i t u d e b e rw e e n ra nges of active a n d passive mot ion . Physioth e ra p i sts h a ve l o ng appl i ed gen tl e pa ssi ve p ressure to g u i d e t he p a t i en t 's move m e n t to the e n d of range so that a c l ea r estimation of ra nge a nd a ny pai n resp o nse can be gained (M aitland, 1 986) . The meri t of th is practice w as we U-i U u st ra t ed b y Dvorak et al. ( 1993). They fou n d q u i te marked d ifferences i n t he freq u ency of segm ents j u dged
hyp omobil e ,
no rma l
hyp e r
a nd
mobile in t h e i r X-ray analysis of su bjects performing vol u n ta ry fu ll ra nge of cervical motion versus motion taken pa ssively to the limit of range.
Differentiation of structural restraint to motions D ifferential analysis of the s tru c ture lim iting motion inc rease s the acc u racy of the p hys i c al ti n d ings , wh i ch guid es optim a l trea tment selectio n . Restricted cervi cal l a teral fleX i o n , for exa mple , c o u l d be t h e res u l t of
Fig. and
1 1 .4 The downwa rd and med iaJ exc u rsion of the
C3 facet is
C2
tested iIl l a reral flexion t o d e te c t e n d-of-ra nge
motion loss.
jOin t res triction, muscle tig h tness o r la c k of p a i nfre e movement or exte n s i biJ iry of neural tissues . I n i t i a l stru c t u ral d ifferenti a t i o n is ma d e by o bse rvi n g if t he de crease segmen tal
in
lateral
b loc k ,
flexi o n
is
associ a ted
wh o l e
w i th
a
of the three p l a nes of prinl a ry motio n . I n a d di tion ,
more
the segm e n t is d ire c tly s t ressed with gentle m a n u a l
symme t rically li m i ted (musc l e or neura l tissues). The
fo rces applied in a nteroposterior, p os teroa n te ri o r and
latter i s further d ifferenti a te d b y p rete n sion i n g the ne rvous system b y su ppo rting the arm in a bd uctio n
lateral d i re c tio n s in the zygapop hys ia l j o int face t planes . The j oi n ts a r e also e x a min ed in posi t i on s of
a nd ex ter n a l rota t i o n a n d in ves tig at in g i t s inf l ue n ce
combined move m e n ts as d i re c t e d by t h e fUl d ings of
on
or
the
motion
is
the range of l a teral flexion (Elvey, 1 986) .
t h e a c tive move m e n t examination (Fig.
1 1 .4). The
tissue re sistance to motio n , i ts n a tu re and any pain re s pons e to testing a re assessed t o m ake d e c i s io n s
Manual examination of segmental motion
abo u t t he location a n d p ro b l e m s of the segme n ts
Ex a m i n a tion of a c tive range of movem e n t p rovid es
which a re link ed to t h e p a tien t 's sym p t o m s . As wel l ,
info rm a tion a bou t th e regi on 's i mp a irme nt a n d gives
a ny ex c e ss motion or hypomo bi l i ty which c o u l d b e
preliminary direc t ives towards the n a t u re and site of
c o n t r i b u ting to t h e problem is sought i n a dj a c e n t
the
p hysica l
dysfu nc t i on .
Manual
exam ina t ion
of
segments
or
reg ion s .
In
th is
way,
the
a r ti c u l ar
segmen ta l motion and tissue c ompli an ce p rov i d e s
component of the
m o r e d e ta il ed informat ion on t h e location a n d nature
im p a ir men t a n d functional disabiliry a re i d e n t i fied
of the p hysi cal dysfunc tion in the s pinal segm en t . Th e techniques of m a n u a l s p inal segmen tal exam ina ti on are well-descri bed in p hys iothera py texts (Mait land , 1 986; Gri eve , 1 988; Edwards, 1 992; B o y l ing a nd Pa lastanga , 1 994 ; G rant, 1 994a). In su m ma ry, mot ion at the segment i s tested and pa lp a ted in each
pa tie n t ' S symptom s , move m e n t
and re cord e d . S p e c ific directives for t rea tm en t are ga ined , as well as im pairm en ts docu mented w hich can be expected to change with i m p roveme n t in the p a tie n t 's sy m p t o m s . Manua l examination h as shown good se nsi ti vi ry a n d sp ecifici ry to de tec t the symptomatic level in
Copyrighted Material
1 78 Clinical A natomy and Management of Cervical Spine Pain spinal p a i n p a t i e n ts when compared to other med i ca l d i ag n o sti c t e chniqu e s such as n erve o r j o i n t blocks and even mobil i ty X-rays Oull et al. , 1 988; J e nse n et al. , 1 990; J ano s and Ray, 1 99 2 ; Philli p s a n d Twomey,
1 996) . It has also p roved sen sitive in the d e tection of cervical j o i n t dysfu nction in some p at i en ts s uffering post concussional head aches (Treleaven et at. , 1 994) . While m a nual examination may be a ble a cc u rately to de tec t the p resence of
a
pa infu l zygapophysial j o in t,
or centra l in tervertebra l joint, it is not pathology specific . Rather, i t p rovi d e s the essen tial p hysica l p a rameters upon w h i c h physical treatment can be selected and evaluated.
Examination of the nervous system The effect of any p a thol ogy or trauma on the nervous system is assesse d by testing two fu nctions. A clinica l ne u rol ogic al exa m i n a t i o n i s performed as a b a s ic test for normal conduction of the central and p e riphe ral nervous systems . Any signs of central nervous system compromise, a s may occur with spinal canal stenosis fro m any cause, require im med ia te medical consulta
tio n , if not a lready d ia gnose d . Signs of spin a l nerve , o r nerve root, irritation or compression l il(ewise requ ire c a refu l
by
mon itoring
presen c e
p rovides
the
trea ting
d irec tion
to
cliniCia n .
physical
Its
man
ageme n t . The second fu n c tion o f the nervous system which i s tested is that of its free movement and extensibility. The role of adverse neuromechanics or m echan o sen s it ivity of the nervous sy ste m in upper q u a d ra n t
Fig_ 1 1 . 5
p a in syndromes has received considera ble attention
ordered a p p l ic a t i o n of ge n t l e shoulder
ove r t h e past d ecade (Elvey, 1 986; Butler, 1 99 1 ) . As a clinical p h e n o m e n o n , it is not uncommo n , especially
in p atie n ts with neck a n d a r m p a in . It has a lso b e e n
The
brachial p l exus tension
shoul d e r a bd u c tion
test i nvo lves
g i rd l e
the
d e p ression ,
(90') and e x t e rn a l rota t i o n , w rist and by elbow extensio n . The sequence
h a nd exten s i o n fo llowed
can be
va ried .
attribute d a r o l e i n some c h ronic u p p e r limb di s orders
(U pto n
and
McComas,
Q u i n tner, 1 990; Yaxley and Jull,
1 97 3 ; Elvey, 1 986; 1 993). The ne rves
the mselves may become sensitized from the patho
gird le a n d prevent a r m exte n s i o n , and notes a ny
logy in neighbo u r ing a rtic u la r or muscular stru c t u res
reprod uc t ion
(Bu tler, 1 99 1 ) o r, i n some cases, the nerves them
potentially stresses many other mllscu l a r, fascial and
of the
patien t ' S symptoms. The t est
se lves m ay have suffe red some d i rec t strain t h roug h ,
ligamen tous structu res o f the c e rvicobra c l l i a l region
for exa m p le , a traction e lement i n inj u ry (Q u intner,
and upper l imb ( M os e s and Carma n , 1 996) . There
1 990) . What is being revea led c linical ly, as well as in
fore,
the la bora to ry, is that i n these situations the nerves
added via contralateral cervi c a l latera l flexion .
a re
infl uence on patients ' ar m sym p to m s ,
se nsitive
to
move ment,
evoking
considerable
a
s tress m o re s e l ec t ive to t he nervo lls sys tem is as
Its
well a s the
p rotective m u scle response (Ha l l et at. , 1 99 3 ; Hall
l i m ita tion to l a teral flex i o n , is assess e d . S e l v a ra t n a m
a n d Quintner, 1 995).
a p plica tion of the brachia l plexus te n s ion test (Elvey,
e t al. ( 1 994) proved t h e d iscriminate va li d i ty of this sensiti zing manoeuvre and the b rac h i a l te n s io n test to d e tect mechanosensitivity i n the upper quadrant n e rvo u s syste m . They conducted a n e x p e r im ent
1 986) . The test involves an orde red sequence of
w h e re the test wa s used sllccessfl. i 1 ly to diffe rentiate
The
ro l e
quad ran t
of
mechanosensitivity
n e rvous
system
is
of
elicited
the
upper
through
the
m ove me n t of the shoulder and girdl e , the forearm , wrist and hand (Fig.
1 1 . 5) . The
test stresses the trunks
of the brachial p l exus and the cervi c a l nerve roots , with most effect on C5 and C6. It is applied gently, a nd when positive , the clinician p e rceives the onset of m u scle guarding, which a t te mpts to elevate the
b e tween norma l con t ro l s u b j ects and s u b j ects with
shou lder and arm pain where m e c h a nosensitivity of the n e rvous system cou ld (patie n ts a fter ope n h e a rt s urgery) a nd c o u l d not ( p a t ien t s with s u p raspin a t u s ten d i ni t i s) be exp ec te d t o be part o f t h e c a u s e of t h e p a i n syn d ro me .
Copyrighted Material
Physiotherapy management of neck pain of mechanical orig in 1 79
There a re seve ra l va riations to t h e origin a l brachial
to rque p rod u c t i o n a nd control o f t h e whole tru nk .
p lexus tension te s t w h ich have been developed with
The local system inclu des t h e d eep m u scles w h i c h
the a i m o f p l a c i n g m o re selec tive tension on t h e p e r i p h e ra l n e rve t r u n k s (Butler, 1 99 1 ) . I n a d d i t i o n ,
have d i rect a ttachments to the vertebrae an d w h i c h have t he a b ility to support a n d con tro l or actively
both
s pin e
n e u romeni n geal structu res i n the s p i n a l ca n a l ca n be
stabilize
tested in a cep haloc aud ad direction to assess t h e i r
segmental leve l .
the
as
a
whole
a nd
at
the
1986 ;
There h a s been a signifi c a n t c li n ic al breakthrough
Tro u p , 1 986 ; B u t l e r, 1 99 1 ) . Ca reful differentiation of a
with the rec e n t disco ve ry o f a dysnulCtion in the
contribution to a pa in syndrome (Maitl a n d ,
restriction of upper cervic a l flexion is oft e n requ i red ,
stabil.i zing capacity of some deep muscles of the
parti c u l a rly i n patients w i t h c e rvicogenic hea da che.
tru n k ,
T he articu l a r, musc u l a r and neurome n inge a l struc
versus ab d o minis (H ides et al. , 199 4 , 1 99 6 ; Hodges
with a
the
l u m ba r m ul tifid us and
the deep trans
ofte n
and Richardso n , 1 9 96) The problem i n t h e segm en tal multifidus in the a c u te , first-e pisode low back
reprod uces head p a i n . Conn e c tive tissue attachm e n ts
pain p atients was t h oug h t to re late to reflex inhibi
tures of the upper c e rvical a rea a re all stressed passive
upper
cervica l
flexion
test
which
have a l so recently been identified between t h e rec t u s
tion whil e t h at in t ran sve r s us abd omin is was identi
capitus posterior m i no r a n d dura mater (Hack et at. ,
fied a s a deficit in motor con trol . A m anifestatio n o f
1 99 5) ,
b e e l ic i ted i n t h e
t h e re b y increasing the intimacy of the re l a tion S o m e d iffere n t i a t i o n between restriction of
cl i nical setting , is t h e ina b ility of the patient to h o l d
motion due to muscle or neu ra l tissues can be made
a s e t ti ng o r lOW-load isometric contraction of the
shi p .
by repeating the upper cervical flex i o n test with the
p re t e ns i oned c a u d a l ly thro u g h a straight leg ra ise . An increase in resistance to th e move m e n t suggests a greater i nvo lve ment of neural n e rvous
sys tem
tissues i n t h e clysfunc tion .
a complex n e u romotor task ( Keshener et al. , 1989).
As with every other re g i o n in the body, m uscles w il l
p a i n , trauma and
or
p o s tura l
t h i s reflects a loss
supporting
fu n c t i o n
of the
m u scles, rel ated to lessening of typ e I m u s cle fibre a c t i o n (Richardson a nd .lu l l , 1 99 4 , 1 99 5 b) . I n t h e n e c k , t h e re a re l ikewise m a ny m u s c l e s con necting t h e head to t h e verte bra l c o l u m n and is e me rging to support t h e model of a
b road grou p in g in t o glo b a l a n d local muscles based
Contro l of head and n e c k postures i n n ormal fill1ction
react to
that
muscle. I t has been a rgued o f tonic
evidence
Examination of tbe muscle system
is
these dysfunctions, whi c h c an
pathology. In pa tien ts with
cervical p a i n disorders , the c h a l l enge is to i d e n tify
on
their
m ore
a n a tomical
i mporta n t
stud ied
the
through
loca tion
fill1c tio n s .
function
some
o f individ u a l
exercise-induced
T2-weighted
and
Conley
magnetic
et
neck
their
( 1 995) muscles
sh ifts
contrast
resonance
of
al.
images.
in The y
(g l o bal
dysfu nctions in the m u s c l e system which a re linked
showed t h a t the m o re s u p e rfi c i al m uscl e s
to
system) such as sternocl e id omasto i d (ven t ra lly) a n d
the
pa in ,
patie n t 's
d i s abi lity. Identifying
pathology
and
fill1ctional
such l i nks d i rects w h i c h fu nc
tions of th ese m u scles a re c r i tica l to tes t . There h a s been
s e m i s p in a lis capitus a n d s p l e n i u s c a p i t u s (dorsal ly) m a d e a greater contri b u t i o n to torque p ro d u c tion
far greater vo lume of research
than t h e i r deeper synergists (local system) l o n g u s
into back a n d abdom i n a l muscle fun ction i n low back
capitus a n d longus colli and semispinatus cervicus
pain
pa t i e n ts
a
tha n
th ere
has
been
into
muscle
fu nction of t h e neck a nd shoulder girdle c o mp lex. It
and
mul tifidus
respe c tively.
Conley et al.
( 1 995)
fo u nd tha t , w h ile these muscles did n o t c o ntribute
ha s been the interest in t h e ro le of i n sta b i l i ty i n back
as m u c h to torque p rod u c t io n , they were the o n e s
pain, pa rtic u l arly the hypothesis of lack of control of
whi c h
the
a t t ributed
segme n t 's
1 992a , b) , cl inica l
that
neu tra l has
researc h .
dysfu nction
In
zone
prompted tr y i n g
associated
with
to
motion new solve
(panjabi,
d irections the
low back
in
musc l e
pain
and ,
the refore , devise the most efficacious re habili tatio n ,
d e m o nstra ted rhis
to
resting
act ivity. T h e
their p o s tu ra l ,
Mayoux-Benhamou
et al.
a u t h o rs
supporti ng
( 1 99 4) have
also
rol e .
sup
ported t h e imp o r tance of t h e longus c o l li for pos
t u ra l
control
muscles,
of t h e
includ ing
cervical those
of
c u rve . These the
deep
craniocervica l
well-placed to offer spi n a l segmen tal
bo t h clinicians a n d resea rchers have recen tly focused
regi on ,
on muscle contro l and act ive stabil i zation (Saal and Saal , 1989; Robison, 1 99 2 ; Ri c h a rdson and Jull, 1 99 4 ; Wilke et ai. , 1995) In normal fu nctio n , all muscles h ave a rol e in p roducing movement a n d in post u ral a nd spin a l co nt ro l , a l though some fLUlctional di v isi o n s between m u s c l es h ave been suggested (Be rgmark, 1 989 ; Richardson an d .lul l , 1 99 4) Bergmark ( 1989)
control and sta bilizatio n .
endurance of the neck flex o r gro u p (Silve r m a n e t
grouped t h e tru n k muscles i n to a global and local
al. , 1 99 1 ; Wa tson and Trot t , 1 99 3 ;
syste m . The g lo b a l system incorporated
1 99 4 ) In an assessment of gross muscle func t i o n ,
s u p erfici al
the more
m u sc l es which have a p r i m a ry ro l e
in
are
The critical question to a s k i s : what is t h e m u scle dysfunction associa ted with neck p a in ? There has been comparatively little research in t o the cervical musculature in p a t i e nts with n e c k pain syn d ro me s . However, in line w i th clinic al theory O a n d a , 1 983), a
dysfunc t i o n
which
has
e merged
is
a
lack
Treleaven
of
et at. ,
Ve r n o n et a l . ( 1 992b) found that patients w i t h n e c k
Copyrighted Material
1 80 Cli nical A natomy and Management of Cervical Spine Pain pain demonstrated g e n e ra ll y less torque p roduction i n all pla n e s , but th ere was a grea ter loss in strength of the cervical flexors as opposed to the cervical exte nsors. From our clinical and res earch findings of the n a t u re of t h e dysfu n c tion i n the deep muscles in the lumbar sp ine , we developed a clinical test for the cervical region to foc u s m o re specifically on the deep c raniocervical and cervical flexors, namely, rec tus c ap i tus anterior and late rali s and longus c a pit u s and colli Gull , 1 994) . In l in e with their normal function of tonic or postu ral support, the test examines these muscles ' ability to maintain a low-level tonic contraction by m a i n tai n i n g a preC i se upper cervi cal flexion pOSitio n (see p. 1 8 1 fo r a full desc ription of the test). Prel i m i nary s tud i e s of deep neck flexor holding capacity in asymp tomatic sub jects a n d subjects with neck p a in ind icated m arked differences in performance (unpublished data). F u r thermore , initial indications a re t h a t restora tion of their tonic (suppo rting) c a paci ty parallels a reduc tion in neck pain and headache (Beeton and J u l l , 1 994). La boratory-based evidence is emerging to support the cl i n ical evid ence of a more intricate muscle dysfunction in neck pain patients ra ther than mere ly a gros s uniform reaction in a l l muscles. Uhlig et al . (1 995) stu d i e d muscle fibre composition a nd muscle fibre t ra ns fo rm atio n in biopsy studies of selected n e c k muscles of patients with persistent cervical p ain of various pathologies. They fo und t h a t there was a n increased relative amount of type IIC fi b res i n all muscles studied, indicating that muscle fibre trans fo rma ti o n occurred with neck pain. Fi bre transforma tion always proceeded in the d i rec t io n from ty p e I (slow oxidative fibre) to type l I B (fa st glycolytic fi b re) , which fu nctio n ally suggests a l oss of the tonic or p ostural suppo rt i ng capacity of the neck m uscles as a dysfu nction in neck pain p ati e n ts , a dysfunction akin to that fou n d cli n ic a l ly in back pa i n p a tients . Notably, there was a m u c h higher p revale n ce of transitional fib res (type II C) in th e neck flexors than the extensors and ch anges in the flexors were presen t and most evident in t h e ear ly stages of the neck disorder « 2 years ' duration). Within the n ec k flexors, there was more evidence of transformation in the lo ng us colli , a m u scle of the d eep local syste m , tha n in the sternocleidomastoid (gl o bal sys te m) . Fibre transformation in the extensors was far less than in the flexors and occu rred co nsiste ntly over many years. Of the neck extenso rs examined (rectus capitus poste rior mi nor, obliqu us capitus i nferior, splenus c a pitus , trapeZius), fibre tra n sformations were most evident i n obliquus capitus inferior b u t , i n contrast to t h e flexor s , t h i s occ urred a t later s tages o f t h e diso rder (symptoms >2 yea rs) . The h igher per centage of fast-type lIB fibres persisted as a perma nent fe ature in these patients' m u scles , even thou g h tra n sforma t i o n activity ceased with time . Nota bly, neck p a i n also persisted .
