Clinical Anatomy and Management of Cervical Spine Pain

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Clinical Anatomy and Management of Cervical Spine Pain


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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( 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 .

References Outline oj OrthojJaedics. Adams, Je. . Livingstone, p . 1 5 4 . 1 1 th edn. Adams, M A . W e . (1 986) T h e stages of d isc dege n e ra t i o n a s reve a l e d by d i scogram . ] Bone join/ Surg. 688: 36. AI-Mefry, 0. , Borba, A . B . , Aoki, N., Anglu3co, E . , Pa i t , TG. ( 1 996) The tran scondylar a pproach to ex t radura l n o n neoplastic lesions of t h e c ra n i overte b ra l junction . ] Neul'Osarg. 84: 1 - 6 . And e rsson , G . B .J. ( I 983) T h e biomechanics o f t h e posterior e lements of t h e lumbar spine. Spine 8: 326. S Vest i n g R A . et a!. ( 1 995) Anatomic Ba i l ey, A . S . , re l a tionsllip, i l o racic junction. Spine 20: 143 1- 1 Ba rnsley, L . ( 1 993) The p a thop hysioJ ogy of Hex/on - Extensions/Whip Sh apiro, eds) . Spine: Stat, lash Injuries of the Art Philad e l p h i a : H a nl e y a n d BeJius, pp. 329 · B a rr, M . L . , The Human Nervous ,\)stem, 4 th e d n . Philade lp h i a : l-l a r p e r & Row. B e n so n , D. R . ( 1 983) The spine a n d nec k . I n ilfusculoskele tal Diseases oj Children (Ge r s hw i n '''I . E , Robbins D . L , eds). New York: Gru n e & St ra tto n , p. 469 B l a n d , J H ( 1 987) Disorders oj the Cervical Sp ine Diag nosis and Medical Management: P h ilad e l p h i a WB Saunders. Bogd u k , "i. ( 1 99 5) Ed itori a l . Scie nritlc monogra ph of the associated supplementary Quebec d isorders. Bog d u k , N. , ( l 988) The in nerva t i o n of cervical Spine 1 3 : 2 - 8. Boh l m a n , H I spondylosis and myelopathy r.eaures Qackson D.W. , ed.) S u rgeo ns, pp. 81 - 97. o f myofascial p a i n syn Bonica, J.J. ( I d romes i n general practice. I I . M.A. 1 6 4 : 73 2 - 738. Bovlm , G. , Schrader, H., Sa n d , T. ( 1 994) Neck pain in the generA l populati o n . SjJine 1 9 : 1 307- 1 3 09 Brd i n , L. , Wi l ki n so n , M . (eds) ( 1 967) Cervical SpondylosiS

Philadelph i a :

