Disorders of the Cervical Spine

From WiserWiki

[edit] Disorders of the Cervical Spine

John H. Bland

The extremely flexible cervical spine is the body's most complicated and mobile articular system; it is designed for mobility at the expense of stability.The seven small, comparatively fragile cervical vertebrae (C1 to C7) with their extensive ligaments, capsules, tendons, and muscle attachments are poorly designed to protect their contents compared with the skull above and the thorax below.The cervical spine balances a 10-to 15-pound ball, the head, on the lateral masses of the atlas.

Many clinically reported and distinct syndromes arise from abnormalities of the tissues of the cervical spine alone.Even more syndromes arise from distant structures, but they are associated with signs and symptoms referable to the cervical spine, head, shoulders, and upper extremities.These disorders constitute a considerable portion of any physician's practice.

[edit] EPIDEMIOLOGY

More than 10% of the Swedish population recalled having at least three episodes of pain in the neck in a 1984 study.Up to 12% of women and 9% of men experienced neck pain with orwithout associated arm pain.Seventy percent of adults who visited their physicians for neck pain were well or were improving within 1 month.Neck pain is a recurring clinical event and for most patients a mild to modest, transitory nuisance.

[edit] ANATOMY

The nucleus pulposus, present at birth, gradually disappears between ages 12 to 14 years and 35 to 40 years.Little if any nucleus pulposus remains in any of the disks in the cervical spine.Thus persons over age 40 cannot herniate the nucleus pulposus.The uncinate process, a bony development laterally and posterolaterally, enlarges with increasing age and presents a bulwark that prevents herniation of the intervertebral disks posterolaterally.^[1]

From the level of C3-4, the posterior nerve root exits are below the level of the vertebral disk.Thus the nerve roots are found regularly with increasing obliqueness from above downward.Clinically, it is impossible for the disk to compress nerve roots within the spinal canal, because the root exit zone is below the level of the disk.After age 40 to 45, all dural root sleeves (exit sites) become fibrotic and stiff.All zygapophyseal joints (posterior joints) have menisci capable of proliferation into a pannuslike structure over the cartilage surface, which is clinically significant.^[2] The anterior nerve root is low in the intervertebral foramen and thus is unlikely to be compressed.The posterior root is well protected from the point of view of any disk herniation; however, the zygapophyseal joints can become enlarged, osteoarthritic, and osteophytic and compress the posterior nerve roots.Any radiculopathy (although radiculopathy itself is rare) is a consequence of the zygapophyseal joint abnormality, not of the uncinate process or the alleged joints of Luschka.

Considerable disparity exists between the anteroposterior diameter and the transverse measurement of the spinal cord as it relates to the internal diameter and transverse diameter of the spinal canal.“Fat” cords and “thin” cords are seemingly a genetic endowment; the ideal is a thin cord and a capacious spinal canal, a constitutional characteristic.

Preganglionic sympathetic fibers are not present in the cervical spine because they originate from thoracic (T1, T2, and T3) levels and have their first synapse in one or more of the three cervical sympathetic ganglia.The postganglionic fibers travel in three directions: (1) distributing into the upper extremity, providing all autonomic function to the arm and hand; (2) reentering the intervertebral foramina and the spinal cord, with connections in the vestibular apparatus, cerebellum, hypothalamus, and thalamus as well as to the spinal nerves; and (3) accompanying vertebral and carotid arteries, following their distribution in the brain with multiple connections.^[3]

The anterior portion of the spinal canal is characterized universally by bars of osteophytes at the level of the intervertebral disks, sometimes compressing the cord to varying degrees.The ligamentum flavum is usually hypertrophic and hyperplastic, projecting into the posterior spinal canal.A 30-degree turn of the head normally kinks the ipsilateral vertebral artery.A 45-degree turn kinks both vertebral arteries.In the presence of osteoarthritis, disk disorders, and facet disease, vertebral artery compression is not rare and can become symptomatic.

Physiologically, the cervical spine is characterized by a high degree of motion.When any part of the musculoskeletal system is put to complete rest, series of events will culminate in total destruction of a joint in approximately 4 to 6 months.Wherever there is the least motion, there will be the greatest degree of pathophysiologic change in the involved tissues.Because the cervical spine is virtually never completely still, it is especially vulnerable to partial immobilization and at considerable risk by total immobilization.Prolonged immobilization in a cervical collar may result in stiffness, pain, and limited motion.Immobilization, partial or total, should be avoided as much as possible.^[4]

[edit] PATIENT EVALUATION

[edit] History

Knowing the patient's age and occupation is extremely important.Cervical osteoarthritis with myriad syndromes is a disease of later life.Trauma and “crick” (spasmodic torticollis) occur in younger people.Occupations requiring continued or intermittent hyperflexion, hyperextension, or overrotation of the cervical spine may produce and prolong symptoms.Details about previous injury are important.Whether the patient wears bifocal glasses may be pertinent because bifocals usually require the patient to extend the occiput, atlas, and axis complex and to flex the lower cervical spine.Inquiry about the type of pillow the patient uses, if any, frequently reveals useful information. Additional questions may be what type of chair the patient uses at home or at work, and how the patient sits in his car and uses the TV and computer.