This laboratory evidence supports the clinical observa tio n s a n d p re l imi n ary data which suggest that a p ri m ary dysfu nction i n the neck muscles is a loss of tonic supporting capac ity, that the dysfu nction is r e lativ e ly greater in the neck flexors and within the neck flexors: it i s the deep m u scles, which have the important s egmenta l supporting fu nction, that dis play t h e greatest d y s fu nctio n . Impo rtantly, Uhlig et al. (1 995) found that the musc l e dysfu n c tion was not pathology-specific a n d sugges ted that pai n was prob a b ly the sti m u lus for this p a ttern of musc l e reaction. This work supports the cu rrent new directions in therapeutic exercise for spinal p a tient s which ta rget these supporting muscles (Ri c h a rdson a nel Jull , 1 9 95a) . The re a r e other dysfu nctions in the muscles o f the n ec k and shoulder gird le complex whic h c a n occur in neck p a i n patients . Loss of ton ic pos t u ra l function in the lower scapular sta bilizers (e . g . the m i d , lower trapeZius, serratus a nterior mu scles), so importa nt for upper quadra n t p os tur a l fo rm and contro l , is a fre qu e n t fm ding cl i n ic a lly (Beeton and J ull, 1 994: Jand a , 1 99 4 ; J u l l , 1 994 : Wh i te an d Sa h rman n , 1 994). I t is considered that this i s a n o t her key muscle group for reh a b ilitation of the nec k pain patient. Other muscles c a n become overactive and tight, themse lves becoming a source o f pain as well as imposing unnecessary additional stresses on articular or neural stnlctures . These include many of the axiosc ap u l a r muscles such a s the levator scapu l ae , scalenes, u pper tra pe Z i us a n d va rious girdle muscles such a s the p ec t ora l s and latissimus dorsi . The upper cervical extensors may a lso become shorten ed . Any of these m uscles may become overactive as a guardi ng response to joi.n t pain or neural mech ano senSitivity. AJte rnatively, their i n c re a se i n activity m ay refle c t abnormal neuromotor control which m ay h ave a cen tral progra mming ori g i n or arise from a not ideal periphera l environment (I-Iall et aI. , 1 993 : Edgar et al. , 1 994 : Janda, 1 994 : Wh i t e and Sah r m a n n , 1 994) . While clinical theories of d ysfu n c ti o n a l imbalances in activ ity levels of the axioscapular muscles are weU develope d , there is little researc h into their preva lence. Thi s probably reflects, in part , the difficu lty in obtain i ng q ua n t ifia b le measu res of t hi S musc l e char acteristic. However, it does seem t h at, while the loss of tonic supporting fu n c tio n of the neck mu s c les , partic u l a rly the deep neck flexors, is a u nive rsal reaction to neck p a i n and patho logy, the presence of tightness in pa rtic ular muscles is not (Treleaven et al. , 1 9 94). Ra the r, other additional influences (e .g. prob lems of motor pa tt e r n i ng, neura l tissue mechano sensitivity or extensibility) a re likely to be at play when these m u scle dysfunctions are present and contributing to the problems. Such a s itua tio n h igh li g h t s the need for dysfunction-based prescrip tion of exerc ises for successful outcomes an d u nderscores the shortcomings of proVid ing p a tie n ts with ge neral exercise sheets .
Copyrighted Material
Physiotherapy ma nagemen t of neck pain of mechan ical origin 1 8 1
Tests of muscle function
occurrin g . Therefore, an indirect m e t h o d to assess
Dysfu nction in the muscle system is sought clinica lly thro ugh a series of testing procedures. Those relevan t to the re h a b i l itation of active stabilization and n e u ro motor c o ntrol will be e m p hasize d .
their pe rformance was d evised wh ich moni tored the subtle move ment produced by the muscle actio n . The upper cervical flexion action causes a very sl ight flexio n o r flattening of the cervical curve . This subtle displacement is monitored with a n infl ata ble pressure sensor (Stabilizer, C h a ttanooga , S o u t h Pacific) w h i c h i s positioned suboccipi tal ly behind t h e n e c k (Fig .
Tests of ho ldi ng capacity of the deep seg mental and p os tu ra l supporting muscles
1 l .6). For the baseline starting pOSiti o n , the sensor i s inflate d to fill t h e s p a c e betwe en t h e p lin th and n e c k
Wh ile a ll muscles have a postura l sup porting ro l e , the
without p u shing the n e c k fo rwards (20 mmHg).
deep neck flexors of the c ra n i ocervi c a l and cervical
The testing action is a p u re head nod wh ich the
region and the lower sta b il izers of the scapula are
clinician must ca refu lly teach to the p a t i e n t . The
those which exhi bit the early and often quite m a rked
ge ntleness and precis ion of the action need to be
dysfu ncti o n . The muscle s ' tonic holding capac ity is
reinforce d . Wh e n the patients h ave poor activa tion
exa m i ned by testing their abil i ty to hold a low l oa d ,
capabilities of their deep neck flexors, they will tl)' to
isome tric contraction w h i c h re p li c a tes their fu ncti o n .
use
Te sting must be p recise and accurate to isolate the
holding contracti o n . These m u s t be iden tified a n d
targe t
corre c te d . T h e common substitutions to mask poor
muscles
dysfunctioned
as
m uch
as
possible
synerg ists which
might
from
non
a ttempt
to
substitu te for and mimic the correct action . regions
a re
tested
thro ugh
to
mi mic
the
c orre c t
deep neck flexors include recrui ting the superfi c i a l the hyo ids and platysma. Alternat ive ly, the patient
pa tient's
may perform an inco rrect chin re traction action or
a b ili ty to hold a precise inner-range upper cervical
m ay try to compensate fo r p o o r tonic fu nction by
flexion action .
pe rforming the action too quic kly.
For c l inic a l testing ,
the
strategies
flexors, sternocleidomastoid and sca l e n e s and even
The deep neck flexors of the cra niocervi c a l and cervical
su bstitu t i o n
the patient is
lyin g to e l im inate load (head we ight) . This ensures the muscles are tes ted in
the
as much isolation as possible from synergists (e . g .
score
sternocleidomastoid) which a re necessa rily recmi ted
inc rease (from the
when
nu mber o f successfu Uy completed
posi tioned
supine,
re sistance
supported
on
a
is
crook
added . The
fo lded
towel
p a tie n t 's placed
head
under
is the
Subjects are requ i red to a ttempt 1 0 1 0-s holds of
ideal
upper cervical flexion a c t i o n . A p erfo r m a nce is
cal culated
performance
by
m u l tiplying
baseline wo uld
the
p ressure
of 20 m m Hg)
by the
1 0-s holds . An
c o nstitute
a
1 0 mmHg
OCCiput only, of a height such that there i s a neutral
increase of p ressu re with the patient ab]e to p e rfo r m
he a d - neck starting position . The muscles to be tested
t h e 1 0 sets of holds, giving a pe rformance score o f
a re deep and a re
unable
palpated to de terrrtine
to be seen or u n iquely
if a correct contraction i s
Fig. 1 1 . 6 performed
The
test
of holding
by maintaining
a
1 00 . A s mentio ned , o u r p re liminary d a t a suggest t h a t neck pain patients are we ll below t h i s ]evel.
capacity of deep
Performance is quan t ified in directly by monitoring to hold
the neck
neck flexors
is
p recise LIpper c e rvical flexion position.
the
patient'S
ability the
p o s i tjon v i a a pressure sensor p l a c e d b e h i n d
neck.
Copyrighted Material
1 82 Clin ical A natomy and Management of Cervical Spine Pain ligaments c a n be indicated for a patient following a c u te tra u m a , such as from a motor vehi cle accid e n t . The u p p e r c e rv i c a l a r e a is not u ncommonly inj ured in whiplash inj u ry and the inj u ry mechanism exposes the alar liga m e n ts to i n j u ry (Dvorak et aI. , 1 987; J6 nsson et al., 1 9 9 1 ) . The clinical and rad i ological stress tests involve lateral flexion or axial rotation (Re i c h
and
Aspinall,
Dvora k ,
1 986;
Dvora k
1 987;
et al. ,
1 989) . The sensitivity and specificity of
these tests have not been present proble m s in
vivo,
esta b l i shed
and
both
re sul ting from pain and
patient guard ing . The symptom of dizziness and any other signs of vertebrobasilar insufficiency are foremost in the mind Fig. 1 1 .7 The [est of tonic holding capacity of the lower sca p ular sta bilizers. Note that the arm i s
in s l ight abduction
with the elbow fl exed to d iscourage su bstitution with latissimus dorsi .
of any practitioner using manipulative thera py proce dures for t h e cervical spine. Inj u ry to the vertebral arte ry is a ve ry real , albeit rare risk which can have d isastrous consequences. Testing protocols exist to atte m p t to id entify the a t-risk patient (Lewit, 1 98 5 ; Austra lian Physiotherapy Association Protocol, 1 988; Gran t , 1 994b), although their sensitivity and spec ific
The tonic h o l d ing capacity of the lower scap u l a r
ity are unknown. The va lid ity of some tests is in doubt
stabilizers (mid , l ower trapeziu s , serratus anterior) i s
(Thiel et al. , 1 994). The ethica l issue is whether the
tested w i t h a modified classic grade 3 musc l e test
be nefits of high-velOCity manipu l a tive thrus t proce·
(Kendall et aI. , 1 993). The major modification is that
d u res ou tweigh the risks (Powell et at. , 1 993) and
the arm load is eliminated by resting the arm by the
data a re lacking to debate this issue ra tionally.
side . The patient is reqUired to hold the scapula
The presence of arm pain , hypoaesthesia and other
against the chest wall in a position of re traction and
va scular symptoms can direct the inclusion of a
depressio n (Fig. 1 1 .7). The patient's a b il i ty to pe rfo r m
number of tests . These may a i m to compromise the
1 0 1 0-s holds of t h e scapular position is tested . T h e
interve rtebra l foramen and structures in the thoracic
patient's performance is inadequate w h e n he o r s h e
inlet or reveal dysfunction in the sympathetic nerv
l o s e s control of scapular position or substitu tes the
o u s system . Other medical and radiological exa mina
co rrect performance with other muscle action, i . e .
tions can be u n derta ken as releva nt to d iffere ntial
the latiss imus dors i , u pper trapezius o r rh omboids.
d i a gnosiS in support of the cli n ical examination.
Tests of muscle length
Conclusion of examination
The axioscapular, girdle and neck muscles p rone to hypertonicity and
tightness a re tested and
these
procedures a re well-described in clinical texts Oan da ,
T h e problem-solving process of the clinical examina tion culminates with the p hysiotherapist gaining understanding of patients themselves,
an
their n eck
1 98 3 ; Travell and Simons, 1 983) . Carefu l d ifferential
problem and their expectations of treatment out
testing i s required of those muscles which have a
come.
close relationship to major neu ral structures, nota bly
physical diagnosis are m ad e . The l a tter depicts and
Both a provisional p athoanatom icaI and a
the upper trapezius, scalenes and deep subocci pital
d efines the dysfunctions in the articular, muscular
extensors . Edgar et al. ( 1 994) revealed that people
and ne rvous systems which a re l inked to patients'
with normally less flexibil i ty in their u p per-quadnlnt
pain a n d functional limitatio ns. The p resence and
neural systems h a d less appare n t extensibility in their
n a ture
upper trapezii . This was reasoned to be a normal
strategies selected in managemen t .
of the
dysfu nctions
guide
the
treatment
the authors caution
It is essential that the clinician has ind i cators to
both clinicians and patients against routine stretching
guide the progress of treatment a n d to evaluate the
without knowing precisely the underlying cause for
efficacy
the muscle respo nse .
patient, the most important outcome is pe rmanent
protective p h enomenon and
of the
management
progra mme . To
the
relief o f the pain and disability for which they so ught treatment. The specific func tional d isabilities re por
Special investigations There a r e factors in the patient's symptoms and
ted by the patient a re used as primary outcome measures o f treatment effec tiveness . The p hysio
history which d irect the inclusion of other specific
therapist
tests which are e i ther stru c t u re- or systems-related .
in terested in the cha nges in physical impairments
Clinical and radio logica l tests of cra nioverteb ra l
seeks
the
same
outcomes
but
is
also
which are as a res u l t of their treatment. The l i nks
Copyrighted Material
Physiotherapy management of neck pain of mechanical o rigin 183 between changes in i m p a i rments (or dysfunction)
moveme n t has on impairments i n the other sys t e m s is
a n d c h anges in symptoms guide intellige n t treat m e n t
assesse d . In this way, the dysfu n c t i o n in each system
selection a n d a p p l ication
precise tre a t m e n t a d d e d
i m p a irments need
to be quantitatively
q u a litatively docurn o n i to re d .
m e nted so that
articular dysfunction Physiotherapy
A
m a n i p u la t i ve t h e ra p y,
bilizing exe rcises and exercise to i mprove muscle P hysiotherapy m a n age m e n t a in1s to reverse the dys
support a n d c o ntrol for the c e rv i c a l segments a re the
fu n c t i o n c a u sing the p atient's neck pain and d i s a b ility
principal therapies p hysioth e rapi s t s use t o m a nage
All
as we1l a s p reve n t recurre n t e p i sodes o f p ain
joint dysfunction and i ts resultant symp t o m s .
systems may requi re active mana ge m e n t a n d physio
Manipula tive t h e rapy incorporates the techniques
therapy manage m e n t is i n c l u sive o f the following
o f passive segm e n ta l j o int m o b i l i z a t i o n (rhyt h m i ca l ,
t h e rapies:
manip u l a tive
t h e rapy,
specia l i zed
t h e r
apeutic exercise and muscle fu n c t i o n strategies, rec o ntro l , e rgo-
education of posture nomic
application
and
p rocedure s) ,
The
h igh-ve l o c i ty,
l ow
and a l leviate the effe c t dv�fl1 n c l i o n m a y have o n o tlin
req u i re d .
muscular system s . S e l e c t io ll
Manage m e n t
precise
c o m p rehensive,
often
is gui d e d by the n a t u re
and
c o m p l ex
neurom uscula r - a rticular system . T here
is
in the exa mination.
elicited
t h e integrat e d
dysfunctions which cervical
and
t h erapy a r e to rel ieve
of
a i d s as
phys i c a l
electrop hysical
l ow-ve locity
force , smalJ-a m p l i tu d e j O int manipul ation techn i q u e s .
physically as abnormal specific plancs and abnormal t i s s u e resistancc to
now u n e qtuvocal evidence t h a t i nterve n t i o n i n o n e
i n d uc e d mot i o n . This c o u l d be caused by muscle
system a l o n e d o e s not guara n tee resolution of dys
rea c tivity o r s p a s m , o r incre a s e d or d e c reased c o l
fu n c t i o n in o t h e r systems (Hides et at. , 1 996) a n d all
l agenous tissue stiffness (Tha be ,
systems require exacting m a n age ment. The talent in management o f neck p a i n synd romes
1 986; ] u l l et at. , 1 988; S h i rley and Lee, 1 993) a n d will u sua lly be
accompa nied
by pain. Techniq u e selecti o n is also
i s to recogrtize w h e re i t i s most e ffe c tive to i n tervene
d irected by t h e location o f the segmental dysfu nc
i n to the cycle o f interrelated dysfunction (Fig. 1 1 . 8) .
tion, whether the dysfu n ction o riginates i n the u p p e r
practice t o guide
T h e model used trea tment s election . interve ntion
h e r influences a re t h e
of effe c t of a n
the process o f
in
on
1 986)
(Maitland ,
c e rvica l zygapophys i a l
p rogression is each the
m a n i p u l a t ing a
system
e ffe c t of
j o i n t or inhi biti s eva l uated by
ing a hypertonic assessing any c h ange i.n
of techniques c a n be
p a in and m ove m e n t . In
martipula ti ve p h y s i otherapy texts a n d will n o t be
turn , the effect that t h i s pain rel ief o r increased j o i n t
d e scribed in detail (Ma i t l a n d , 1 986; Grieve, 1 988; Edward s , 1 992; Ka l te n b o r n , 1 993). M a n i p u l a tive ther apy
� t \ t . ;< \ :�::;�� /'� 1 "
Neural Tissue
Mechallosensitivity
!jl
,o o
cycle
o f in terrelated
the
restore l ateral flexio n
..
technique s a re p roposed
dySfunCI ion
m a nipula tion-Lnd lIceci
iJ iO!llCcilartical effe c t s o f passive
""
pain
and
restore
its
Zu"man et at., 1 989; H e rzog in
1 99 3 ; the
articular, muscul a r a n d nervous systems which is manifest the cervi c a l pain syndrome.
to
o f t h e segmen t 's axial
....... Control
The
s p e c ifi c a l ly
related movement. For instan c e , restoring the down
Callaclly
-"
a p plied
ward a n d m e d i a l glid e of the superior fac e t of a
'----
Fig. U . 8
are
speCific a lly to t h e d irection of 1110tion loss or its
JOi n t Dysfu n ction
POO ' Pos t u re
techn iques
assessed dysfu n c t i o n a n d , in the m a i n , they re l a te
CERVICAL PAIN SYNDROME
in
Lee
et at. ,
1 99 3 ;
Petersen
et at. ,
1 993 ;
Vic e n z ino et at. , 1 994; Wright . 1 995). The n a ture o f t h e techn ique will refl e c t t h e intent i o n o f i t s effe c t . I n s i tuations o f ac u te pai n a n d j o int tissue damage, fo r
Copyrighted Material
1 84 Clinical An atomy and Management oj Cervical Spine Pain segment to maintain movement gain s . Either the neck can be positioned to foc u s movement at a particular level (Fig. 1 1 . 3) or pa tients can be taught to use their own fingers a s
a
p roprioceptive cue for a particular
jOint. There
is
co mmonly
a
need
for a
number
of
segm e n ts to be t reated c o n comita n tly, using different teclmiques for diffe rent rationa les. A s imple example is w h e re gentle passive m o b itiza tion techniques a re being used to treat the p a in arising from a segment with s u btle translational ins ta bility. Simultaneously, n e ighbouring
segments
are
mo b ili zed
to
reduce
hypomobil i ty so that movement will be distributed more normaUy between segments, aUevia ting strain from
the
symptomatic
s eg m e n t .
However,
local
man ip ulative therapy treatment to joints will b e in vain
the
if
segmental
instab itity
problem
is
not
a d d ressed through correct muscle stabiIi zation tra i n ing . Muscle retl.lining is an in tegra l component of treatment of j oi n t dysfunction.