D. , Wi l ki nson, M . (1 95 2) The of cerv t ( :iI

m a n ifestat i o n s

1 8 '-225. \1ill e r, C A . , R e a , G . L . e l al J1ll:lging of t ra u m a to the rhol':! ,.ic 17: 54 1 - 5 50 It m pleton, A.W, H odges . acqui red and con ge n i r;d A.jR. 92: 1 2 5 5 - 1 2 59 B u i rski , G . , S i l berste i n , M . (1 993) The symptomatiC Ilimba r d isc i n patients with l ow-back pa i n. ,SjJine 1 8 : 1 808 - 1 8 1 1 . Bu tler, D. , Tratl m ow, J H , And ersson, G . B ../. et al. ( 1 990) D iscs dege n e l�lte befo re facets. Spine 1 5 : J 1 1 - 1 1 3. Cai l l ier, R. ( 1 968) Low Back Pa in Sy ndro me, 2 n d e dn . Philadelphia: F A . Davis Carpenter, R . L. , Ra uck. R. L ( l 996) Refractory head and ot>ck p a i n A d iftic u l r problem a n d a new a l rernati ve A nesthesiology 84: 249 - 2 52. I. 1 1')87) Spectrophotometric i n osteoa rth r i t i c synO\ l :l 1 "16: 375 - 379 1')')5) Cervical c e n t r a l cord trigemin a l n u c l e u s : a 2 16 - 240 ( I ')H5) Correiatil'e Neuroana/r'IJI F tiona! Neurology, 1 9 t h cdn. Ca l iforn i a : l.ange M e di c a l Pu blications, p. 1 6 2 . Clarke, E. , Rob inso n . P K . ( 1 956) Cervical myeloparhy: a complication of cervica l spondylOSiS, Brain 79: 4 83 - 5 1 0. Compere, E.L. , Tac hcl j i a n , M .O . , Kcrna[lan, WT. ( l 9 5 9) The Luschka j o i n ts . Their a n a tomy, ph y s i ol ogy a nd pathology. A m. ] Or /b op. Surg. 1 : 1 "9 - 1 68 Day, LJ. , Bovill, E . G . , Trafton, P C; . e/ Cli ( 1 994) O rthopedics. r n: (:11 rnm t Su rg ica l Diagnosis and Trea tm(,l1 t (\X'JY L W. Appleton Lange , pp. 1 0 I - I ) (] 980) Diagnosis of low back In: Tue Lumbar Spine ed.), 2nd e d n . Kent: D. , Pen n ing, L et al. ( I diagnosis of the cervical IjJine 13: 74 8 -7 5 5 . D y c k , f> ( 1 98 5) Pa raplegia fo l lowi ng chemonucleolysis. Spine 10: 359. Eguro, H . ( 1 983) TI�lIl sverse mye l i ti S fol l owing chema n ucleolysis. ] BoY/e join! SlIIg. 6 5A: 1 328. Eisenstein, S . M . , Pa rr)" e . R ( l ')87) The I limba r facet a rthrosis synd rom e . C li n i c a l presenta t i o n a n d a rticul a r su rface changes. J Bone j()int Stng 698: 3 -7 . EI-Khou ry, G . Y , Renfrew, D.L. ( 1 99 1 ) Pe rclitaneOllS p roce d i agnosis and t reatment of [';lcet j o i n t inj e c t i o n , and 61-;5 - 69 1 . Epste in , ]. A . ( 1 987) I nd ivid ual cerv i c a l spinal stenosis. I n Spine : S t a t e o f the ( I 'PH) The biomechanical adval1tJ,Qt h i p e(lel.15ion for u p r i g h t m a n '" othe r anthropoids. Spine 3: 3 ,, 6 - 3 4 5 . Fa rfa n , H . E ( 1 980) T h e sc i e n t ifk b a s i s of m a n i pula t i ve p rocedures . CUn. Rbeurn. /Jis. 6: 1 59 - 1 78 .



Management of Cervical Spine

18 Clinical sil1atomy M a rgo,

K. ( 1 99 4 ) D i agn o s i s , treatmen t a n d prognosis i n

p a ti e n ts w i t h l o w back p ai n . A m . Fam. Physicia n

49:

1\la roon ,

238:

n e rv e root in d i s c prolapse. Lancet McArd l e , C B . , Crofford , S u r fa c e

M .J,

2:

320.

DiagnosiS

and

7, 4 2 3 - 4 4 1 . ilk:v!. (196m

Bosto n :

Manipalalil '/? Techniques

P" osp e c t i ve

:111 0

c o r re l a t i o n

of

asympto

c! iscogra phl

2 : ,00 - 3 1 2 .

( 1 9�S) ,l1antpulalion Past and

Present. Lo n d o n : Heinelll31lJl Medica l .

H.

Schmorl , G . , JlI ng h a n m , S t ra t t o n , p p .

Pain DiagnosiS and

( 1 97 1 ) The Human Sp ine in

2nd

edn.

New York:

&

Grune

, 1 48 , 1

( 1 9,)(» D i scovery the a u to n o m t c n e rvous I. 5 . :\'(,U)'I)/. PsycfJirrlry 35: 1 08 1

D.

syste m . A rch.

M crskey, H . ( 1 993) Psyc h o logi c a l consequen ces o f w h i p l a s h . I n : Cervical Flexion -Extension/Whiplasb Injuries (Te a se l l

R.W.

Reviews

S h a pi ro .A. P , c d s) . S p i n e ' State o f t h e Art

S h e ! o kov,

B.

(1 to

t h e mselves

256: 3 1 7 R . W. , Jones,

O i sease (R eg11l

c h e m o n uc!eolysis

R.H.

( 1 99 1 )

16,

Construct

validity

of

-H38.

( 1 9 5 2)

t r u n k s . Nature

1 29 :

ext re mi t ic' o f sym p a t h e t i c 533 - 53 4 .

OliS System, Edi o b u rgh

L i v i ngstone.

01

( 1 9 3 5 ) H e r n i a tion o r r u p ture

in terve rtebra l d i s c i n to the spin a l c a n a l .

lhe

N Engl ] Med .

385 - .

It!

H e rzog,

( 1 994)

ima g i n g m o d a l i t i e s . o rd e r

5p ine

b a c k p a in .

the A rt Reviews

Meet. 73: 5 5 - J 08 . F.J (l 9 9 4 ) Trearme n r of a c u te i nj u ry of the c e rv i c a l s p i n e . ] Bon ejoint Surg 76: 1 882 - 1 896 ( 1 99 5 ) W.O. , S koHo n , M . L . L R. I'orce Oil S c i e n tific monogra p h of A.V,

Eism o n t ,

whi p l a s h-asso c i " t"'..! d is o rd e r s : rcd e fU1 ing ' W hl P l a s h " and

H.A.