[edit] Physical Characteristics.

Physical characteristics such as neck length, receding mandible, high arched palate, crooked teeth, and asymmetry of facial bones and muscles should be noted.Information about temporomandibular joint (TMJ) function is important.Investigation of a painful bite, limited jaw opening, or swelling of the TMJ area may lead to a proper diagnosis.

[edit] Pain Characteristics.

Three phases or periods of the patient's pain history should be investigated during the interview: onset, course, and present status.The location, size, distribution, quality, intensity, severity, and duration of the first pain should be noted.Fig.124-1 illustrates patterns of reflexly referred pain from visceral and somatic structures.Box 124-1 lists for common disorders causing cervical and shoulder pain.Head pain is common in and characteristic of cervical syndromes.A lesion at the C6-7 level may cause neurologic or myalgic pain and muscular tenderness in the precordial or scapular region and may suggest angina pectoris.

Figure 124-1 A, Anterior and posterior referral sites from distant visceral or somatic structures. B, Posterior referral sites. C, Distribution of all shoulder structures derived from fifth cervical (C5) dermatome-myotome-sclerotome. D, Distribution of dermatomes and sclerotomes of upper extremities. (D from Lance JW, McLeod JG:A physiological approach to clinical neurology, ed 2, Reading, Mass, 1975, Butterworth.)

[edit] Paresthesia and Weakness.

Numbness and tingling occur in the segmental distribution of the nerve roots, often with no demonstrable objective sensory change.Weakness is uncommon but requires inquiry.Patients who have trouble balancing their heads because of muscle weakness have clearly lost power.

[edit] Symptoms.

Eye symptoms and signs associated with cervical syndromes include blurring of vision, frequent change of glasses without improvement, relief of pain by changing neck position, increased tearing, retroorbital pain, and strange description of eyes “being pulled backward or pushed forward.” These signs and symptoms likely result from irritation of the cervical sympathetic nerve supply to eye structures.Change in equilibrium occurs because of irritation of sympathetic plexuses surrounding the vertebral arteries orfrom vascular insufficiency.Dysphagia can be caused by muscle spasm and anterior osteophyte compression of the pharynx and esophagus (Fig.124-2).

Figure 124-2 Diffuse idiopathic skeletal hyperostosis.Laminar bone at C3-4 level has pushed esophagus forward, stretching tissues and causing dysphagia.

Multivalent pathogenetic mechanisms explain many bizarre symptoms, some of which are unrelated.A patient comment such as “I can't get a deep breath” may be caused by C3 to C5 lesions whose roots innervate the diaphragm and other respiratory muscles.Cardiac palpitation and tachycardia may result from unusual positions or hyperextension of the neck caused by irritation of the C4 nerve root supplying the diaphragm and pericardium or by irritation of the cardiac sympathetic nerve supply.Nausea and vomiting, poorly defined pain, and paresthesia may be caused by cord compression.Drop attacks may result from abrupt loss of proprioception; the patient may collapse without loss of consciousness, often with the ability to rise and continue with previous activity.Differentiating psychoneurosis from cervical syndromes is a common problem, usually reflecting theexaminer's inexperience with nerve root compression, sympathetic nervous system involvement, cervical cord compression, vascular insufficiency, and diseases and trauma of cervical bone, muscle, and joint.

[edit] Physical Examination

Most patients with cervical spine syndromes require a complete physical examination in addition to a thorough musculoskeletal examination with appropriate regional focus.

[edit] Posture and Movement.

The patient should be gowned and sitting upright to determine the range of motion of the cervical spine.The patient's posture should be observed from the front, back, and side while the patient is sitting, standing, and walking.Anatomic details such as scapular height, spinal curves, head tilt, and head position should be noted.The cervicothoracic and thoracolumbar junctions and the sacral area should be examined.The presence of cervical lordosis, kyphosis, and lumbar lordosis should be specifically investigated.Gait analysis may help in making a diagnosis such as scoliosis, congenital lesions, or even a lumbar spondylolisthesis, which is reflected clinically in the cervical spine.The patient's ability and willingness to move should beobserved, looking particularly for head or neck guarding.The acuteness of the problem should be assessed.