Treatment of neural tissue dysfunction There
have
been
considera ble advances in
thera
p e u tics within p hysioth erapy for the recognition, diagnosis and
man u a l therapy
treatment
of pain
syndromes pa rticularly rela ted to pathomechanics of the n e rvous system (Elvey, 1 98 1 ; Butler, 1 99 1 ; Quint
Fig_ 1 1 .9 A high-velocity,
low-a m p l i t u d e m a nipulative thrust
technique to restore righ t lateral flexio n to the (righ t)
C2 3 -
zygapop hysial jOin t .
ner and Elvey, 1 99 3 ; Hall and Quintner, 1 995). A text h a s been devoted to the subject (Butler, 1 99 1 ) . For the purposes of discussion here, a simplified treat ment
p a radigm
p rovide
an
will
be
insight i n to
used . Th is will the
serve
to
type of m a n agement
which might be used to address this form of n e u ral and
tissue dysfu nction - that rela ted to adverse mechanics
rhythmically i n a p ainfree m a n n e r to u t ilize a n a lgesic
with res u l ting pain a n d me ch a nosensitivity of neuraJ
exa m p l e ,
movement
is
applied
very
gently
effects of movement and encourage movement for i ts
tissu e s . For detailed read ing on n e rve i nj u ry, neuro
mechanical effects. Conversely, a cute p a i n with j o int
mechanics
and
locking, pu rportedly from a meniscus e n t ra p m e n t o r e x t rapment ( M erc e r and Bogd u k , 1 993), m a y direct use of a gentle high-velocity manip ulative th rust technique to gap the j oint, to inhibit the muscle
referred
landmark texts such
to
pathomechanics,
the as
reader
is
Brieg ( 1 978),
Sunderland (1 978) and Lundborg ( 1 988) . Neural tissues of the upper forequarter can be inj ured d irectly in assoc ia tion with joint an d muscle
activity and permit the j oint a n d meniscus to m ove
inj u ry. As m o re commonly occurs, neural tissues can
fully again .
be compromised by the sequelae of joint pathology,
In
other dysfunc t i o n ,
techniques may
need to be applied at the end of a j oin t's a b n ormal
injury and the re pair p rocess. The broad o p tions for
hypo m o b ile range to restore normal p hysiological
management therefore include treating the related
ra nges of motion. Such tech n i q u es may b e in the fo rm
j o int
of either specific low-velocity o r high-ve locity proce
t i s s u e s o r u s ing a c o m b i n a t i o n of both methods
d u res (Fig . 1 1 .9). It
is
imperative
dysfunction ,
d i rectly
m obili zing
the
n e u ra l
( E l ve y, 1 986; Bu t l e r, 1 9 9 1 ) . The model of immediate that
m ovement
gained
by
a
assessment of effect of an i n te rvention on a positive
manipulative thera p y technique is reinforced by both
neural tissue test as wel l as other jo int and musc l e
the mechanical and neurophysical benefits of ac tive
signs again guides treatme nt se lection a n d progres
move m e n t . It has been shown that move m e n t gained
s i o n . Adverse n e u ra l mechanics and mechanose n s itiv
by a specific manipula tive technique performed in
i ty c a n contribu te to both acute and c hronic pain
isolation will b e lost within 48 h (Nansel et al. , 1 990) .
sta te s .
The patie n t must pe rform a c tive move m e n ts d i re c ted
M a n i p u l a t ive therapy treatment of t h e jOint dys
a s locally and precisely as possible to the affe c ted
function may su c c essfu lly resolve the sensitivity in
Copyrighted Material
Physiotherapy management of neck pain of mechanical origin 1 85 most p o t e n t sin g le m ovement for t he cervical n e rves and brachial p lexus is scapular d e p ressi o n .
An y technique c h o s e n which direc tly add resses ne ural structures is always performed gently and in an exploratory manner. Any treatment progression
is
carefulJy guided by the re-evaluation of the response
in the neural tissue tension test. Overe n t husiastic application of technique can p rovoke , rather th an relieve, the p a in associated w it h t he neural tissue dysfunction. The advent of d irect move m e n t therapy to
the
nervous
system
together
with
a
greater
understa n d i ng of the scope o f neural tissu e dysfunc tion h a s broadened and fu rth ered the management of m u sculoskeletal
disorders .
Research
docu menting
the nature of the syndromes and the nat u re and validity of the clinical neural tissue tests is increasing. Howeve r,
the mechanism
of action
of successful
neural tissue therapeu tics is an important area of future research which is only beginning (Slater et aI. , 1 99 4 ; Vicenzino et al. , 1 994).
Treatment of the muscle system and neuromotor control Proper fu n c t ioning of the muscle system is essential to offer the joints sup port and c o n trol and to preve n t adverse strain , reinjury and further p a i n . Achieve ment of muscle c o n trol is freque n t ly commensurate with pain control (De rrick and Chesworth,
1 99 2 ;
Beeton and JulJ , 1 99 4 ; Richardson and Jlill , 1 99 5 a)
Fig. 1 1 . 1 0 A combi ned a rticular and neural tissue tech· nique. The C5 - 6 segment is mobilized into contralateral lateral flexi o n . To maxim i ze effects o n neural tissues, they a re p retensioned with the a r m posi tioned i n a submaxi ma l test positio n .
and is a fund amenta l component of j oint treatment. Specific muscle and movement dysfunc ti ons h ave been iden tified in patients with c e rvical dysfunction, as previously described . Based o n our c linical and research work, therapeutic exercise strategies h ave been devised specific ally to address those muscles which a re dysfu nctioned in neck pain and to exerc ise them according to the i r fu nctional demands (Jull,
neural structures, al l owing free pa inless movement to
1 99 4 ; Richardson and Jul l , 1 99 5 a , b) . This places an
retu rn. Often techniques need to be devised which
emphasis
a im s i m u l taneously to move
control directly to address the major muscle dysfu nc
the j oint and neura l
on
sta b i l i zation
training
and
movement
structures t o reso lve the d ysfu nction. For exampl e ,
tions linked with neck p a in and pathology. Add ition
a n teroposterior glides (Fig . 1 1 . 4) to a m id t o lower
ally,
dysfunc tioned cervical segment may be performed
requirement in this proximal sp ine and girdle region
active
sta b ility
is
a
predominant
functional
while the tru nks and roo ts of the b rachial p lexus are
so that the fo rc es from the a c t ions of the head and
moved
elbow
upper extremities are accepted h e re with o u t undue
flexion and exte n sion in t he brachial plexus tension
strains. The exerc ise p rogramme includes progressive
by
the
patient
performing
active
test position (Fig . 1 1 5) . Conversely, a j o in t may be
components which are added as the muscles resp o n d
moved to deliberately move neural tissue simultane·
to the retraining. Some details of the n e w e r asp e c t s of
ously, such as will occur with a cervical , segmental
training will b e given .
con tralatera l lateral flexion technique . The effect on neural tissues could be enhanced during the m o biliza·
tion
by
pretensioning
t he m,
by
positioning
the
patient's p a inful arm in a calculated proportion of a fu ll-tension test position (Fig. 1 1 . 1 0) . The sensitivity
in the neural tissues may also
be
devising
limb
a d d ressed
by
Retraining the tonic holding cap acity of the deep stability and postural muscles
The dysfunction of loss of tonic holding capaCity of
movements
the deep neck flexo rs and l ower scapular sta b ili zers
directly to move neura l structures (Butler, 1 99 1 ) . Th e
is addressed in the flfst instance to restore their
sequences
of
upper
Copyrighted Material
Clinical A nato m)' and Management
Cervical
postural and j o int-supporting function, Optimally, training is commenced in t h e first treatment, t h e only facto r mi tigating against this is if pain is c reated by scapu lar upper cervical fl exion action depression and Th is could n eural upper structures are quite IHcchanosensitivc cervical joints a re acutely painful . In these cases pain must b e settled as a firs t priority, as it will be inhibitory to muscle action. The functi onal demands of these muscles is tonic hold.ing capac ity with (Richardson without of the fIrst cornponents of re hahilitation, the are exe rcised .fix their precise func tion b u t in a non-fu nctional pOSition . This trains them in as much isolation as possible from the i r syn e rgists to e n su re t h a t t h e y specifically are exer cised and that their dysfu nc tion is unequivocally reversed . deep neck for m a l test of sup inc lying, fcedback iron! the p ressure sensor (Fig. 1 1.6) . Pa tients should comme nce by training at a level they can achieve , for if the task is too difficult they will substitute w i t h unwanted actions o r muscles, as p reviously de scriht'd. For exam p l e . patients m a y be ahle i n i tially to i ncrease the pressure 4 mmHg and three They s h o uld o holds befo re for mal exercise level , performing lying a t least once, preferably twic e , per day. The exercise s hould b e carefully monitored and pe rform a n c e quantified at each treatme n t session. Progres sion is by incre asing the time the c o n traction can be Achievemenl I. O-s holds i s a i m and followed b y improving the stre ngth contracthe p ressure recorded . This which will maximum ImnHg, as p ressures a bove this level are indicative of a substitution s trategy, usually that of an incorrect head retraction action . The lower scapular s tabilizer function is t rained utilizing t h e same p rinciples. If patients cannot against tbe wall in the scapula depression and in p rone I.esl posi tion (Fig. their traini.ng need to begin side lying. The therapist oflen needs to use various facili tation strategies to a ctivate t h e muscle and inhibit its syn e rgists, such as l atissimus dorsi and eve n , in some patients, the scapu lar e l evators. Performance is 0 0 1 0-s i m p roved by increasing rhe holding and progress.i.ng position from prone test to adding of a r m loa d . Progression i s unl i l control scapular position a n d support arm load i n 14 0 0 abd u c tion - t h e classic grade 3 muscle test position for l ower trapezius (Kendall et at. , 1 993). The essence of testing and training the deep and supporting muscles is precision, acc u racy contro l . If a rc p e rmi tteu change to a hold t h e scapular
pOSition, bad patterns are reinforced and the training becomes ineffectual and counterproductive. The c linical skill required accurately to facilitate and for a parallels that the deep h igh-velOCIty manipulation cervical The preCision of training to be thoro ugh ly comp rehended by both clin ician and patient, Integration of holding capacity training into postu'ral control antlfullctional
nr·" U ' , Tl' P ,·
holding patients t o tra i n of the deep flexors and scapular stabil izers several times per day to i mprove their tonic function and to imp rove patterns of neuro motor contro l . Postural retraining requires patients to assume a correc t u pright, neutral s p in e position to t rai n i ng, a consciolls acti vation is added, hold of th� muscles, lower the deep transstabilizers versus abdominis (Richardson and Jull, 1995a) . Assu mption of the correct neutral spine, postural position with the low-leVel activation of these mus cles corrects the head position and seems automati callv to s u btly activMe the deep neck flexors indeed the lumbar extensors. such as rn u l t.ifidus. Retraining a correct, n eutral spinal can be difficul t in patients with poor proprioception and motor control. Re-education usually begins in t h e l umbopelvic region a nd the patient trains to assume an uprigh t neutral position of the pelviS with a l u m bar lordosis often discrete use the shoulde rs-back postural method a s correction . This i s results incorrect thoracolu mbar o r t h o raci c lordosis (Fig. 1 1 . 2b) rather than the correct l umbope lvic position which will enco urage balanced, thoracic and cervical curves . The postural m u scle activation is added to the correct spinal position . The patient is scap ular the correct act iva tion A common I ry too is that patients muscles and the correct muscle action with thoracic · extension or even with scapular retrac tion and e levation. 'n1e correct muscle ac tion needs to be facil itated with an e mphasis t h a t only a muscle contraction of 1 0 - 1 5% of maximum is ret rain th e tonic supporl:i ng role of muscles. Again sub tlety and of control to be well-understOod by pal l e n t . Frequent repet ition is n ecessary to retrain a new postural and muscle s k i ll and improve holding capaCity of t h e supporting muscles. To maximize compliance, practice must not be too intru sive into lifestyl e , need to patient's usually i n corporate p ractice t h e i r everyday aclivilles and ci!lli cian should them identify cues and
Copyrighted Material
Physiotherapy management of neck pain of mechanical origin J 8 7 times t o pra c ti s e , for exam p l e , w h e n ever t h e y answer
2. Re-education of t h e pattern o f axioscapular mus
the telephone, when stationary in the car a t traffic
c l e sequencing a n d
training and
l i gh ts, etc . Patients ultimately t h e posl ma i
This is usually begun ;l cl..i o n into a b d uction
lifestyl e .
Exe rcise a n d
levers in all planes with o r
u s u a lly n o t a
problem when
activi ty d u r i ng arm move
relieves their
neck p a i n . This is
shown b y simply
demons trating the
rec iprocal relaxa-
neck a n d trunk coOlrol
3.
gravitational and upper-limb
scapul a e muscles,
tion . The p a inful
for exa m p l e , are palpate d near t h e s u p e romed ial
patients' working, or recre a t i onal activit i e s .
border of the scapu l a . Allow the patient to feel the p a i n relief and rel axation in t h e m u s c l e s o n rep a l p a t i o n following assum p t i o n of a correct p o s t u ral position with gentle activation of the lower scapu lar sta b i l izers .
Co-contraction exercises Muscle co-c o n tra c t i o n of agonist and a n tagon.is t is a s t ra tegy for active j o i n t sta bilization (Kcshner et at. ,
Muscle-lengthening procedures The technical aspec ts d u res
a re
1 989; Andersson and Winters, 1 990). It is l inked to
well-:Jrldressed
and
( 1983). More
r o l e of t h e muscles
Simons
cause of the
muscle overactiv i tr
i d e n t ifi e d . Add ressing
this issue will inJiuencc
a p p roach and
help to achieve a achieved b y
a n d s u p p o rt ind epem i e n t
mlt5 c l e ·lengthening p roce-
stretching
instilming
gram m e alon e .
pOSi tions, for exam p l e , sitting,
effe c t than is ever Factors which
pro-
prone, p ro p p e d o n e l bows.
might u nderlie the
any exerc i s e , t h e spine s h o u l d b e positioned in its
p resence o f a t ig h t o r hypertonic muscle w hich
correct neutral pOSit i o n . Some ge ntle presetting of
requ i re prim ary attenti o n include a d a p tive length
t h e d e e p and postural muscles seems t o e n h ance the
cha nges to poor p ostura l for m , p rotective
hype r
effect o f e x e rcise. An effe ctive exerc ise for home use
tonicity
neural
i s a self-ap p lied ge n t l e , s u s ta ined rotatory resistance
tissues (note especia lly u p p e r tra p e z i u s , scalenes,
of mechanosensitive
a pplied rhythmically to alternate sides of the head to
suboccipital extensors), lack o f sta b i l i ty fu n c t i o n of
co-activate the neck flexor and extensor muscles.
synergistic muscles, and
or shortened
poor patterns of muscle
1 99 4 ; 1 994).
activity (Hall et
1 994;
Jull , 1 994 ;
Throughout the e ntire exerc i s e p rogramme, the deep neck flexors a n d
Ja n d a ,
c o ntin u e s to b e tested W i l h and
activity
Re-education
1 1 .7) a s i t
Patients c o n t i nue to
and 11U)vemellt
of move m e n t control a re
Poor p a tterns of conside red to be system p rogramming Oanda ,
i s d iffi c lIlI
check if they have
the
these whole
muscles treatm e n t
tile central n e rvous
p a r t of t h e i r continuing preven tive p ro
as well as the
gramm e after d i scharge from active treatment. I t is
1 994)
res u l t o f pain and the inhibitory and excitatory effects
the d e e p muscles whose fu n c t i o n is so vital for
of inju ries o n the muscle syste m . The muscle system
segmental support and control and ironically i t i s
will also be affected by d i suse p ost-inj ury (Richardson
these muscles w h o s e fun c t i o n is most c o m p romised
and ]ull ,
b y j O in t p a in and p a t hology.
to
1 994). These
poor p a tterns are u s ually linked
inadequate stabili ty c a p a c i ty o f the deep
and
postura l supporting muscles o f t h e s p i n e a nd gird l e s . O n c e t h e s e m u scles
act ivated and train e d ,
both in isola t i o n
c o n t ro l , t h e
stabilization p rogra m m e a p p ropriate t i ming
d uring move m e n t
with and without whic h m ay requi re
advice should be should
basic p atterns
train t h e interaction
t h e ir
a n d equipment m a y b e .
and gl o b a l musnot
cles. These are:
cover
recre a t i o n a l environm e n ts .
which are used to
p o o r postural a n d movemenl
c o n trol a n d p o o r j o in t sup p o rt . Pat i e nts must u n d er
1 . Re-e ducation o f th e synergistic action between the
sta n d that they hold in their muscle systems the key
deep and superfic i al neck flexors in the through
to effe ctive j o in t s u p p ort and protection from rec u r
range control of c e rvical flexion .
rent p a in .
Copyrighted Material
Cervical
(finical A natomy and Management
Vertebral Column (Boy ling, J,D. a n d Pal asta n g a , N , eds) .
Conclusion
E d i n b u rgh : C h u rchill Livings t o n e , p p . 3 1 7 - 3 3 2 . Bogduk,
key issue in
p hysiotherapy m a nagement of
with cervical
syn d romes
artic u l a r systems. Examination is a pro bl em-solving exerc ise which aims to provid e a provisional patho anatomical diagnosis_ Most importantly, it depicts the exact d ysfu n c t i o n s i n the t h ree systems which a re major
to the palien! 's p a in and sI'm.p roms, fu nctional d i s a b ili ties documented
tion and p rogression of techniqu es are guided by an o f effects
mod e l . The
ini t i a l
aim
of
phys iotherapy man a gement is to relieve the patient's d isability. The
neck p a i n prevent recurrelll provided
of
continue
sim ple
exercises
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which
everyday
posture s as a liJclong p reventive h abit, trained thctll s f'lves to cle a n
E,
BOismare,
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c e rv i c a l trigger p o i n t . Cephalalgia
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( 1 993) Cervicoge n l c headache:
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ergotamine
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.rD. , Pa lastanga, N. (eds) ( 1 994) Gri e ve s Modern Manual Therapy, 2 n d edn . Ed in b u rg h : " hurehill Livi n g-
Boyling,
'
M M.,
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s p i n e as
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a
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as t h e y teeth
life l ong preven t i ve m e a s u re against
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LateraJ isa tion of headache: poss i b l e ro l e of an u p pe r
c a u s e o f chroniC
m aintenance o f j o i n t prote c t i o n a n d c o n trol . They a re to
I)f
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key
exercise programme tha t focllses, a t discharge, o n
t h e i r deep
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objective ly
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C ( 1 993)
o cc i p i ta l headache
exren s i o n -
the efficacy
tf(°cl tment can b e
A p rill ,
21 3- 21 7.
rccognItion
complex dysfu n ction in the n e u ra l , muscular a nd
N.,
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!l. R. ,
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Tbel: 1 : 9 9 - 1 0 5 Stefano, G. e t al. ( 1 993) Factors i nf l u e n c in g recovery from h e adac h e after c o m mon whi plash . Br. Meet. ] 307: 6 5 2 - 6 5 5 .
Longus co l l i has a pos tur a l hm ction o n cervi c a l c u rva ture.