S t e in e r,

( 1 94 3)

20:

(BS ) .

R oe n tgenologic

m a n i fe s t a t i o n s

A Pre-clin lrlli View Of Osteoartbritis

and

who , h m1id

(]

S u n d e r la n d , S .

1 9 : ] -(,1 - 1 76 5 .

An a to m ic:ti perivertebrct l I nfl uence,

Tbe Resea rch StatLts

intervertrhL11 fora men .

Spinal

Attst. Prescriber 1 7 :

N1NCDS

9 - 1 2.

Nachemso n , A . L . ( 1 911 5 ) Advances in low-back p a in, elin.

Manipulative M o n ograp h

Tberapy no.

1 5.

(Go l d s t e i n

Bethesd a ,

Departm e n t of H e a l t h , Ed u c a t i o n ,

266 - 2'7r;

Orthop.

Edin

E.S. Liv i n g s t o n e .

corner

avail a b l e

40:

Medical S c h oo l .

( 1 99 4 ) T h e n o n p h a r m acological t r ea t m e n t o f

N a t i o n al

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).


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


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


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.


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).


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


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.


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,


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

resonance imaging of s p i n a l tra u m a . Br. ) Radia l. 64: 3 86 - 402

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


52

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.

edn (Be se m a n n , E . F , tran s )

( 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

b e h a v i o u r o f t h e cervical d iscs

d u r in g life . I n : Cet'l'ical Pain (H irsc h ,

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

f M PT 1 3 : 2 0 7 - 2 1 4 . P D. ( l 990b) A c o m p a rison

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


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 .


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......

- -- 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


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,


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


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

,


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.

,


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 .


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


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


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.


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


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


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


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.


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.


to

the

ex p e ri en c e

69: 895 - 903 .

ante rior with

craniocervical

72

p a t i ems

.

.f.


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


(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,


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,


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\

Clinical Anatomy and Management of Cervical Spine Pain

Conservative Management of Cervical Spine Syndromes

Pitfalls in Cervical Spine Surgery: Avoidance and Management of Complications

Clinical Pain Management Chronic Pain, 2nd edition

Clinical Pain Management Cancer Pain, 2nd edition

Clinical Anatomy of the Lumbar Spine and Sacrum (4th Edition)

Radiography of the cervical spine in trauma

Physical Therapy of the Cervical and Thoracic Spine, Third Edition

Fractures of the Cervical, Thoracic, and Lumbar Spine

Reconstruction of Upper Cervical Spine and Craniovertebral Junction

Clinical Kinesiology and Anatomy

Clinical Kinesiology And Anatomy

Clinical Pain Management: A Practical Guide

Clinical Pain Management Acute Pain (Hodder Arnold Publication) - 2nd edition

Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy

Handbook of Pain Management

Pain Medicine and Management

Bonica's Management of Pain

Essentials of Pain Management

Pain Management

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Pain Management

Pain Management

Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students

Genitourinary Pain and Inflammation: Diagnosis and Management (Current Clinical Urology)

Chronic Pain (Pain Management Series)

Chronic Pain. Pain Management Series

Clinical Pain Management Practice and Procedures, 2nd edition

Cancer Pain: Assessment and Management

Clinical Anatomy and Management of Cervical Spine Pain

Conservative Management of Cervical Spine Syndromes

Pitfalls in Cervical Spine Surgery: Avoidance and Management of Complications

Clinical Pain Management Chronic Pain, 2nd edition

Clinical Pain Management Cancer Pain, 2nd edition

Clinical Anatomy of the Lumbar Spine and Sacrum (4th Edition)

Radiography of the cervical spine in trauma

Physical Therapy of the Cervical and Thoracic Spine, Third Edition

Fractures of the Cervical, Thoracic, and Lumbar Spine

Reconstruction of Upper Cervical Spine and Craniovertebral Junction

Clinical Kinesiology and Anatomy

Clinical Kinesiology And Anatomy

Clinical Pain Management: A Practical Guide

Clinical Pain Management Acute Pain (Hodder Arnold Publication) - 2nd edition

Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy

Handbook of Pain Management

Pain Medicine and Management

Bonica's Management of Pain

Essentials of Pain Management

Pain Management

Pain Management

Practical Management of Pain

Pain Management

Pain Management

Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students

Genitourinary Pain and Inflammation: Diagnosis and Management (Current Clinical Urology)

Chronic Pain (Pain Management Series)

Chronic Pain. Pain Management Series

Clinical Pain Management Practice and Procedures, 2nd edition

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