[edit] Physical Abnormalities.

The patient should be observed for any abnormal appearance such as extreme height or shortness, an unusually long or short neck, retracted mandible, crooked teeth, or high palate.These abnormalities, as well as facial asymmetry, abnormal facial development, and asymmetric bone and muscle development, suggest congenital anomalies of the cervical spine, particularly the upper third.

[edit] Neurologic Examination.

Table 124-1 lists screening tests.

Table 124-1 Neurologic Screening Tests

[edit] Spinal Movement.

With the patient standing, movement of the entire spine in flexion, extension, lateral flexion, and rotation should be observed.Passive ranges of motion should be determined, then actively increased.All four motions should be tested against resistance to observe the patient's motor power and to determine whether muscle contraction against resistance produces pain.The goal is to produce signs and symptoms that will identify the pain-sensitive structure for a precise diagnosis.

[edit] Shoulder Examination.

The examiner should determine whether the shoulder or any structures within it are contributing to pain in the neck (see Chapter 125 ).

[edit] Testing for Nerve Root Compression.

The quadrant position is used to alter the size of the intervertebral foramina and determine whether the nerve root can be compressed.Head extension is tested first, so that the inferior facet of the vertebra above glides posteriorly on the facet of the vertebra below, thereby narrowing the foramina.If this maneuver produces shoulder pain, paresthesia, or numbness, the nerve root is compressed in the foramina.Other maneuvers should not be attempted.If the patient does not experience these symptoms, lateral flexion should be attempted, which closes the foramina toward the side of the flexion and opens it on the opposite side.If this maneuver produces the syndrome, other maneuvers should not be made.If it does not produce the pain or dysesthesia syndrome, full rotation should be added, which maximally closes the foramina on one side and opens it on the opposite side.If active range of motion produces the syndrome, the examiner need not use the quadrant position.

[edit] Head Compression Test (Spurling Test).

Compression of the head, causing force transmission to the cervical spine, may induce pain by narrowing the intervertebral foramina.Upper extremity radicular pain or paresthesia produced or intensified by this maneuver is indicative of nerve root irritation.Localized, nonradicular pain suggests that soft tissue or joints are the pain-sensitive structures.The test is performed with the patient sitting.The physician places one hand across the other on the top of the patient's head and gradually increases downward pressure.The patient is instructed to report pain or paresthesia and its distribution.Repeating the test with the patient's head tilted to either side, backward, and then forward increases the test's sensitivity.

[edit] Distraction Test.

This test predicts the effect of cervical spine traction in relieving pain or paresthesia.Nerve root compression may be relieved, with disappearance of the symptoms and signs, if the intervertebral foramina are opened or the disk spaces extended.Pressure on joint capsules of apophyseal joints is also decreased by distraction.Muscle spasms of any cause may be relieved.The test is performed with the patient sitting.The physician places the palm of one hand under the patient's chin and the other under the occiput and gradually increases the force of lifting, removing the weight of the skull and distracting the foramina, disks, and joints.This test is continued for 30 to 60 seconds.

[edit] Palpation.

The examiner palpates the anterior and posterior cervical triangles for the brachial plexus and examines the site of the subclavian artery.Deep palpation also allows examination of the transverse processes of the atlas and axis and sometimes the third vertebra.Identification of landmarks in the anterior triangle assists in clinical orientation, such as in the identification of a fractured cervical vertebra.The hyoid bone is at the C3 level.If signs and symptoms are associated with C3, tenderness may be present at this level.The thyroid cartilage is at the upper level of C4, the thyroid gland at the lower level of C5, and the first ring of cricoid cartilage at the C6 level.

[edit] Appearance of the Back.

The levator muscle of the scapula, the trapezius, rhomboid and scalene muscles, and superior angle of the scapula should be observed for atrophy, weakness, and neurologic signs.The deltoid, supraspinatus, and infraspinatus muscles should be observed for atrophy.The skin should be examined for thickness, color, scars, temperature, past incisions, and ecchymoses.The carotid arteries are palpated for tenderness.The sternocleidomastoidmuscle and its function are examined.Sites of tenderness are marked with a felt-tipped pen and correlated, if possible, with the local structures.Table 124-2 lists cervical spine diseases with unusual pathogenesis.Fig.124-3 outlines the pathophysiologic mechanisms of common soft tissue cervical spine syndromes.