Ra i n e , S . , Two m e y, L. ( 1 994) Postu re o f t h e hea d , should e rs
Surg. Radiol. A n a t. 1 6 : 367 - 37 1 .
and thoracic s p in e in comfortabI e e re c t s l.1 n d ing . A ttst. J Physiothe r. 40: 25 - 3 2 . R e i c h , C , D vo ra k , ]. ( J 986) T h e fu n c ti o n a l eva l uation o f
c o i nc i d e n ce ' Neuromdiology
Mai t l an d , G.D. ( 1 986) Vertebral
a l ges i a . ] Manual Manipul.
33: 4 7 5 - 47 7 . Manipulation,
5 t h ed n .
Ra danov, B . P. , S tu r z enegger, M . , D i
Lo n d o n : Butterworth .
Me rcer, S , Bogd u k ,
the
c e rvi c a l
N. ( 1 993) I n t ra-a rti cul a r inc lusions of
sy n o v ia l
j o in ts .
Rb euma to l.
Br. ]
32:
705 - 7 1 0
c ra niocervical ligaments in S i d e fl exion using X-rays . -'
Mercer, S . R . , j u ll , G . A . ( 1 996) Mo r p h o l og y of the celvi c a l i n te rver t e b ra l d isc : im p l ic a t i o n s for M c Kenzie 's the
disc
de ra n ge me n t
synd ro m e .
Manual
m o d e l of TheJ: 1:
Manual Meet. 2: 1 08 - 1 1 3 .
Reve l , M . , Andre-[)eshays, e . , Minguet, M. ( 1 99 1 ) Cervico c ep h a l ic ki nesrhesic s e n S i b i l i ty in pa t ie nts with c e rvi ca l
Three
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76 - 8 1 . Mim u ra , M . , Moriya, H . , Wat,mabe , T e t
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1 1 3 5 - 1 1 39 . Moses ,
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1 : 2 - 1 0.
Ri chardson ,
e . A . , jul l ,
G.A.
( 1 99 5 b)
An
bisto.-ical per
spectlve on tlJe development of clin ical
tecbniques
headache. Headacbe 33: 90 - 95 .
eva luate and treat the
system of Ibe
A . , Cre m a t a , E . e t al. ( 1 990) Time course conside rations for the e ffects of uni lateral l ower c e lvic a l
lum bar spine. Monograph no.
Na nse J , D. , Pe neff,
a d j us tm e n ts with re sp e ct to the a m e l iora tion of c e rv i c a l
Melbourne: Aus tralian
Ro b i s o n ,
lateral-flexi o n passive e n d-r a n ge asymmetry. J Manipui.
R. ( 1 99 2)
The
a ctiue sta.bilising
back
sta b i l i zation tra i n ing. Pa rt I . Occup.
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Saa l , ) . A . ,
Spinal Disord. 5: 383 - 389.
Schne id er, G . ( 1 989) Re stric t ed
Pa nj a bi ,
Saal , ] . 5 .
The lumbar ,p ine.
I.
Ph y s io r h cra p y new
( 1 989)
to
Society, p p . 5 - 1 3 .
s c hoo l
p re sc r i pt i o n :
},Ied. 7: 1 7 - 3 l .
No n o pe ral iv e
tre a t m e n t
of
herniated l u m ba r i n te rve rtebral d isc with raci icnlopathy. An o u tcome s tu d y. Spine
Copyrighted Material
14: 4 3 1 - 4 3 7 . shoulder move ment: cap-
Physiotherapy management of neck pain Of mechanical orig in 1 9 1 su lar c o n t rac t u re or ce r v i c a l A us!: }
referra l Pbysiother. 3 5 : 97- 1 00 .
a c l i n i cal s tud y. E . F. ( 1 994) Non
Selvara t n a m , P) . , Matyas, T. A , G l a sgow,
invasive d i sc r i mi n a t i o n of b ra c h i a l p l e x us i n volvem e n t in upper limb pa i n . Spine
S hir l ey, D. ,
19: 26 - 3 3 .
betwee n
l u m ba r poste ro-a nterior mobili ty
and l o w b a c k p:l in . } Manual Manipul. Tb el: 1 : 2 2 - 2 5 .
Silverman, J , L . , Rodriquez, A . A . , Ag r e , J, C ( 1 99 1 ) Q u a l i t a ti ve cen'ical flexor s tre ng t h in h ea l t hy su b j e ct s a n d in subjects w i t h m e ch a n i c a l neck p a i n . A rch. Phys. Mea.
72 : 679 - 68 I
Rehabil.
cri te r ia i n c o m n1 0 n m i gra i n e . A c o m p a r i son
\vith cel-vico
ge n i c h ea d a c h e . Punct. Neurol. 7: 289 - 29 4 . Sjaastacl , 0., Bov i m , G. ( 1 99 1 ) Ce rvi coge ni c headache . T h e d ifferentiation from common m i gra i n e . An ov erv i ew. FunCl. Ne u ra l. 6: 93 - I 00. Sj a a sta d , 0., S au n t e , C , Hovda hJ , H . el £II. ( 1 983) Cervico h e a d a ch e . An h y pot he s i s .
0. ,
Sj aasta d ,
F re d rik s e n ,
TA.,
Cephalalg ia 3: 2 4 9 - 2 5 6 . S a n d , T el a l . ( 1 989a)
U nila te ra l i ry of h e a d a c h e i n c lassic mi grai n e . Cepbalalgia
9: 7 1 - 7 7 . 0. , F r e d ri k s e n , T A . , S a n d , T ( l 989b) T he l oc a l isation of the in i tia.l p a i n of attac k : a comparison between classic m igra in e a nd ce rv i c o g e nic headach e . Fu nct. Neural. 4: 73 -7 8 . Sjaasra d , 0 . , j o u b e r t , J. . Eisas, T el a l . ( 1 993) H emi c ra ni a c o n t in u a a nd cervicoge n i c h ead a che . Sep a ra te headaches o r two faces o f the same headache) Funa Neuro/. 8: Sjaasta cl ,
7 9 - 83
Slate r, H . ,
V i c e n zi no ,
B . , W r i g h t , A . ( 1 994) 'Sympathetic
nervous system fu n c t i o n . } Manual Mcmipul. Ther. 2: 1 56 - 1 62 . Smythe, H . ( 1 994 ) . T h e C6 - 7 syn d rom e - clini c a l fea nlres ancl tre a t m e n t response . .l Rheumatol. 2 1 : 1 5 20 - 1 5 2 6 . S tewa rt, S . G . , j u l l , G . A . , N g , J. K . - F. e t £I I . ( 1 995) An in i t i al a n a ly s i s of t ho ra c i c s p i n e movement" d u r i ng unilateral a rm el eva t i on . .f Ma nual il1anijJu/. Ther: 3: 1 5 - 20. o n p e r i p h e ral sym pa t h eti c
M . , You n g , A . ( 1 984) T h e con t r i b u t i o n o f reflex
i n h i b i t i o n to ar t h rogeno u s m u sc l e wea kness. Clin.. Sci.
67: 7 - 1 4 . Stllrzenegger, ,vI . , D i Stefa n o , G . , Radanov, B . P et a t . ( 1 994)
Prese nting
sym p rol1ls a.nd signs aiter w hi p l a s h i n j u ry : the
i nfl u e n c e
of
mechani s m s .
Neurology
44,
]. G . , Simons, D.G. ( 1 98 3 ) Myofascial Pain and
Dysfunction.
M , R a d anov, B . P . D i Stefano , G . ( 1 995) The e ffect of a c c i d e n t mechanisms a n d in i t i a l fi nd i n g s o n the l o ng- t er m course of whiplash inj u ry. } New-ol. 242:
S t u cLenegger,
443 - 4 4 9 .
Tre lea ve n , ]. , jull, l oske l e tal
L. ( 1 994)
G. , Atkinson,
dysfunction
in
10 Therapeutic Exercise. V i rgi n i a : Reston .
h e a d a c he .
Cephalalgia 1 4 : 2 7 3 - 2 7 9 .
Tro u p , ] . D . G . ( 1 986) B io m echa ni cs o f t h e l u m b a r s p i n a l
Bio m ech. 1 : 31 - 4 3 . Y , Weber, B . R . , Gro b , D. e l
U h l ig,
at.
( 1 995)
w ith dys fu n c ti o n o f the cervical spi n e . } Orthop. 24 0 - 249. A . R. M . , M c Comas , A ,J . ( 1 9 73) The d o u b l e crush in
patients
Res. 1 3 : Upton ,
nerve e n t ra pm e n t s y n d r o m e s . Lancet 2: 3 5 9 - 362 .
M., Trunk
Ve rcautere n ,
( 1 982)
Va n
Ben e d e n ,
a s ymm e t ri e s
M . , Ve rp l a e t se ,
in
school
7: 5 5 5 - 56 2 .
p o p u l a t i o n . Spine
Ve rn o n , H . ( 1 989) Ex p l o ri ng t h e effect of a s p in a l m ;mi pul a tion o n p l asm a beta-e n d o rp h i n levels in no rm a l
men.
Spine 1 4 : 1 27 2 - 1 2 7 3 . Ver n o n ,
H.,
St eim a n ,
r,
H agi n o ,
a n el
Ther:
in
con t raction
Cervicoge n i c
migra i n e : a des c r i pt i ve study } Manipul. Phvsiol.
15:
m uscle
C ( l 99 2 a )
headache
dysfu n ction
4 1 8 - 4 29. 1',
Ve r n o n , H.T., Aker,
A.ra m e n k o , M . et a l . ( l 992b) Evalu
ation of neck m u scle
s t re n gt h with
dynamometer:
a modified sp hygmo and
re liab iliry
va l i d it y.
}
Mcm ipul. Pbysiol. Thel: 1 5 : 3 4 3 - 3 4 9 . B . , Collins, D . , W r i g h t , A . ( 1 994) Sudomotor c hange s ind uced by neura l mobilsation t e c ll.ni qu es in a s ym p to m a t i c subj e c t s. } Manual Manipul. Ther. 2 :
Vicenzino,
66 - 7 4 . Watson , D. , Tro t t ,
P ( 1 993)
Cerv i c a l heaelach e : an i n vestiga
tion of n a tural head post u re a n d u p p e r cervic a l flexor m uscle perfo r m an c e . Cephalalgia 1 3: 2 7 2 - 284 .
White, A.A. ,
M . M . ( 1 990)
Pa nj a b i ,
CliniCClI BiomechaniCS Of
the Spine. P h i l a d e l p h i a : J B . L i p p inc o t t . Wll.it e ,
S.G.,
pai n .
S a h r m a nn ,
a p p roach
In:
SA ( 1 99 4 )
A m ove m e n t system
t o m a n agement of m u s c uloskeletal
Physical Therapy of the Cervical and Thoracic
Spin.e (G ra n t , R . , e d . ) . New Yor k : C h u rc h i l l L ivi n g s to n e , pp. 339- 3 57.
Ciaes,
L . E . et £II. ( 1 995)
of the lumbar s p i n e w i t h d iffe r e n t biomech a n i c a l in
S tabi l i ry i n c rease musc l e grou p s : a
vitro st udy. Spine 20: 1 9 2 - 1 98 . A n i n vivo
W i ll e m s , ] . M . , J u ll , G . A . , Ng, ]. K-F. (1 996)
s tu d y
thoraCic
s p i n e . Clin. Biomech. 1 1 : 3 1 1 - 3 1 6 .
A. ( 1 995) HypoaLgesia
review
of a
p o te n t ia l
Manual Ther. 1 :
po st-ma n i p u l a tive t h e ra p y : a
n e u rophysiologic a l
mech a n i s m .
1 1 - 16.
as
tool to d ocu m e nt
thera p e u t i c
res u lts aSSOCiated
of a p roposed mechanism for t h e relief of s p in a l p a i n with
Electromyogra p h y and
et £II.
R.
B el g i a n
a
tension test: an investiga tion of re s po nse s in normal subj e c ts . At/sl: ) Phys io the l: 37: 1 4 3 - 1 5 2 . Yaxl e y, G . A . , j u l l , G . A . ( 1 993) Adverse t e ns i o n i n the n e u ra l syste m . A p re limin a ry st u dy of te nn i s e lbow. A uSI: } Physiothel: 39: 1 5 - 2 2 Zusman , M . , Edwards, B . , Donaghy, A. ( 1 989) I nvestig a t io n
Mea. Singapore 22: 1 87 - 1 92 . nncl i n gs
Fi ber
com posit i o n and fi ber t ra n sfor m a t i o n s i n neck muscles of
Wrig h t ,
Su ncie rla n d , S. ( 1 978) Nerves and Nerve Injuries, 2 n d c d n . Ed inb u rgh : Churchill Livi ngsto n e . S we e ne y, T , P re n t ice , C . S a a I , J , A . et £II. ( 1 990) Ce rv i c o t h ora cic m u sc u l a r srahil i 7_1 tion tec h n i qu e s . Phys. Mea. Rebabi/', Stale Art. Rel( 4: .� 35 - 3 5 9 . Taylor, J R . . Fi nch, P. ( 1 993) A c u t e in j u r y o f t h e n e c k : a n a to m i cal and p athological basis o f p a i n . A tm. A cad. H . ( 1 9 8 6)
&
Cerv i c a l m u scu·
post-conc ussi o n a l
of t h e p rimar y a n d coupled ro ta t io ns of the
S u l.livan, P E . , Ma rkos , P D. ( 1 987) A n In teg rated Appro a ch
diagnostic
Will i a ms
Tl"igger Po in.t Manual.
Tbe
Wilkins .
W ilk e , H .] . , Wolf, S . ,
688 - 693
Thabe,
9: 1 0 5 - I 1 0 .
Biom ech.
balance
accident
Mea. 2: 53 - 5 8 .
D on a t , ] . et a l . ( 1 994) Effe c t of va rious head and neck pos i t ions on vertebral a r tery fl ow. Clin.
m a n o me ter
slump ' : th e effecrs of a n o ve l m a n u a l thera p y te ch n i q ue
Stokes,
s a c ro il i a c j o i n t s . } Manual
Wa l la ce , K . ,
c a n a l . Clit!.
.
Sjaastad , O. ( 1 992) La t e nl J i ty of p a i n and o t h e r m igra ine
genic
H.,
Travell
Le e , M . ( 1 99:;) A p re li m i na ry inves tiga t i o n of the
re lation ship
and
j o ints Th i e l ,
with somatic dysfu nc t i o n s i n t h e u p p e r cervic a l sp inal
Y:I x l ey, G.A. , J u l l , G . A . ( l 99 l ) A m o d ified u p p e r l i m b
passive
joint
Copyrighted Material
movement. Manual Med. 4: 58 - 6 1 .
I� Contraindications to cervical spine manipulation A. G. ]. Terrett
Figures commonly quoted for serious injury follow
Introduction
ing SMT have been: 1 in several tens of millions of manipulations
1972);
(Maigne,
I
in
10000 000
Head - neck pain and dizziness are symptoms which
(Cyriax, 1978); I in 1000000 (Hosek et at., 1981);
spinal
and 2-3 per milJion (Gutmann,
manipulation
therapy
(SMl)
p ractitio n er s
usually accept as possibly indicating spinal joint and/ or muscle lesions, and therefore they may be indica tions for
same
SMT.
While this is true in many cases, these
symptoms
contraindicate
can
SMT.
indicate
pathologies
1983; Dvorak and
Orelli, 1985). It is to be noted that, as the subject is being better investi g a te d the estimated incidence is ,
increasing.
which
This chapter discusses vertebral
artery dissection (VAD), where the initial symptoms may be head-neck pain and/or dizziness, which may
Case analys is
prompt the patient to consult a pr a ct i tion er.
A rat i o n al e for the prevention of complications
from
1. 2. 3. 4.
SMT
may be based on an under stan din g of:
Examination of cases reveals the following age and
gender
d i s tr ib u ti on
,
practitioner
involved
and
sequelae.
The causes of reported complications from The contraindications to SMT. Diagnostic assessment of patients prior to
SMT.
SMT.
Avoiding certain therapies in patients thought to be at risk.
Age dis tr ibution of pa tients who suffered VBS
5. Avoiding those techniques which are thought to carry the greatest risk.
It has been suggested that 'most risks of this nature
6. Emergency care procedures, should an injury
are expected to be founc! in the elderly' because of
spondylitic
occur.
an d
arteriosclerotic
changes
(Taylor,
1981). Table 12.1 summarizes the age and gender of This study is based upon 185 cases collected from
the cases reviewed. The age distribution graph of
the English, French, German, Scandinavian and Asian
patients who suffered VBS fo.IJowing SMT (Fig. 12.1)
literature, which were reported from 1934 to 1995.
easily dispels the idea that these in j u ries are more
likely to affect the elderly. At first glance, there does appear to be a predilection for
Incidence of vertebrobas ilar s toke following SMT
SMT
accidents in the
30-45-year age group (Ladermann,
1981). Closer
analysis does not reveal any greater risk in any age
range (Terrett and KJeynhans, 1992: Terrett, 1996). The superimposed curve in Figur e 12.1 is
an
The actual incidence of post-SMT vertebrobasilar
analysis of 6187 consecutive patient visits to an
stroke (VBS) is not known, but can be expected to be
practitioner's
higher than the reported incidence.
recorded more than once); the horizontal line
Copyrighted Material
age
SMT
office (many patients are therefore 10%. =
Contra indications to ceruical spine manipulation 193
Table 12.1 Age and
sex
Age (years)
distribution o/people suffering lJertebrobasiiar stroke after spinal mcinipulaUon therapy IV/ale
Cases
Deaths
Cases
Total
Sex unknown
Female
Cas es
Deaths
Deaths
Deaths
Cases
6-10 11-15 16-20
I
2 1-25 26-30 31-35
4 6 18
3
36-40
1S
3
41-45 46-50
12 2
51-55
7
56-60 61-65
1
2
I
2
3 18 28 18 9 6 4
:�
2 6 4 2
I
47 35
9 7
3
24
3
9 11
5
4
5
2
2 2
2
66-70
')
Unknown Total
74
13
2
2
2
1
2
7 24
6
2
5
2
16
5
99
19
12
2
185
34
Th e increased number of accidents reported i n the 30-45·year ag e group appears simply to be a ref l ec tion of the age group m ost lik ely to seek the services of a practitioner of SMT Therefore, factors slIch as a pat ient s age and the . presence or absence of dege n e rati ve osseous or vascular changes do not appear to be important in ·
'
Gender distribution of patients who suffered post-SMT VBS It has been stated that the group most a t risk of VBS
following SMT a re yo u ng females. Of t h e 185 cases r e viewed here, the gender was known in 180 cases,
asseSSing
a patient's risk of ma n ipula tiv e iat rogenesis (T e rrett, 1987c, 1996; Terrett and KJeynhans, 1992).
which revealed:
•
103 fem ales (57.2%), of w h om 17 died (16.5%).
Age of patients who suffered post-SMT VBS
•
77 males (42.8%), of whom 13 died (l6.9%)
Age and g e nd er
known for 162 of the patients. The ag e range for the patien ts was : are
185
The initial impression is that th ere s eems to be a
greater risk for females. Closer examination reveals that thi s does not indicate a female sex predilecti on
,
but simply re f lects the greater n umb e r of female •
•
Males (n = 69): 7-63, with an average of 37.8 years. F em ales (n = 93): 20-68, with an avera ge of 37.1
p ati e n ts seeking SMT Studies have foHoWLng ma le -female patient
years.
1994)
revealed the percentages:
40.7-59.3%; and 44.8- 5 5 . 2% (Chr i sti enseo,
1993,
The age distribution for mortality when a ge and
gender were known was:
Practitioner involved and sequelae •
Males (n = 12): 23 -51, with an average age of 38.0 years.
•
F emale s (11
=
17): 33-60, wit h an averag e ag e of
387 years.
Table 12.2 lists the pra cti tioner involved and the seque.iae. As is to be expect ed the g re a te r number of cases have involved chiropractors, becaus e th ey p e rform most of this typ e of treatm en t In the USA 94% of SMT is p er fo rm ed by chiropractors, 4% by osteopaths and 2% by medical practitio n er s (Sheke IJ e ,
.
The 5 cases of death where age was un known we re
one m a le, two female s, and in two cases the gender was not stated.
and Brook, 1991; ShekeUe et at., 1991).
Copyrighted Material
AnatOlrlj
194
and Mal/{/!:St'ment of Ceruical Spine Pain o o o o o o o
0 0 0
0 0 0 0 0 0 0 0
0 0 0
0 0 0 •
0 0 0
• • • • • • •
0 0 0 0 0 0 0
0 0
0 0 0
0 0
• • •
0 0 0 0 • • •
0 0
0 0 0
•
L,...w
0 0
0 11 -
0 - 10
0 0 0 0 0 • • 21 -
- 20
0 • •
• • • 41
-
0 0 0
0 0 • • • • •
0 0 0
45
-10
51
-
0 0 0
0 0
• 55
1)1
-
56
Fig. 12.1 Age d i s t rib ution of post spinal manipulative thera py (SMD vertebrobasUar distribution of patients ,mending practitioners for SNIT. Open circles post-SNIT circles pI.lSl-SMT VBS who died age
=
Copyrighted Material
65 66
!e)
71 - 75 76
- 85
stroke (VBS) cases comparul to VBS case
who did
not
die; fiLled
Contraindications to cervical spine manipulation 195
Table 12.2
Practitioner
and sequelae of 185 CR
Practitioner
6 4 5 2 2
Chiropractor ChiroprJctic Medical practitioner
Osteopath Physiotherapist
cases of vr:trlebrobasilar stroke
ACR
Ri'lD
U·K
8 6
5 I
7 27
Total Cil
=
Compiete r"covery; ACR
syndrome with rt'Cover),: LIS
=:
=
LIS·R
36 13 7 5 5 2
9
Self Naturopath Wile Barber Kung·fu practitioner Unknown
(1934-1995) LIS
Death
Total
5
13 5 8 3
77 30 25 13 7 5 3
3
22
34
185
10 IS
21
almost complete recovery; U·K
2
80 =
unknown; RND
=
6
residual neurological deficit; LlS·R
=
locked·in
locked-in syndrome/tetraplegia.
Note: One case tn the dearh column had been a cast: of tetrapit:gia,
cat es th at rot ati on is th e singl e most effective m ov em ent p roducing decrease in bl ood fl ow - it applies the gr eat est st ress to t h e VA (deKJeyn a nd Nieuwenhuyse, 1927; deKJeyn and Ve rst e egh, 1 933;
Mechanisms of cerebrovascular
injury Clinical anatomy The ve rtebral artery (VA) courses upwards, enc ased
w i th i n the tran sver se foramina of th e cervi c al v e rt eb· rae. On exi ting the foram en in th e axi s verte b ra, th e VA abandons i ts alm ost vertical cou rse to pass upwa rds a nd l a tera Uy to re ach the f or am en of the atlas tra nsv er se process. Th e VA s are not f reely mova bl e at t he C1 a nd C2 tra nsverse f o ramina, but are rela ti vely fix ed by fib ro us tissue. The VA th en p rocee ds a rou n d the l at er al mass of th e a tl a s, e nters the foramen m a g n u m a nd, at the l ower b or d er of th e p ons, unites wit h th e VA of th e opp osi te side to form the b a sila r art ery. T h e p os te ri or infe rior c e reb ellar arteries (PICAs) le ave the VA s JUSt before they j oi n each oth e r to form the basila r artery. Th e b a sil ar a rt ery passes up th e a nt e ri o r surf ac e of the brai nstem, anel divides t o bec ome th e posterior c erebral art eri e s .
Clinical biomechanics R otati o n of t he cervical sp ine to the extent of 45 500 occurs chiefly at the atlant oax i al j oi n t. This is ab out half of total c ervical spi ne rotation (Sel ecki, 1969). Du ring head rot ati on, becaus e the VA is fixed at th e C 1 and C2 tra nsverse foramina, it is s tretched/ te nsioned, comp ressed and t o rqu ed. Rese a rch in dio -
T a tl ow a n d B amme r, 1 957; T oole and Tucker, 1960; B rown an d T atlow, 1963; Andersson et al., 1 970; B art on a nel Marg olis, 1 975; G ro ssman and D av i e s, 1982; Yang et al., 1985). While cadav er studies (deKJ eyn and Nieuwenhuyse, 1927; deKJey n an d V ersteegh, 1 933;T atl ow a nd B amme r, 1957; To ol e and T u cke r, 1 960; Brown a n d T atlow, 1963) a re imp or· t a nt, early VA compromise is n o t rep roducible in liv e s ubject s (Refsh auge, 1 994; ThIel et al., 1994; H ay nes, 1 996). In a study of 280 VAs Haynes (1996) found th at 5% l o st th e D oppl e r sounds during r ot ati on to th e end rang e; but n one of these developed any signs or symptoms of brainstem i s chaemia. I t is important to note t ha t in no case of l a teral flexion was t h e re any ,
l oss of the D opple r signals (H ayne s, 1996); an d the ca dav e r study of Tool e an d Tu ck e r (1960) also i n d ic a ted that l a teral fl exion pl ace d less stress on th e VAs . This should be considere d whe n a rati onale for th e applicati on of SMT to the upp e r c e rvi c al spine i s dev eloped (Terrett an d KJeynhans, 1992; Ter re tt, 1 996) Du ring normal daily a ct ivi ties the bl ood fl ow in the VAs fluctuat es (Bakay a n d Sweet, 1953), b ut symp· toms do not occu r in h e althy indivi dual s . T herefore, occlu s i o n of one VA does n ot ne cessarily reduce th e arter i al supply t o th e p osteri o r fossa v i a the basilar or p osterio r cerebeUar ar teries. C omp re s si on or sp asm of a VA fr o m C] 2 rotati on will in d uc e sympt oms o nly if fl ow i n th e c o nt ral ate ra l VA is already c ompr omise d .
Copyrighted Material
-
Clinical Ana/omy and Management
Table 12.3
Cervical Spine
Non·spinal manupulalive therapy vascular
accidents associated with head rotation and/or extension
Ciliidbirth (yates, 1 1963;
smgr[on or anaesllWliS[ [luTing surgery flsh(:r, 199'1; Nosall el Callisthenics
til., [99'1; Tettenborn
el ai., J99,,)
(Na gler, 1973) al. 1977) (OkaWaf'd and Nibblelink, 1974) during radiography (Fogelholm and
Yo ga (Nagler, 1973; Hanus et Overhead work Neck extension
exten sion for
:I
nose (Fog<:lilolnl
driving a vehicle Sherman et ai, 198 I. Yang
Karli,
and
the head wlnle
Sherman, 1977;
Karli,
et al., 1985)
Archery (Sorenson, 1978) Wrestling
(Ro gers and Sweeney, 1979)
Emergency resuscitation (Saternus and Fuchs, (982) gazing (Barty, position
1983)
Swimming (Tramo dancing (Dorev
Mavne.
1986)
filness exercise (pry"e·Phillips, 1989) Beauty parlour stroke (Weintraub,
Tai chi (Oh,
Fig. 12.2 Str e t c h, torque and compression applied to the vertebral artery between the atlas and axis vertebrae with
1992. 1993)
J 993)
cont r a latera l rotation.
Normally, during
head movement:;. occlusion
compressioll
not producc
the Cl
carotid artery
sufficient
been reponed. Only 5.
process
decrease in f low to produce ischaemic signs and
cases of internal carotid artery injury associated with
symptoms, or the development of infarction. In most
SMT have been reported (Lyness and Wagman, 1974;
cases the development of infarction indicates an
Beatty, 1977; Murthy and Naidu, 1988; Braune et aI.,
underlying arteriopathic process, other than brief
1991; Peters et al., 1995).
occlusion. !lumber of cases where sus·
have been or repetiri\(:
normal
pOSition
Arterial wall
actiVities has produced brainstem isci1aemic acci· dents in the absence of SMT (Table 12.3). Functional
The mechanism of injury to the nervous system from
tests may have screened out some, but could have
a vertebrobasilar accident is brainstem ischaemia,
precipitated VES in others. These cases would no
which may be due to:
doubt have been high risk had they been treated by and even though the
outcome
been
Tra II ma to the
most likelv
have
vasospasm. Trallma to the
wall prodllclIlg II·ansient wall producing d:muge to
the arterial wall.
Injury
sites
There have been cases ofVES followi.ng SMT which were subsequently examined
to the VA.,
sonography
their
injury could
by stretching, postulate
sites
cervical
can
is believed
by angiograms,
(Terrett,
these
trlll1sient arteri;iI for
be
and
which no eyiciencc of vas·
the
may
neurological
compressed or injured by spinal movement (ferrett
sequelae.
and Kleynhans, 1992; Terrett, 1996). Rotation applies
found, the onset of symptoms is often immediate -
the greatest stress to the arterial structures in the
too quick for clotting to have occurred, and this most
upper cervical spine. The most reported site of post·
likely indicates spasm. Spasm would he particularly
damage processes,
where
hClwcen Cl and
transverse
are relativelv
tixed
Even in cases where arterial damage is
delclnious in the
at
and C2
Copyrighted Material
of hypopla�l;l
arterio·
the contral:lteral VA, or if the CCHHI�llateral
Copyrighted Material
198 Clinical Anatomy and Management of Cervical Spine Pain
Intima
Media
Advenlitia
I ,
I
j
I
Intimal tear Subintimal haematoma
/
Thrombus
I
�
.. \
\
Direction
Direction
of flow
of flow
B
A Intimal tear
Subintimal haematoma
with embolic formation
with dissecting aneurysm
Thrombus
\
Embolus
!
t. � :z
\
Direction
Direction
of flow
of flow
c
o Occlusion of PICA
a
by di st l propagation of dissecting aneurysm Rupture of a dissecting aneurysm through the intima
Pseudoaneurysm
\\
( Direction
Direction
of flow
of flow
E
F
False saccular aneurysm
\
\ \
Direction
G
of flow
Fig. 12.3 (A) Subintimal haemaroma; (B) intimal tear; (C) intimal tear with e m b ol i c formation; (D) subintimal haem<1toma with dissecting aneurysm; (E) r u p tu re of <1 dissecting aneurysm through the intima; (F) occlusion of posterior inferior cerebellar artery (PICA) by distal propagation of dissecting aneurysm; (G) false saccular aneurysm, Frol11'rerreu (1997) with permission,
Copyrighted Material
Contraindications to cervical spine manipulation 199
Post-SMT stroke syndromes centr� I
Post-SMT usually
nervous
conforms
to
system
one
of
injury
the
(stroke)
following
=
syn
Presenting
dromes:
I. Wallenberg
(dorsolateral
medullary
or
retro
olivary) syndrome (occlusion of the PICA). The acute
Table 12.4 Major presenting complaint aIpatients who subsequ.ently had a spinal manipulative tberapy-induced vertebrobasilar stroke (n 137)
signs
within
and
several
sy mptoms
weeks.
usually
Most
disappear
patients
have
a
significant degree of recovery, but often experi ence residual neurological deficits.
2. Locked-in syndrome (cerebromedullospinal dis connection, occlusion of the basilar artery). Most patients with locked-in syndrome die early in the course of the disease. The survivors usually remain in a chronic locked-in state, as the medullary vital centres
automatically
maintain
complaint
Percentage
Neck pain and/or stiffness Neck pain/stiffness and headache
47.4 197 16.8 58 2.2
Headache Torticollis Low
b;lCk
pain
2.2
Abdominal complaint
1.5 1.5 1.5 0.7 0.7
Scoliosis/kyphoscoliosis
Head cold/cold in the Upper thoracic pain Upper-limb nLunbness H"yfever
head
and
respiratory
cardiovascular function, although a few cases of substantial recovery have been reported (Khurana
et aI., 1980; McCusker et al., 1982; Carmody et al., 1987; Povlsen et al., 1987; Bell v. Griffiths, 1994)
_
3. Other brainstem syndromes.
Patients with verrebrobasilar TlAs may have many attacks before they suffer a VBS (Weiner,
1981).
Symptoms due to VA compromise (five Ds And 3 Ns) should alert the practitioner not to manipulate the neck, and that the patient may require immediate
4. OCCipital lobe injury.
medical referral (Weiner, 1981). If the patient suffers
5. Cerebellar injury.
from carotid TlAs, medical referral is inlperative as
6. Thalamus injmy.
patients may suffer a complete stroke after only a few episodes
Patient
-
10% in the first 6 months, then 6% in 1
year (Weiner, 1981). Signs and symptoms of carotid
history
artery ischaemia include:
Tables h�ve been produced which attempt to identify
pre-existing pathological and/or altered ph}'siological risk factors of VBS if SMT is proceeded with (George
aI., 1981; Terrett, 1983; KJeynhans and Terrett, J 985; Henderson and Cassidy, 1988). It is now
et
apparent that very few of the factors, either alone or
J. Hemianaesthesia. 2. Hemiparesis or monoparesis. 3. Headache. 4. Dysphasia. 5. Visual field disturbance.
6. Confusion.
in combination, specifica.lly increase the susceptibil
ity to post-SMT VBS. Different facets of the history will be reviewed.
Bruits If, ciuring review of symptoms, a patient states that an audible bnJit has recently developed (which may be
Presenting complaint
associated with symptoms such as headache and
T he presenting complaint of patients who suffered VBS after SMT was given in 137 (74'){,) cases (Table
12.4). It can be seen that there is little that could alert
neck pain), the patient should not be manipulated, as this may indicate signs of an impending spontaneous dissecting aneurysm (Mas et aI., 1985, ] 987).
the astute practitioner of an impending VBS, as most patients were young healthy individuals, suffering from musculoskeletal complaints such as head and/or neck and/or shoulder pain, without any predisposing VBS risk factors.
Contraceptives Several authors have listed oral contraceptives as a potential risk factor. VBS following SMT in women taking oral contraceptives has been reported in only 4
Transient ischaemic attacks (TIAs)
cases (MueUer and Sai1s,
] 976; Ladermann, 1981;
Brownson et aI., 1986; Peters et al., 1995), indicating When it review of systems reveals transient ischaemic
most likely no causal relationship. Also noted is that
symptoms,
only
it strongly
suggests
the
necessity
medical referral and for the exclusion of SMT.
for
one
smoker.
Copyrighted Material
of
these
women
was
reported
as
a
Cervical
Managernen!
Clinical Anatom,
Women taking oral contraceptives are at a greater
tIle number of women who present to SMT practi
risk of vertebrobasilar thrombosis than those not
tioners offices after childbirth complaining
taking contraceptives (Bickerstaff, 1975) However,
pain, this would not appear to indicate any causal
source of emholi (Ask-Upmark COlli raceptive
pill
fmm the
these cases
Bickerstaff, 1976\ faking the not appear
predispose
headaches
such patients to any grearer risk of post-SMTV13S.
Strokes in migraine patients are rare, but can occur,
Cigarette smoking and atherosclerosis patients with
stroke risk
hvpertension, hyperlipidaemia, heart mellitus, decrease
and are usually in the posterior cerebral artery (distal branches of the VAs; Broderick anel Swanson. 1987;
in cerebral
smoking blood
f low
(Rogers
et at.,
1983). A review of the 185 cases reveals that 1 1 patients were recorded as smokers: Females - seven
have melllimltd that a
migraine
important. precipitating
some cases posl-SMT V13S (Zimmermann et ai., 1978; Anonymous, 19150; Krueger and Okazaki, 1980; Solomon and Spaccavento, I ')82; Carmody et at., 1987; Mas et at., 1987; Cashley, 1993). Migraines are a stroke risk factor in young adults (Spaccavento
1.981;
Males - four cases (33-55 years), ..ver.. ge .. ge 42 years.
Only one patient smoked over the age of 45 years. chronic
the
Solomon
spasm in
(29-4 1 years). average age
(Zimmermann
years. •
1990). Several
hccn shown
and
Spaccavento,
1982),
patients may exacerbate
1978), ami migraneurs ltypercoaguJ8
(Dlliessio,
1978). W hile no definite predisposition can be demonstrated in migraneurs, it would appear to be unwise to stress or irritate theVAs during a migraine attack, when arteries are in an irritable state,
risk T he most important V13S risk factors to identify in the history are:
Osteoarthritis OSIC()�lrlhritis does SMT. If it
Sudden severe pain in the side of the head and or appear to increasc
that:
would be
1. The older age group would be at a significantly greater risk,
2
wh.ich
risk of
which they are not (Terrett and
from any pain
patient
had before. Dizziness, unstelldincss, giddiness,
Sudden severe head and/or neck pain
KJeynhans, 1992; Terrett, 1996).
Many SMT practitioners are not aware that the earliest
Osteoarthritic compromise of the vertehral artery
symptom of VAD (with or without SMT) is usuaUy
would be most
spinal
occur at
a5
head and/or from any minutes, hour�.
or even
J{adiographs of elderly patients with a diagnosis of
the onset of neurological dysfunction. Mokri et al.