Figure 124-3 Pathophysiologic mechanisms of soft tissue cervical spine syndromes.

Table 124-2 Cervical Spine Diseases With Uunusual Pathogenesis

[edit] RADIOLOGIC EVALUATION

Technologic advances have greatly improved imaging of the cervical spine.Arthrography and diskography are rarely used.Development of low-toxicity, water-soluble myelographic contrast has ushered in the era of computed tomography (CT) myelography.Magnetic resonance imaging (MRI), with continuing refinements in software technology and surface coils, has added a new dimension of noninvasive evaluation of the cervical spine and spinal cord.

Conventional radiography of the cervical spine includes anteroposterior (AP), AP odontoid, lateral, and right and left oblique views.Two AP views are needed.The AP odontoid through the open mouth demonstrates the entire odontoid process and may also show atlantooccipital or atlantoaxial joints.The second AP view includes the lower cervical spine from C3 to T1.A lateral cervical spine radiograph should show the base of the skull, seven cervical vertebrae, and the end plate of the first thoracic vertebrae.If shoulders prevent clear imaging of the lower vertebral bodies, a coned-down, or “swimmer's view,” of the cervicothoracic junction is obtained.Oblique views illustrate the neural foramina, pedicles, and the superior and inferior articulating facet joints.

The radiographic evaluation of trauma patients must be carefully tailored to prevent further neurologic injury.In a cooperative, neurologically intact patient, AP, AP odontoid, lateral, and right and left oblique views are obtained.Only if these radiographs are normal is it safe to proceed to flexion-extension views.In severely traumatized patients or those with neurologic deficits, only AP and lateral survey films are obtained without moving the patient.Further cervical spine evaluation of trauma patients is accomplished by CT scan.CT scanning accurately demonstrates fractures and displaced bone fragments that could cause serious neurologic injury by compromising either the spinal canal or neural foramina.

In radiologic evaluation of the cervical spine, MRI has several advantages over CT scanning.In contrast to CT, no ionizing radiation is involved.MRI has a higher contrast resolution, allowing it to differentiate between soft tissues, both normal and pathologic, with great sensitivity.Unlike CTscans, bone artifact does not degrade MR images.Multiple imaging planes (e.g., sagittal, axial, coronal, oblique) are available without repositioning the patient or significantly prolonging the length of the examination, an important advantage in the injured patient.The entire cervical spine is studied in sagittal and coronal images.

MRI study requires a cooperative patient.Disadvantages include extreme motion sensitivity.In addition, dense cortical or compact bone has few hydrogen protons and therefore is seen as a signal void on MR images with limited spatial resolution.Thus MRI may fail to delineate fractures and poorly defines bone spurs and calcification.MRI is more expensive than CT scanning, and patients occasionally are too claustrophobic to endure the study.

[edit] LABORATORY STUDIES AND DIAGNOSTIC PROCEDURES

Few laboratory studies are guided by results of the history and physical examination (e.g., occasional spinal tap, HLA typing, immunoglobulins, rheumatoid factor, antinuclear antibody).Diagnostic procedures include radiologic evaluation, occasional biopsy or electrodiagnostic studies, and less often CT scans, MRI, angiogram, or radionuclide studies.These diagnostic studies, as well as chest radiographs and electrocardiograms (ECGs), also help to exclude neck pain from metastatic disease and referred pain from chest pathology (e.g., Pancoast tumor, pneumonia, heart disease).

[edit] GENERAL MANAGEMENT

Maintaining optimum overall fitness contributes significantly to the success of management of cervical spine disorders and disease.Management and active treatment of disease, as well as rehabilitation of cervical spine disorders, are strongly linked to the rest of the spine and to the body as a whole.^[5][6] Patient education contributes greatly to success.Classes about arthritis are available through the Arthritis Foundation.Patient handbooks and educational materials may be helpful.Physical therapy modalities can be categorized as cryotherapy, the use of physical cold;thermotherapy, both superficial and deep, the use of heat by any method that provides heat;mechanical therapy, the use of massage, whirlpool, and methods that move the tissues about in various ways; and electrotherapy, stimulation of nerve and muscle by electric current.Cervical collars play a relatively small role in stabilizing the spine but remind the patient to minimize neck motion.The cervical spine is particularly vulnerable to loss of function when immobilized.The collar may provide comfort and warmth, psychologic benefit, and marginal control of movement.^[5][6][7]

[edit] Cervical Spine Pillows.