VBI secondary to cervical spondylosis, when com
( 1988) found the initial manifestation of VAD (not associated with SMT ) was head pain in 60% of cases, vertigo and oscillopsia in 20%, and focal neurological in 20%. Sturltlnq.',ger ( 1994) found headache prominent syrnptom in 869, et al. ( 199'1) Indicated that the toreheacl/check [0 the produce pain
pared to age- and gender-marched controls (Adams et
at., 1986), failed to demonstrate any difference in the of radiograpbic changes. It radiographs 01 only confirming nnnnuln.'"
concluded
cervical spine
little
high incidence
in the
occiput/neck, and to the upper trapeZius region. Report of this distinct type of pain, although non
Postpartum
specific as an isolated symptom, should raise slispi cion of the possibility of an underlying VAD. As long
four of the
being
postpartum (Masson
et at.,
Modde, 19H5,
Considering
symptoms
Copyrighted Material
of
lind/or neck diagnosed
ischaemill to VAD
absent, be
Contraindications to cervical sp ine manipulation 201
While the majority of cases of head and/or neck
Jepson, 1963; Wing and Hargrave-Wilson, 1974; Cote
pains are major indications for SMT, in some circum
et at.,
stances
causes of dizziness have to be kept in mind, and a
the
same
symptom
which
prompts
the
1991; Fitz-Ritson, 1991) but other possible
patient to seek care may be due to VAD, which is a
differential diagnosis should be made (Giles, 1977).
major contraindication to SMT The problem for the
The problem for the practitioner is:
practitioner is that often the head and/or neck pain due to VAD cannot be differentiated from a mus culoskeletal region. This is a dilemma for the prac titioner,
as
severe
head
and/or
neck
pain
of
a
musculoskeletal origin (without signs of brainstem ischaemia)
which
wilJ
respond
to
SMT
is
very
common, whereas VAD is uncommon. The incidence of VAD has been reported to be only about 1-6 patients per year in a large hospital (Hart and Easton, 1985; Biller et at., 1 986 ; Mas et at., 1987; Mokri et at., 1988; Sturzenegger, 1994,). To complicate the problem further, VAD may be totally asymptomatic. One study found three patients with asymptomatic VAD while investigating other suspected lesions (Mokri et at., 1988). These silent VADs appear to occur predominantly in cases of multiple dissections of cervical arteries (Hart and Easton, 1983; Chiras et at., 1985; Mas etat., 1987). This finding raises the possibility of an as yet unknown underlying arteriopathy which predisposes to vessel dissection. Evidence of fibromuscular dysplasia has been found in 23% and 33% of patients in two studies (Hart and Ea ston, 1983; Mas et at., 1987).
A review of 27 cases of non-SMT VAD (where central nervous system dysfunction was not one of the earliest signs) revealed that the delay in the onset of central nervous system dysfunction after the onset of headache or neck pain was: •
30% after less than 1 day.
• •
15% 1, 2 or 3 days later. 30% 1- 2 weeks later,
•
25% 3 weeks or more.
1. Dizziness is usualiy the prominent symptom of
VBI, and often unaccompanied by any of the other signs and/or symptoms. 2. There is no simple method available to the SMT practitioner to determine whether the dizziness is due to VBJ (contraindication to SMD or whether it is due to a disturbance of artic ular and/or muscle proprioceptive input (an indicat i on for
SMD.
Many cases have been reported where SMT was proceeded with in a dizzy patient, with disastrous results (Terrett, 1990a, 1996; Terrett and Kle ynhans, 1992). In these cases, the practitioner may have had no effect, or may h a ve aggravated existing VA pathology, resulting in VA damage, but is blamed as having caused the VBS. Because available assessment methods do not enable
SMT
practitioners
to
be
absolutely
sure
whether or not the symptom of dizziness/giddiness/ unsteadiness/vertigo (or even head/neck pain) that the patient is suffering from is due to arterial wall p athology or not, in such patients it is recommended that treatment methods which excessively stress the
VA walls not be used. It is suggested that SMT should be modified, or other forms of therapy used (soft tissue therapy, accessory joint play movements, heat, ice, physiological therapeutics, etc.). If, after one or two treatment sessions, the dizziness decreases, then this most liI<ely indicates that VBI was not the cause, and that normal SMT methods ca.n then be used. One case is presented here to i liustf".Jte a not uncommon scenario, where dizziness in the history should alert the practitioner to modify or alter treatment.
These findings suggest that many cases of VAD attribured to SMT practitioners may have existed prior to treatment, and may have been the cause of the symptoms w h i ch prompted the patient to seek care (or they may have been silent). Therefore, the practitioner who was bla m e d for the arterial and neurological damage may not have had any effect on the course of the disease process, or at worst may have hastened the inevitable. Because these scenarios are possible, it is suggested that teclmiques which excessively stress the VAs should not be used on any
A 31-year-old female consulted a medical practi tioner, suffe ring signs of a TIA (nausea, head ache, vertigo, slurred speech, ataxia of gait). The practitioner recognized the nature of the
TlA
attack
and
referred
the
patient
to
a
neurologist for a lumbar puncture. However, the practitioner did not recognize the TlA as a contraindication to cervical
SMT
and manipu
lated the cervical spine. Immediately following cervical SMT the patient had a VBS, due to dissection blocked,
of left
both VAs
(right
artery
artery
80%
blocked).
intensive
care,
the
100%
After
2
patient.
weeks
Dizziness, unsteadiness, vertigo, giddiness
neurological defiCit, and impairment to higher
in
improved,
The signs of VBI (five Ds And three Ns) should be known to all SMT practitioners.
but
was left
with
patient a
then
permanent
level thinking (p revi ously a gifted screenwriter, now a fLle clerk; Saltzberg v. Hawkins 1991).
Observant SMT practitioners would be aware that
This scenariO, of brainstem signs and/or symp
patients suffering fi·om dizziness often respond dra
toms which should have alerted the practitioner,
matically following upper cervical SMT (Davis, 1953;
may be much more common than the
Copyrighted Material
literature
.!02 Clin ical .A natomy s u ggests , a u t h or s
but
b e c a u s e the re ports a re written by
m o re
mortem,
Management of Cervical Spine
interested
reson a nce
the
n e u rology,
computed
� n g i ogra p h i c ,
In agnetic
in
i m a g ing
l i kely this i m portant
p ost
t o m ogra p h i c
scao
or
findings,
for SMT p ra c t i t i o n e r s
n o t c o m m e nted u po n .
o f VB\, D i z z i n ess i s t h e most common symp tom of VBI, and may be u na c c o m pa n ied by any other sy mptoms o r signs: the refore t h e a b sence of other bra i l Nc m signs a n d/or sY fll j)[i )ms does
a lways
ex c !tJ d c t h e po.ssi h i l i ty of a \',lSC l l i a r ca w,(
When
posi tive ,
these
tests
only
i n d icate
that
rotati o n h a s possibly p ro d u c e d brainstem i s c h aem i a , p o ssi h ly due to c o m p re s s i o n o f one VA . 3 n d i n a cl e oppos i te ancry HO'VI/C\'cc when
qume pa tency
Patient examination
sign s rmd symp[oln� are p rese n t , t h e re i s
to t he
p a t i e n t , so fu r t h e r eva l u a t i o n is i n d i c a ted a n d m a n ip· T h re e m a j o r tests h ave been described a s b e i n g a bl e to d e t e c t those p a t i e n t s a t r i s k of VBS following SMT.
u l a t i o n sho u l d not be perfo r m e d . There a re fo u r m a j o r prohlems with th e�e p ro-
Tiley a re
ced u res a s a pne'(l i C i O r o f Yll"
1 . B l o o d pressure measure m e n t .
1. E v e n if you have
2 . N e c k a u s c u l t a ti on .
:1
a
SMT:
nega t i ve t e s t re su l t , Vl3S m a y s t i l l
o c c u r beca use these tests rep roduce s o m e o f t h e s t resses of S M T o n the oss("o u s - a rt i c ll b r - mlls-
F u n c t i o n a l vascu l a r tests .
c u lo - l i g a m e n t o u s - vascu l a r stru c t u res, o f t h ru st
p re d i c t t h e
Blood pressure measurement
cannot
which
fu r t h e r
s t re tc h t h e VA , a n d d a m age t h e vesse l w a l l (Fig.
1 2 . 3) Bolton et at ( 1 989) d e m o n s t rated the l i m ited
Review o f cases r e ve a l s t h a t t h e vi c t i m s a re u s ua lly you n g , a n d r h ne is no c o n S i s te n tl y l()lI n d h y p e r· ta king
hypo tens i o n . T h e re fo rc .
o f these tqtSo-·l n_ tI P:l[lcnt i n
d i agn ostic
blood press u re
to i d e ntity ;lny VA
tests
the
d o e s n o t a p p e a r to be p a r t i c u larly usefu l in d e term in
problem,
i n g any i nc reased r i s k o f VB S fo l lowi n g S M T.
graphy reve a l e d o c c l u s i o n of o n e VA .
subsequent
d igita l
s u b t raction
a n gio
H;lynes ( 1 996) in a s t u dy of 280 VAs fo u n d tlut
(5%)
I
Neck auscultation
ve l o p ed Review of cases of p o s t-SMT Vl3S revea l s t h a t t h e n e c k l !lese was
b ru i t
1. 0 we re'
firm e d by a ngiogra p h y a o d one was c o nfirmed a t postmorte m . O n e case invo lved c a rotid a r t e ry d a m age (Murthy a n d N a i d u
,
gra p h y a n d s u rgic al was h e a rd
1 988) w i t h p o s i t i ve arterioand y e t
c a rotid
signs
none or
t h ese
symptoms
deof b ra in s t e m
A n egat ive test resu l t c a n n o t be i nterpreted to t h a t t h e rc no a rteriopathic process in the T h e refo re , t h ese tests a p p e a r to b,' i n adequate
Seventeen
cases invo l ved VA d a ma ge . o f w h i c h
a ny
hut
ischa e m i a .
wa s a u s c u l t a t e d for b r u i t s i n 1 8 c a s e s (Te rrett, 1 996) .
none
Doppl e r sollncl stopped d u ring
rot a t i o n ,
in all b u t the m o s t grossly p a t h o logical o r h ighly susce p t i b l e cases. T h e re have been at l e a s t two cases wh e re
patie n ts s u ffe red VA
t ra u m a a fte r
I1cg,lIive test resu l ts (Pa r k i n et at.,
Lindy,
n e c k a u sc u l [ a t i o n .
A s t h e re were n o a r te r i a l b ru i ts d e tected a ft e r t h e
2 . .lhere is a p ro b l e m of fa l se-pos i t i ve tests (Terrett,
a rt e r i al d a mage, i t wo u l d b e h igh ly u nli k e l y t h a t a b ru i t
1 983), as ve rtigo and nystagmus of cervical o r i gi n
wou le! h a ve b e e n d e tected p r i o r t o S MT. Therc to re , i t
(jo i n t a n d/or m uscle) a re well-d o c u m e n t e d , w i t h
the
a u t h o r'S
o p in i o n
lIstening
p ressure,
that
the
b r ui ts ,
t a k i ng of
t h e o r i e s being r["l a t e d to
s t im u l ;l l i o n o f c e r-
s y m p a t h e t i c s o r t o cerv i c a l muscle . md j o i n t
p rac t i t i o n e rs
at. ,
1 9 5"1 ; G ray, 1 9 56; de jong,
i n to a fal se sense of secu rity t h a t t h e y a r e d oing a
r e c e p t o r s ( G a y r a l et
releva n t vertebroba s il a r sc re e n i n g exa mi n a t i o n .
1 977; Liedgren a n d O d kvist, 1 979; Maeda , 1 979: Hulse,
1 98 3 ; Thi e l et ai. ,
d i z z i ness c a n
Functional vascu lar tests
1 994)
This
type
of
ex pected 1 0 respond well to
The a u th o r h a s often expe r i e n ced cases where There a re at l e as t fo u r vari a t i o n s o f the VA p a tency
testing befo re SMT produced d i zz i n ess , b u t t h e
tests (H o u l e , 1 97 2 ; KJeyn h a n s , 1 980; Geo rge et al. ,
di zziness c o uld n o r be re produced after soft-tissue
98 1 ; Te rreH a nd We b b , 1 98 2 ; Te rrett, 1 98 3 ; 1 988; H e n d e r s o n a n d
t.:assidy,
1
In
aU.
t h e [�lpy a n d
p a t i e n t ' s h e a t! i s h e l d fo r 3 0 s i n t h e prem a n i p u J a t i ve position
(e . g .
rota t i o n ,
rotation
with
exten s i o n )
S M T, i nd ic l t i n g vcrt.e hroge n i c
d iZi i n e s s .
Ihi e l et al. ( l 994) h a d a n experi m e n t a l gro u p o f
1 2 s u bj e c ts w h o h a d p o s i t i ve fu n c t i o n a l ve rtebro
b e fo re SMT, a n el t h e p a tie n t i s o b s e rved for a ny s i g n s ,
b a s i l a r teslS a nd a
'illch a s nystag m u s , a n d
n:irl l c d s y m p l O m s d u r i n g ce rr:l i n p o s l f i o m o f the
t o rep o r t a ny sym p t o m s
Copyrighted Material
h i s t ory of d i zziness a nd/or
Con traindications to cerv ical sp ine
manipulation 203
head and ne c k . U s i ng d u plex Dopp ler u l t ra s ou n d ,
Rega rcting tra c t i o n , some have con s i de red t h a t t h i s
dec re a se in VA blood flow was de tec t e d i n
make s rotation S M T safer. This belief is n o t s uppo r ted
no
t h e s e p at ie n ts (or i n the 30 s U b jec t s in t h e contro l group) d u ring t h e fu nc t i o n a l v a sc u la r te s t position . 3 . There is no ev i d en ce to suggest t h a t these tests, w h e n pos i ti ve ,
indicate any u n d e rlying arterio
p a t hy or al tered a n atomy which wo u l d p red i spos e to arte r i a l wa l l dam age and YES if SMT were proce e ded with.
4. There have been cases where merely p l a c ing the h ead i nto the rota ted p osi t i on has in d u ced a stro ke (Roche et aI. ,
1 96 3 ; G a tterm a n ,
mend el aI., 1 98 4 ; see Ta ble
1 2 . 2) .
1 98 2 ; Danesh
by
study
one
extension
and
of
41
cadavers
ro ta tio n
(82 VAs),
occluded
five
w he re
(6%) VAs ;
w h e n tra c ti on w a s the n added , another 2 7 c o m plete
3 2 or 39%); all occurre d above C2 level (Br own a n d Tatlow, 1 963).
occlusions occ u rre d (n =
Continued treatment of a patient after signs of arterial damage have become evident h a s b ee n docume n ted (Te r rett , 1 987b, 1 990 b , 1 996; Te r re t t and Kleyn h a n s , 1 992) t ha t many cases of YES after SMT could have bee n avoided h a d t h e It
Wh i l e w e h ave to a d m i t th ese i n a d e quacies , i t i s still considered th a t wh e n a po s i tive res u l t i s f ou nd ,
prac t itione r understood t h a t t h e symp t om s post-SMT
caution is prude nt.
were d ue to arterial trauma, an d that fu rther tra u m a
Risk
to an a r te ry already u n d ergoing patholog ic a l cha nge can o nly be expected t o aggravate t h e conditio n . The s i gns of VA damage c a n p rese n t in o n e o f three
reduction
ways :
There a p pe a r to be two major p robl ems o c c u rring with S M T assoc i a te d with V13 S , which are:
Ns) .
1 . Rota t i o n a l SMT 2. C on t i n u i ng to tre a t a person with SMT after signs and/or s y m p to m s of a rter i a l d a m age have be come evident. C h a nge s i n SMT tech nique c a n e asily be m a d e so a s t o minimize th e
the
r i sk s of SMT
Rotational SMT Of the 1 8 5 cases, the method of SMT was described
i n 7 6 cases (4 1 %), which reveals that ro ta tio n was lIsed in 6 5 . 8% of cases, ro t a tio n with ex te n s ion , flexion and/or tra c t i on was u sed in 29%, a n d toggle
rec o il repeated three t i m es was used i n 1 . 3% . Tra c t i on
:') .9%. In
1 . S u d d e n onset of severe head a n d/or neck p a i n. 2 . Vertebrobasilar i sch a e m i a (the five Ds A nd three
3 . Both t h e a bove occ urring togethe r. As alrea d y d esc r ibe d , t b e earliest sign of d a m age to the VA w a l l is often head a nd/o r neck p a in . I f head and/or neck pain occurs fo llowing upper cervical
SMT, th e practitioner s h o u l d n o t rema n i p ulate the neck in the mista ken b e l i e f that the first treatment was not d one co rrectly. Those patients in whom head p a in ( us u a l ly occ i p it a l) and/or neck p a i n began d u ring SMT usu al ly describe t h e pain a s : 1 . I nunediate, sudde n , d uring SMT. 2 . Distinctly different from p a ins previou sly suf fe red .
3 . S h a rp d isc o mfo rt , excru c ia t i n g , intense, vio l e n t , severe .
witho u t other moveme n t s ,
If p a in o cc ur s w i t h o u t the signs of i sc h a em ia , it is d ifficult for the p rac titio ner to know whether it is a
ment.
j o in t and/or muscle pain rea c tion to the SMT, but the
was lIsed in
94 . 8% of c ases rota ti o n , w i t h o r was u sed in th e treat
That ro tation is the ce rvi c a l movemen t most like ly to d a m age the VA wal l is su p po rte d by rev iew of five
so urc es :
author s u ggests that SMT should not be re p e a ted in
c ase the p a in i s d u e to VAD. Sy mpto m s after cervical SMT, such as fa i n t i ng a n d n a u se a ,
1 . Haemodyn a mic stud ies i n cad avers . 2 . H a e m o d yna m ic s tu d i e s in Live s u bjects. 3. The me c h a n i s m invol ved in non-SMT VA da ma ge i s us u a lly n e c k rota t i o n , o r ro ta t i o n w i th exte n sion . 4. Post-S MT a ngiogra phy consistently reve als the VA d a mage to be be twe en C 1 and C2 bec a u se rota tion compresses and stretches the VA most at this leve l .
5 . Po s t-S M T YES autopsy in ves tigat i o n s co nsisten tl y re vea l the VA damage to be b e twee n C l - 2 .
have b e e n ca lled by Maigne ( 1 972) sym
pat he tic storms . Several a u t hors have pos tula te d that irri ta ti o n of t h e cervical sympathetic n erves may cause
spasm
of
branches
the
verte brobasilar
(Neuwirt h ,
Maigne , 1 97 2 ; Jackso n ,
1 95 5 ;
a rte r ies
and
Stewart,
the ir
1 96 2 ;
1 977) . Al th o ugh this is a n
attractive theory fo r various head ,
chest an d arm
symptoms, it needs to be s u p port e d by re s e a rc h .
A study of the neural c o n t ro l of VA blood flow fou n d n o evidence to support t h e c o n te n t io n that cervi c a l les i o n s could affe c t hind-bra i n blood flow
Copyrighted Material
(B ogd u k e t
204 Clinical A natomy and Ma nagement of Cervical Spine Pain al. , 1 98 1 ) . VA bl o o d fl ow was fou n d to be p rofou n d ly
conti n u i ng to retra u matize an artery a l rea d y u n d e r
un res p o nsi ve to stimulation of any component of the
go i n g p a tho logica l cha nge .
cervical s y m p at h et ic system and i t w a s concluded t h a t
may recover.
the
t h e o ry t h a t irri tation of cervi c a l sy m path e tic
nerves can alter VA blood flow i s u n tenable . The re for e
,
Left a l o n e , th e pa t ie nt C o nti n u i ng to treat the patient may
resul t in death, tetraplegia or permanent n e u ro l o gi c a l
d e fic i t .
practitio ners sh o u ld be c a refu l before asc ri b i ng post SMT reactions to s ymp a t he t ic storms, a n d be a wa re
that th e y m o st like ly indicate either alteration of up p er
cervical p ro p rio c e p t i ve inpu t or, more d a n ge ro u sly,
bra i nstem ischa emia in duced by VA tra u m a (Terrett,
Emergency care
1 990a , 1 99 6 ; Te rrett and Kl ey nha ns 1 992).
A p ra c t i tioner m a y s t i l l be u n fo rtu n a te e no ugh to
us ually the pro m i nen t symptom in b o th cases a n d , i n
even after all p rec au t io ns have been tak e n .
,
The problem for the pract i ti on e r i s that dizziness is
the absence of other signs of isc h a e mi a
i t is not
,
h a v e a pa t i e n t d e velop signs of bra i n stem ischaem ia
I f po s t SMT VBI s i g ns o c c u r (Terrett, 1 987b, 1 990a , -
p o s si bl e t o d et e rmine t h e c ause . T h e s e p a t i e n ts may
1 996 ; Terrett a nd Kleynha n s , 1 992):
e ffe c t
1 . Do not rerncmiputate tbe patie n t 's neck. There is n o t h ing to gai n from retra u m atizing a n a rtery u n d ergo ing pathological c h a n ge , a n d it may in fact resu l t in fu rth er arterial damage and d i saster. 2. Observe tbe patient. The s y m ptom s may re s o lve within a s hor t t im e , in d i ca ti ng either transient VBl , possi bly d u e to sp a s m o r proprioceptive
subsequen tly res p o n d well to SMT and s uffe r no ill
as d izziness usu a lly res p o n ds we l l to SMT
,
(D av i s ,
1 963 ; Wing a n d Hargrave Wilso n , 1 974 ; C o te et at. , 1 99 1 ; FitzRitso n , 1 99 1 ) . However, i t i s sugg e ste d that in su ch cases, because 1 9 5 3 ; Jepso n ,
of t h e p oss i bil i ty of serious d a m age, i t wo uld be irresp on s i b l e to pro c e e d wi th rotation t h rust SMT
t e c hniqu e s , which are the most l i kely t o stress the VA wa ll . I t seems t o b e conrting po s si b l e d i saster, as th e re are n o dia mine w llll t er tho are
di zz i n ss
�
1( s
-ill!.. e
ic methQds av a i l a ble to_octJ -
s mpt om s of pos t-SMT pain or
cervi it
�
p ro p oc e Q ti ve
or
·
.
system sti� r t o VAn. In tnese pa ti e n t s other fo r m o f therap to, tbe.. up_p�r cervical
symp
spine shouJa be u
.:.-
,
d i zziness.
3. Refer tbe patient. I f the sy mp t o m s d o not s u b s ide do
not
pani C
and
re m a n i p u l ate
the
,
pat i en t s '
neck.
If the p a tient'S sym p to m s p rogress and do not
abate, he or she n eed s to be hosp italized . The prac ti tioner's assistance in describing what
To ill ustrate t ha t to continue m a n ip u l a ti o n of the
neck after the onset of signs of b ra i n s t e m ischaemia is
happened may be he lpful i n i ns t i t u tin g the correct th e ra py qu i c kly.
irresp o nsi bl e the fo l lo wi ng c a s e is p rese n te d as a n o t ,
uncommon scenario. (For other c as e s
,
see Terre tt
,
1 990a , b , 1 996; Te r r et t and Kl e y nh a n s , 1 99 2 . )
C onclusion
A p r e vi o u s l y hea l t hy 3 1 -ye ar o l d male u nd e r -
we n t a c e rvical man ip ula t io n from a m e d i c a l p rac t i t i o ne r fo r a
h ea d ach e
and
stiff neck,
which h e h ad developed after p l a y ing te n n i s . Two
hours
after
the
fi rst
ma n ip u la ti o n
he
Several authol-s have mentioned that patients with
signs a nd/ o r symptoms of VBI c a n re sp o nd be n e fi
c ia lly fo l l owin g SMT. T h e author agrees that many
cere b ra l and crani a l nerve·type signs and/or sy m p
returned to the p ractiti on e r wh o i n j e c te d h i m
t o m s ca n res p o nd to SMT (Te rre t t 1 984 , 1 988, 1989 ,
i n t ravenou sly with Va liu m a n d manipu l a ted his
1 993 , 1 99 4 , 1 995), but rea ders should appreciate that
neck again . He b e c a m e d i s o riented and did n o t rega in
fu ll
consciousness.
Th e
p ra c ti t i o n e r
again m a n i p u la t e d his neck a b o ut 2 1; h l a te r
,
when
the
p at i e n t
gave
a
large
groan
and
d eve l op e d p ins an d need les in t h e arms an d
,
a p a tie n t whose sym ptoms are due to VAD, a nd
thrombus fo rmatio n , is no t l i k e ly to respond benefi cial ly to SMT. This is s ue
has been confuse d by some wri t i ng
a b o u t tra nsient ro tational occlusion p roducing t ra n
l e g s His a rms an d l e gs went stiff, he went i nt o
sient
spasm,
preve n te d here is t ra u m a t o arterial structures re sult
.
the rig h t side of h i s face and shoulder clroppe d . He later vo mite d . An a m bu lance
and
was
called ,
and
he was admitted
to
ho sp i t a l 4 h after th e s e con d c e rvi c a l m a nipu l a
brainstem
symptoms . Wh at
ing i n in tra m u ral h a e m o rrha ge s
,
is
tr ying
to
be
lacerations, dissec
tions, aneurysms , th ro mbus a nd e m bolus formation
wi t h resu l t a n t central n e rvous sy ste m d a m a g e ' not
tio n . His c o n d i ti o n d e teriorated a n d he suffered
epi s od es of t ra nsient isc ha e m i a
3 d a y s later (Te r re tt 1 987a, 1 996) .
warning s i gn s in the re vi e w of syste m s and h isto r y,
bra i n death. R es p i ra to r y support was removed ,
If any adve rs e signs a n d/or sympto ms occ ur d u rin g treatm e n t - stop . There is n o thi n g to b e g ain ed fro m
.
As pra ct iti o ner s better understand the pa tho l og y
,
warning
signs during an d after trea tment whi c h
in d ic a t e that trea tment s h o u l d be a l t e re d or c e a se d
,
and the need in some cases fo r the patient to be
Copyrighted Material
Contraindications to cervical sp ine mani p u lation 205
hospitalized, the i n c idence of these in j uries should decrea s e .
patient who develops p o s t-SMT d i zziness s h o u ld
I t h a s been stated that a l l thru s t techn i q u e s are ruled out as da n gerous, and th at ' we shou l d stay OUf
h and u n til i n dications fo r t hru st tec hniq u e s a re q u i te unequ ivoc a l ' (G rieve , that
9. Post-SMT d izziness may h ave many caus e s . The
it is not
1 986) .
t h rust
It is t h e a u thor's o p i n i o n
th a t i s
the
most d a ngero us
component of the manipulation, b u t that it is extre me rota t i o n . Tec h n iques can be modified to aba n d o n t h a t compo nen t w h i ch appears to c a r ry gre a test r i s k fo r o u r patien t s .
n o t be remanipul a t e d , b u t tra n s p o rted to h o s p i t a l fo r observa t i o n .
10. M a ny c a s e s of p a t i e n t inj ury w e r e c a u se d o r made worse b e c a u s e the practit i o n e r d id n o t s t o p treatment, w h i ch had t h e effe c t of fu rt h er traumatizing an artery u n d e rgoing patho l og i c a l chan ge .
1 1 . It is n o t possible to p red ic t a l l p a t i e n ts who may b e presen ting to our offices with p re-existing
Rega rd ing po s t- S M T VB S , t h e fo l l o w in g concl usions
are offe red :
ve rtebral
artery
d i ssections
(or other arterio
path i c processes w h ich m ay pre d i s pose to a r terial d issection), as they may be S i l e n t , or may
I . VBS fo llowing SMT is very ,,I re (nobody knows
i n fa c t be c a u sing t h e head and/or neck pains
w h a t the true incidence is), but m a ny cases c o u l d
(without other wa rning s igns) promp ting the
have been avoided .
patient to seek h e l p . T h e absence of reported
2. Th e re does not appear to be a ny age gro u p or ge nder that is p red isposed to post-SMT VB S . 3 . Cadaver and i n vivo stud ies o n haemodyn a m i c c h a nges
with
neck
movem e n t
i n d icate
c o n t raindications does not mean that the p a t ie n t w i l l n o t su ffe r post-SMT VBS a n d , i n fact, m o s t o f t h e r e p o rt e d cases d id not d o c u m e n t the s u p
that
p o s e d conrraind ica t i o n s . T h e refo re , we ca n no t
ro tation applies greater s t ress o n t h e VAs t h a n
a bsolu tely p rotect these patie n ts b y p retreatment
l ate,JI flexion. Wh il e cad ave r a n d i n vivo studies both come to this conclusi o n , i t i s appare n t that cadave r studies d o n o t acc u ra t e ly reflect cha nges
in vivo . 4 . C u rrent k n owledge i s l i mi te d , a n d p red iction of patie nts at risk by c u rre n tly used p a tient assess
screening.
] 2 . M a n y o f the cases which occu rred in pred isposed patients (pre-existing VA dissecti o n , w i t h o r wi thout e xa m in a t i o n fi n d ings) m a y n o t have occurred had t h e p ractitioners ll sed a m e t h o d o f S M T which d i d not stress the VA w a l l s .
ment methods req u i res m u c h fu rt h e r researc h , an d possibly the adoption in p ractice o f new diagnostic methods (e . g . Doppler u l trasound).
References
5. I n many c a s e s , the p a t i e n t may have presented with a n existing VAD, which may have caused the symptoms
(head
a n d/o r
neck
p a ins)
which
prompted the p a tie n t to consult t h e p ractitioner. The prac titioner, who is t h e n held responsible
fOf cau sing the inj ury, may h a ve had no effec t on the final outcome, or merely hastened the inevita ble . I t is possible, t h o ugh , t h a t without the artery
6.
being
t ra u m a tized ,
its
wall
may
have
healed with no occurrence of stroke . Many of the cas e s of patient inj u ry could have been preve n ted had the practitioner been aware o f VBI si gn s and symp tom s , which should have been e l ic i ted d u ring t h e review of syste m s , or case hi story, an d w h ich should h ave indicated that SMT should not be p roceeded with. This m ay have occurred m o re c o m m o n ly t h a n the
been p revented had the p ractitio ner performed a p hysical examin a t i o n , including ho l d i n g the head
in the premanipulative po s i t i o n while observing fo r signs and/or sym p to m s o f VBI .
The most s evere i nj ur ies foUowing SMT are no t
cases of tra n s i e n t i s c h a e m i a d u e to co mpress ion '.
or
vasospasm ,
but
Are
of vessel
wal l
la cera t ion ,
G . H . ( 1 986)
c ervi c a l spine rad iographs of va l u e in elderly p a tients
'\V ith venebrobasilar insufficiency? Age Aging R.,
And e rsso n ,
Carleson ,
R.,
1 5 : 57- 59. 0. ( 1 970) Ve rtebra l
Nyle n ,
V artery in sufficiency and rot.1tional o b s t ru c t i o n . Acta Med. Scand.
188: 4 7 5 - 4 7 7 .
An onymous ( 1 980) Chiropractors urged t o consider stroke
Med. World News (March 17): 2 3 . E. , Bickersta ff, E . R . ( 1 976) Verte bra.! occlusion a n d o ra l contracep t i ves. 8r. Med. risk .
Ask-Upmark,
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1:
L, Sweet, W H . ( 1 9 5 3 ) I n tra-a rterial p ressures in and bra in . J Neurosurg 10: 3 5 3 - 359 .
the
487- 488. Bakay,
nec k
Ba rto n , J . W , Margolis , M.T. ( 1 975) Rotational obstruction o f t h e vertebral a rtery at the atl a n toaxial j o i n t . Neuroradiol
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Barty, G . M . ( 1 98 3)
Ex p e r t
testimony
Klippel
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Wagga Wagga , Austral i a . 1 2 A u g 1 98 3 , 3 3 Beatty, R . A . ( 1 977) D issecting
li terature s u ggests .
7 . M a ny of the cases of pa tient inj u ry may h ave
8.
A d a m s , K . H . R . , Yu ng, M . W , Lye, M . , Wh i tehouse,
hematoma
of t h e internal
c arotid artery fol l OWing chiro p ract i c cervical manipu la tion . J Trauma Bell v .
17: 248 - 249.
Griffiths ( 1 994) H u nt e r
J
Oudge 01 e n t) .
Court, Common Law Division, Sydney :
in:
Supreme
Sep 1 994 . Case
Bell: "B ur ied a live ." (Aug 29), 2 1 . E . R . ( 1 97 5) Neurological Complications of Oral
also reported
New
14
Anonymous. John
Idea (M agazine) 1 9 87
Bickerstaff,
Con traceptives. Oxford: Clarendon Press, pp. 5 7 - 5 8 . Biller, ]. , H i ngtge n , W L . , Adams, H . P et at. ( 1 986) Ce rvic o
d issecti o n , etc . , possi b l y p re d i sposed by an as yet
ceph a l i c
u nknown a rteriopa thy.
1 2 34 - 1 2 3 8 .
Copyrighted Material
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d issecrions.
A rch
Neurol.
43:
206 Clinical A natomy
and Management oj Cervical Spine Pain
Blallmanis, O. R . , Gertz, S . D . , G ra dy, P. A . , Nelso n , Thrombosis in a c u t e
Stroke 7 :
Bogd u k ,
expe rimental
9- 10.
N.,
Lam bert,
G.,
D o re y,
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M O.
$ 1 . 3 mi llion award
Chiropractic Rep. 6: 6 a n d in Anonymous
MD's
cervi c a l
stro k e . MPJ's Dynamic
m a n i p u lation
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arteries
duc
to
defect
in
the
odontoid
p rocess
and
excessive mobil i ty of t h e second cerv i c a l vertebra. Bull. joh ns Hopkins HosjJ . 9 1 : 1 68 - 1 73 . Ford , F R . , Clark, D. ( 1 9 5 6) Thromhosis of t h e basi lar a rtery with softenings in the cerebellum and bra i n ste m due [0 mani p u lation of the neck. BUll. jobns Hopkins Hosp . 98: 37- 4 2 . Foster 1.'. Thornton ( 1 9 3 4 ) jvl e d i colega l . M a l p ractice: D e a th res u l t i ng from c h iropra c t i c t reatment for headache . }A.M.A. 1 0 3 : 1 260. ( 1 93 5) M a l p ra c t i c e : Cerebr;11 hemor r h a ge attributed to c h i ropractic adj ustment. } A . MA . 1 0 5 : 1 7 1 4 . ( 1 93 7) M a l prac tice: De�t h res u l ti ng from ch i ro p rac tic tre a t m e n t for headache. }A.MA. 1 09: 2 3 3 - 2 3 4 . Frison i , G . B , Anzo l a , G P ( 1 99 1 ) Vertebrobasilar isch a e m ia after neck motio n . Stroke 2 2 : 1 4 5 2 - 1 4 60. Fri t z , V l J . , Maloo n , A. , Tuc h , I' (J 984) Neck m a nipu l a ti on causing strok e . South AjI: Med. J. 66: 844 - 84 6 . Frumk i n , L. R . , 8a l o h , R . W ( 1 990) Wall e n be rg's syndrome fo llow i n g neck m a n i p u l a t i o n . Ne uro logy 40: 6 1 1 - 6 1 5 . G i ttinger, ) W ( 1 986) Occ i p i ta l i rtfarc t i o n following ch iro practic cervical m a n i p u latio n . } Clin. New·o Ophthalmol. 6: 1 1 - 1 :\ . God lewski , S . ( 1 965) D i agnostic d e s t h rom boses verte b ro basil a ire . Assises Med. 23: 8 1 - 9 2 . Good bocly, R . A . ( 1 976) Fata l post-tra u m atic vertebro basilar isc h a emi a . } Clin. Pa /bol. 2 9 : 86 - 87 . Gorm a n , R . F (1 978) C a rd i a c a rrest afier c e rvica l s p i n e mobil ization . Meel. } A ust. 2 : 1 69 - 1 70. G reen , D., Joynt, R .]. ( 1 959) Vasc u l a r a c c i d e n ts to t h e b rai n stem assoc i a ted w i t h neck m a n i p u l a tion s . } A . lvI. A . 1 70: 5 2 2 - 5 24 I-h m a a n ,
G. , Felber, S . ,
Haass, A. et ai. ( 1 99 3 ) C e rvicoce
p ha l i c anery d i ssections d u e to c h i ro p ra c t i c m a n i p u la tions.
H a rd i n ,
Lancel 3 4 1 : 764 -765 . C A . , W i l l i a mson, 1' , Steegma n , A ( 1 960) Vert ebral
artery insuffi c i e n c)' produced by cervical osteoa r t hritic s p u r s . Neurology 1 0 : 855 - 8 5 8 . Hay n e s , M J ( 1 994) Stroke fo l lo w i n g c e rv i cal man i p u l a t i o n i n Pe nh. Cbiropract. } A ust. 24: 4 2 - 4 6. H a y n e s , M .]. ( 1 995) CerviGlI rota t i o n a l e ffects o n vertebral a rtery flow: a case study. Chiropract.} A ust. 2 5 : 7 :\ -76. Hensell , V ( 1 976) Nellro logische S c h ad e n nach Repositions massna h m e n a n d e rWirbelsa u l e . Meel. Welt. 27: 6 5 6 - 6 5 8 .
H eyden , S.
( 1 9 7 1 ) Extra kra n il er thro m botiscber arter
i enversc h l u s s a l s fo l ge von kopf- u n d Ilalsverletzung. !'riat.
Meel. Nordm . 2 3 : 24 - 3 2 . H o r n , S . W ( 1 983) T h e " l ocked-i n " syndro m e following ch i ropractic manip u l a t i o n of the cervical spine. A nn . Emerg Med. 1 2 : 648 - 65 0 . J a n z e n - H a m b u rg , R. ( 1 966) Schlelldertrauma d e r H a l sw i rbel saule, neurologische probleme. Langenb ecks A rch. Klin Cbir 3 1 6: 46 1 - 4 69 J e n tze n , ].M . , Aanatuzio, j . , Peterso n , G . F ( 1 987) C o m p l ica tions of cervical m a n i pulatio n : a case report of fa ta l bra instem infarct with review of the m e c h a n i s m s a n d p red isposing fa c tors . }. Fo rens ic Sci. 3 2 : \ 089 - 1 094 . J o h n s o n , D . W ( 1 993) C e rv i c a l self m a nip ulation a n d stro k e . !Heel. } A ust. 1 58: 290. J u n g , A . , Kehr, P., JlIng, FM. ( 1 976) Das posttra u m a tiche zerv i k a l-sy n d ro m . Man. Med. 14: 1 0 1 - 1 06 . (This case is also re p o rt e d i n Vedr i n e a n d Spay ( 1 968) and Roc he et al. ( 1 963» Kanshepolsky, J, Dani e l son , H., Flynn , R . E . ( 1 972) Ve rtebral artery i ns u ffi c i e n c y and cerebellar infa r c t due to m a nip ulation of the neck. Bull. LA Neurol. Soc. 37: 62 - 66 . Katirj i , M . B . , Reinmll t h , O. M , L� tchaw, R . E . ( 1 985) Stroke due to vertebra l artery i n j ury. A rch. Neural. 4 2 : 2 4 2 - 24 8 . K.i p p , W ( 1 975) Todlicb er flirnstammin!arkt nach flWS Manipulation (disse rta t ion) . Tubinge n , Eberhard Karls lJ niverstitaet, p . 39. Komme rell , G. , H o)'t, w.F. ( 1 973) Lateropulsion o f sa c cad i c eye movements. A rch. New-ol. 28: 3 1 3 - 3 1 8. Koso)" j., G lass m a n , A . L . ( 1 974) Aud i oves tibu lar fin d i ngs with cervical spine tra u m a . Tex. Met/. 70 : 66 - 7 1 . Kramer, K . H . ( 1 974) Wa l le n b u rg Sy n d rom n a c h m a n u e U e r B e h a ncll u n g . Man !Heel. 1 2 : 88 - 89 . Kriege r, D . , Leibold , M . , I3ruckm a n n , H . ( 1 990) Dissektionen d e r a rteria verteb ral.is n a c h zervikalen chiro pra k tischen m a n i p u la tionen . DIsch Med. Wochenschr. 1 1 5: 580 - 5 8 3 . Kunkle, E. C , M u ll e r, ]. C , Odom, G . L . ( 1 9 5 2) Tra u m a tic b ra i n s t e m thrombosis: report of a c a s e a n d a n a.lysis o f the mecha n i s m of in j u ry. A nn. intern. Med. 36: 1 329 - 1 3 3 5 . Lorenz, R . , Vogelsang, H . G . ( 1 97 2) T h ro m bose d e r arteria basilaris nach chiropl-.!k t i schen Manipulationen a n der H a l swLrbeisa u l e . Dtsche Meel. Wochenscb·" 97: 36 - 4 3 . M a I m , J, O l sson , T , Fageriund , M . ( 1 990) Cervil
� 1'., Far ha t , S.M. ( 1 974) Vertebral artery i.l1j u ry from Vchi ropra c t i c m a n i p u l a t i o n of the n e c k . Surg Neurol. 2 : M e ){ I i C ,
1 2 5 - 1 29 Meyerm a n n ,
R. ( 1 982)
Mogl i chke i t e n e iner schad igung der
arte r i a vertehra l i s . Man. Meel. 20: 1 0 5 - 1 1 4 .
M iglets, A . s . ( 1 986) D i scussion i n sudden sensori n e u ra l bearing l o s s follow ing manipulation o f the cerv i c a l s p i n e . Laryngoscope 96: 1 66 - 1 70. M iller, R . G . , B u r t o n , R . ( 1 974) Stroke following c h iropractic m a n i p u l a t io n of the spin e . }A.M. A . 229: 1 89 - 1 90 . M u rase, S . , Ohe, N. , N o k u ra , H . et al. ( 1 994) Vertebra l a rtery
Copyrighted Material
2 1 0 Clinical A n a to my anti Management oj Cervical Spine Pain
inj ury foll o w i ng
mild
n e ck tra u m a : report o f rwo cases.
No Shinkei Geka 2 2 : 67 1 - 676.
Nic k , ]., Co n ta m i n , E, N ico l le ,
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accid e n ts n e u ro l o giq ue s
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Berlingske in: Je n sen
Tidene (D e n ma r k) 1 984 ( 2 3
L.
Melh e d e AIL.
nakke hol d . Ocrober) : 6 . and
Blev behand l e t for
G a b a re til ki ro pra k ro re n . Berlingske Tidene
( D e n ma r k) 1 984 (24 Ocrober) Nyberg-H a n sen ,
R.,
Lo k e n ,
A.C,
Tenstad , O. ( 1 9 7 8)
Bra in
stem l e s i o n wi t h c o m a for five years fo l lowing m a n i p ul a ti o n of the cervical spine ] Neurol. 2 1 8: 9 7 - I 0 5 .
Pa m e l a ,
E,
Beauge r i e ,
L. ,
Coutu rier,
M.
et
al.
( 1 9 8 3)
tro n c basil a i re a pr e s m a ni p u l a t i on vertebrd l e . Press e Med.
12: 1 548. Ph i l l ips , S .] . , M a l o n ey, W.]. , Gray, ]. ( 1 989) Pu re mo ro r s troke due ro ve r te b ral a rtery d i sse c ti o n . Can. ] Neurol. Sci.
Ponge , T. ,
Cot t i n ,
S.,
Pon ge , A.
e/ al.
16:
( 1 989) A c c id e n t
vascu l a ire vertebro-bas i l a i re a p res m a n i p u l ation d u
rachis
56: 5 4 5 - 548. P ra tt-Th o m as , H . R . , Berger, K.E. ( 1 947) Cere b e l l a r a nd s pina l inj u r ies after chiropra c t i c m a n ip u l a t i o n . ]A.M.A. 1 3 3 : c e rvical . Rev. Rhu m .
.A-# � ....
600 - 60 3 .
Pribek,
R.A.
Brainstem vasc ular Wisc. Med. }. 62:
( 1 963)
neCk m a n i p ula t i o n .
t5(J1
I
� a sk in d ,
a c c i d e n t fo l l owin g 14 1 - 143.
R . , Nort h , C M . ( 1 990) Ve rtebra l a r t e ry i nj uri e s ) fo l l o w i ng c h i ropractic cerv ical s p i n e ma n i p u lation � c � r� p o r t s . A ngiology 4 1 : 4 4 .5 - 4 .5 2 . Ccv.J.t.- /\.Ph l/lNtO Rp!"h rock, J E , Hesselin k , J R , Te a che r, T M . ( 1 99 1 "� rtebral
V
)
a r te r y occlusion a n d stroke from cervical self m a n ipu la-
t i o n . Ne urology 4 1 : 1 696 - 1 69 7 . S c h e l lha s , K . P , La tchaw, R . E . , We n d l i ng , L. R. ,
Gold , L . H . A .
( 1 980) Verteb robasil a r inj u ries following cervical manip u l a tio n .
Schmi t t ,
]A.i}cJ.A. 244: 1 4 5 0 - 1 4 5 3 . H . P ( 1 976) Rupturen u n d thrombosen
vertebra lis Schweiz.
363 - 3 6 9 . 1 978.)
S c h m i tt,
gedec kJ e n
nach A rcb.
HP,
(Th i s
Neurol.
mecha nischen
Neurochil:
d e r a r te ria insulten.
Psycbiatrie
1 1 9:
case was also described by Sc h mi t t,
Tamaska ,
L. ( 1 97 3 ) Disseziierende
73: 30 1 - 308 (Th is case was
also described b y Schmitt, 1 97 8 . )
Schwa rz , G . A . . Geige r, J- K . , Spano, A . V ( 1 9 56) Poste rior i n fe rio r c e rebe l l a r artery synd ro m e of Wa l l e n be rg a ft e r c h i ro p ra c t i c
352 - 354.
m a n i p u l a t ion.
S h e k e l l e , P G . , Brook , of
the
use
of
81 : 4 39 - 4 4 2 .
R.H.
A rch.
Intern.
head
of
Ad a m s ,
a nd
A. H .
neck
S u l livan, E . C ( 1 992)
et
manipulations.
182:
] A . M. A .
Med.
97:
B ra i n stem s t r o k e synd romes from '
Cbiro.
cervi c a l adj u s t m e nt s : rep o r t on fi ve cases. J.
Res.
Clin. Inoest 8: 1 2 - 1 6 .
TeaseU, R.W. ( 1 994)
Vertebro-b a s i l a r
a rtery
st ro k e
c o m p lica t i o n of c e rvical m a n i p u l a tio n . Cril.
Rebabil. Med. 6: 1 2 1 - 1 29 . Te rrett, A . G .]. ( 1 9 8 7 ) Vascular
Assoc.
Te rrett,
A . G.]. ( 1 995)
as
a
Reo. Ph),s.
ac c id e nt s .
1 7 : 1 1 7 . (Case a lso re po rted in
I A llSt. Cbiro. Bolto n , 1 98 7 . )
M i s u s e of t h e l i tera t u r e by m e d i c a l
m a n i p u l a t ive therapy i n j u ry. 203 - 2 1 0 . Te rrett, A . G .] ( 1 997) Ve rtebrobasil a r s t ro k e a fter spi n a l m a ni p u l a tio n t h e rap )'. I n : Adva n ces I!I CbirojJractic, v o l . 4 (Lawrence, D.] . , e d . ) . 1 I l i n o i s : Mo s by Yea r Book ( i n p re ss ) . Te rre t t , A . G .]. , Gorman. R . E ( 1 99 5 ) Thc eye, the ce rv ical s p i n e , and s pi n a l m a ni p u l a ti ve t h e rapy: a re view of the li te ra tu re . Chiro. Techn. 7: 4 3 - ')4 . Vedri n e , J . , S pay, G . ( 1 968) Pro b l e m e s me d ico legaux poses p a r les thromboses c o n s c c u tives it un trau mati s m E fere d e s a r t ' e res vertc':brales. Lyon Meel. 27: 5 - 2 1 (This case is a u thors i n d is c u s s i n g s p i n a l
] Manipul. Pbysiol. Th e r. 1 8 :
also
in Roche e/ al. ,
re ported
1 963 a n d J u ng e/ al. ,
1 976 ) Vibert, D . . Rohr m a nilesta ti o n
Le of
Floch ,
J,
Ga u t h i e r,
G.
( 1 993) Ve rtigo as
ver teb ra l artery dissection a fter c h i ro
prac t i c n ec k m a ni p ula t i o n s . ] O/o-Rhin o-LaryJ lgol. 5 5 :
140- 142.
We i nstei n , S . M . , C a n t u , R . C ( 1 99 1 ) Cerebral stroke semi-pro foot b a l l player: a case re p o r t . iHed.
Exerc. 2 3 :
m p tu r c1er
a rteri a ve rtebral is mit todl i c h e m vertebra l i s und basi /a r is Ve rschluss. Z. Recbtsmed.
PG.,
ness oI Spina/ IUanijJula tion for Low
5 28 - 53 1 .
S y n d ro m e de deeffere n t iation mo t r ice par thro m bose d u
348 - 35 1
a/. ( 1 99 I ) lbe AjJpropriate Back Pain: Project Overview and Literature Revie-w. Mo n ogra p h n o . R-4025/ I -CCR/FC E R . S a n ta M o n i c a , Ca l ifo rn i a : RAN D. Sherma n , M . R . , Smialek, J E . , Za n e , W. E . ( 1 98 7 ) Pa th og e n e s is of verte b ra l a rtery occ l usi o n fo l l o w i n g cervical spine ma n i p u latio n . A rch Patho/' Lab. Med. 1 1 1 : 8 5 1 - 8 5 3 . " �rhm on s , K . C , Soo, Y S . , Wa l k e r, G. , H a rvey, P ( 1 982) V ) Tra u m a to the verte bral a rtery related to n e c k m a n i p u l at i o n . Med. ] A ust. 1: 1 87 - 1 88 . '-. S i n e ! , M . , S m i t h , D. ( 1 99.1 ) T h a l a m i c i n fa rc t i o n seco n d a ry to c e rvical m a n ip u l a t i o n . A rch. Plyys. IHed. Rehabil. 74: 5 4 3 - 546 S m i t h , R . A . , Es tri dge , M . N. ( 1 96 2 ) Neurologic c o m p l ications She kel l e ,
t t 19-1 121.
Sci.
in a
5/)OrIS
EX. , Fa l u cl i , H . K . . Woo l h a n d ler, GJ ( 97 1 ) li'a u ma t i c ve rtebra l a rtery t h rombosis . ] Louis lema Med. Soc. 1 2 3 : 4 1 3 - 4 1 4 Yo rk v. Da n ie l s . ( 1 955) M e d icolegal abstracts. C h i ro p rdCtors: i nj u ry to spi n a l me n inges during adj u s t ni e n t s . I A .MA. 159: 809 Zak, S . M . , C a rmody, R. E ( 1 984 ) C e re b e l l a r infarction from Woo d ,
MJ,
LlI1g,
c h i ro p ract ic n e c k m a n i p u l a t i o n : case re p o rt an d review
( l 99 1 ) A comm u ni ty based stucly
c hi ro p ra c ti c service s . A m. ] Public He al/b
of
the
l i te ra tu re . A riz
Meel. 41: 3 3 .3 - 3 3 7 . TJ ( 1 977) I n t ernuc l ea r oph t h a l m oplegia c e rvi c a l m a n i p u l a t i o n . A n ti. Neurol. 1 : .'\ OH.
b u e l , D. , C a rl ow, fol l owi ng
Copyrighted Material
Inde.,,,�
Adjustment,
105
Agenesis of arches Ajar ligaments see Odontoid
Central cord syndrome,
Analgesics for whipl a s h injuries, 80
Cervical collar, 120
Anatomy
for whiplash injuries,
23
cervical s p i ne 6, ,
79
Cervi cal
cervicorhoracic junction, 40
cord compression ,
midcervical spine, 11
fusion, anterior,
Ankylosis, spontaneous, 91 Anulus fibrosus calcification,
10
127 134
musculoskeletal dy sfu ncti o n
105
,
162
rib, 5, 45 1 60
Anterior scalene Antidepressants
Arm pain and paraesthesia
injury,
75
from neck, 12(i
Articular and uncinate
of, tables,
triad, :)
syndrome
, Atlantoaxbl
131
Cervicogenic headache,
62
80 3, 158, 165, 169
Cervicothoracic
imaging, 100 subluxation,
54, 59
13
traction for whiplash injuries,
instability, surgical treatment, joint,
,
ganglion,
127
8
j u n c tion
Atlanto-odontoid joint, im a gi ng, J 00
anatomy, 40
Atlas
movements, 42
ageneSiS of arcilc" and axis imag lll g
,
1
03
ponticles, 105 Autonomic nerves. A,"(ial pain, 126 syndrome, 160
Barre-Lieou syndrome, !O5
Clay shoveller'" iranure, 105
Block vertebrae, 5
Cloward anterior cervical fUSion, 134
imaging, 101
Computed tomography see CT
Bone marrow changes, MRI recognition, Iklchial plexus tension test,
178
92
Corpectomy,
135
Craniovertebral muscles, function of,
Copyrighted Material
65
212 Index
Hyperostosis diffuse idiopathic skeletal, 103 senile ankylosing, 103 syndrome, 1 59
CT
for canal stenosis, 9 1 for foraminal stenosis, 129 for spinal for
techniques, 89
Degenerative changes, vertebral, 45 disc disease, imaging, 89 MRI signs, 92 Depression following whiplash injury, 76 Diffuse idiopathic skeletal hyperostosis, 103 Disc see Interverte bral disc Discectomy, anterior, 134 Discography, DISH, 1 03 Dislocation Dizziness following 74 indicating ischaemia, 201
48 hyperexten�jon, 10 neck, 9 spinal, classification, 141 Instantaneous centre of motion, 56 lntercallary bones, 105 Intervertebral disc, 3 cervical, shape, 66 changes with age, 30 imaging, 76, 89, 92 myelopathy, II overstressed, 14 alter age of, 30, 93
JlInghanns' spinal motion segments, 3, 4, 139 Eagle's syndrome, 106 End-plate sclerosis, radiograph, 90 Ergonomic advice, 187 Examination
chiropractic, 142 neurological, 114, 129
Kimmerle's anomaly, 105
Kinematics of cervical spine, 53 Klippe1-Feil syndrome, imaging, 102 Kyphosis, thorJcic, variability of, 44
orthopaedic, 112 osteopath Ie, p hysi otherapy. Exercises,
128 136 anel rota tion,
coupled,
Fibromyalgi:1 Foraminal
Foraminotomy 137 Forrestier's disease, 103 Functional restoration programmes, 82 ,
Gadolinium e n ha n c ed MRI, 92 G uildford cervical brace, 121
f1avum hypertrophy, II nuchae OSS i fi c ation, 105 Load trans mi ssi on 3 Locked-in syndrome, 199 Longus colli, calcific tendinitis, 107 Low back pain following whiplash injury, 75 LlIschka jOints, 13, 30 ,
resonance imaging, see MRJ techniq ue 122 mohiltzation for whiplash
Halifax
,
Headache
cervicogenlc,
69
following vertebral
cluster, 1
Horner's syndrome,
Hyperextension
artery, 14'7
contraindicJtions, J 47, 192
158 Hemivertebrae, 9 vascular,
orthopaedic, 122
129
injuries,
10
osteopathic, 163 physiotherapy, 18)
Copyrighted Material
1
Copyrighted Material
1
Index Radiography for degenerative disc disease, 89
Translation of neck on head, elastic absorption, 58,
Radiological stress views, 1 3
64 Trigger point injections for Whiplash injuries, Rl
Range of lateral bemHng, 01 Retroli�thesis, radiograph, ()O Rheumatoid arthritis causing atlantoaxial
process,
subluxation,
sharpening, 97
Rotation and lateral bending, coupled, 62
Uncovertebral jOint degeneration, 11 imaging, 96, 97 Upper cervical complex, 157
Scalenus anterior syndrome, 160 nodes,
phenomenon radiograph, 90
Sch\vannoma, MRI, Segrncntal motion, cx(unination, 177
artery
Selecllve muscle relramlflg for whiplash inJurIes, 81
a1l3lOll1)" 29, 195
Shimizu reflex, 11 7 119
injury, caused by rotation, 195, 203
,
classification of, 197
Shock absorption, 3
plexus, 8
Smith-Robinson technique, 134
pressure on nerves.
diagnosis,
disorders,
Vencl)l'()basilar
Spondylitis deformans, imaging,
ischaemia, signs
03
()ssificans ligamelH()sa,
symptoms, 197
after manipulation, 192
Spondylolisthesis, imaging, 99 Spondylosis
Wallenberg syndrome, 199
hyperostotica, 103
Whiplash injuries, 10, 71, 72
degenerative discogenic, 5
chiropractic, 141
12
Spondylotic lipping,
cognitive difficult
Spomaneous ankylosis,
diuincss after, 7i
Squeezed toothpaste sign on MRl, 94
grading, 161
Stellate ganglion, 8
headache after, 74
Stenosis, foraminal, CT for, 129, 1'17 Subaxial instability, surgical treatment, 131 Subluxations, 139
Swimmer's view Sl'1l1jl(Hhetic nerves.
little evidence of accompanying brain injury, 78 osteopathy, 161 prognosis, 77
,8
cervical
77
dl-pression after,
neck comprcs,joll test, 118, !
p�vchological
(7, 50 37
II iter,
75, 76
symptoms, 73
Symptoms and signs of cervical spine disease, table,
treatment, 123 chiropractic, 148
37
education, 79
Sy nostosiS, congenital, 102
facet joint dcnervation, 81
Synovitis causing pain, 13
oqcopathic, 16'1 phy,;iotherapy
78 membrane, Temporal arteritis, 159 Thoracic outlet syndrome, 160 Thrust, high velocity manipulation, 15 2
,
164
Zygapophysial joint, 3
Tinnitus following whiplash injury, 74
arthritis, 11
TOl11ography, see
degeneralive ch;ll1ge:;
15
il1l,l)�ing, 98, 99
pClin, 121
()t' inner stabilit).
whiplash injurlCs,
of,36
Transcutaneous electrical nerve stimulation for whiplash injuries, 80 Transient ischaemic attacks, 199
subluxations, chiropractic, 139, 143 surface anatomy, 26 synovial folds, :)6
Copyrighted Material