The use of pillows specifically designed for cervical spine disorders is an important part of management.They usually provide comfort and relief of pain and allow for normal sleep.A frequent complaint in cervical spine patients is night pain.Correction of poor sleepingposture is often successful in alleviating discomfort.Most people sleep on one or more pillows, promoting long flexion of the neck, with subsequent aggravation of or increase in pain due to muscle spasm.Sleeping with no pillow almost always makes symptoms worse.To sleep prone is to keep the neck rotated, strained, and laterally flexed for long periods.When poor sleeping posture results in head and neck pain, the use of a pillow may be helpful.

Cervical pillows vary in size and types, from air pillows blown up to the thickness that raises the head to the most comfortable level, to a tubular-shaped pillow (Cervipillow), to a multipurpose pillow (Wal-Pil-O).Wal-Pil-O provides four combinations of head and neck support, one of which is proper for almost all cervical spine problems.The Wal-Pil-O cradles the head and supports the neck in both side-lying and back-lying postures.It comprises four pillows in all, with soft and medium centers for head and narrow and wide, firmer borders for the neck.The Shape of Sleep pillow features a neck support ridge that fits under the neck and is a physiologic, biomechanically sound model.Bolster-type pillows in different diameters and pillows with a contour cutout for the head are also available.^[8]

[edit] Cervical Spine Traction

The usefulness and effectiveness of cervical spine traction are well established; it does cause vertebral distraction.This separation allows alteration of the pathologic relationship between the nerve root and compressing disk or between the nerve root and zygapophyseal joints.About 75% to 80% of patients with radicular symptoms receive clear benefit, usually lasting months to years, from optimally applied traction.

Intermittent traction is the best initial application.The clinical problem may be solved that simply.The weight applied ranges from a minimum of 10 pounds to a maximum of 50 pounds (rarely) over 15 to 20 minutes.If significant improvement does not occur over 8 to 10 sessions of optimally administered traction, it should be discontinued.If symptoms have worsened, the physician should identify precisely why the therapy was not successful.The amount of weight used in traction is a function of the patient's size, the presence of neurologic symptoms or signs, the specific lesion for which traction is prescribed, and the patient's general sense of comfort and improvement.The physician is guided by the results of each traction session.With secure improvement, patients may purchase home equipment and continue traction until all symptoms resolve, maintaining close contact with a medical authority.

Continual traction does not permit as much weight as intermittent traction.Increments of weight are added with each session, usually beginning with about 10 pounds, depending on the degree or lack of progress.Trial and error is used to determine distance from the traction pulley, direction of traction, and position.An average level of traction is 15 to 20 pounds for 20 minutes.The patient sits in slight cervical spine flexion facing the door or apparatus, and the angle of the rope is 20 to 30 degrees from vertical; this is a physiologic position (Fig.124-4, A).In general, pain relief occurs sooner and more completely in patients with radicular symptoms than in those with symptoms arising from the connective tissue structures of the neck (ligaments, tendons, muscles, joints).Symptoms related to the upper extremities are much more likely to be relieved by traction, whereas symptoms related to connective tissue structures are more likely to respond to other measures.Traction is manipulative therapy, but it is vastly different from adjustments involving rotational and lateral stretches, which pose a greater risk of root irritation.

Figure 124-4 A, Static cervical traction. B, Manual cervical traction. C, Static home cervical traction.

Cervical traction may be achieved manually.Some authors prefer manual traction because of the immediate sensory feedback and the specificity of treatment (Fig.124-4, B).In manual traction, one hand is placed under the chin with the other under the occiput, or both hands are placed under the occiput.A longitudinal force is exerted at varying angles of cervical flexion, extension, lateral flexion, and rotation.Degree, direction, and duration of the tractive force are guided by the patient's response, the clinical disorder, and the goal of treatment.Relaxation is urged before initiating traction.The degree to which a patient relaxes can be used as a method of assessing potential response to mechanical traction.

Self-administered or home traction should always be undertaken initially in a teaching session so that the patient completely understands the procedures and probable perceptions in the process.Self-traction can be performed with the patient in a supine or sitting position (Fig.124-4, C).The supine position combines the advantages of increased stability and the possibility of relaxation of muscles.

The angle of traction is between 15 and 35 degrees, depending on the clinical response and the patient's interpretation of its efficacy.The type of head halter used affects the angle of traction provided.The perception of force should be about equal under the occiput and the chin.In most patients, slight cervical flexion is preferred because in this position the posterior zygapophyseal joints are separated, the intervertebral foramina are enlarged, and the lateral nerve root canals are released.The application of moist heat before traction is recommended.

The decision for traction is based on the patient's history and physical examination.Two mechanisms by which cervical spine soft tissues can be damaged and fail are short-duration, high-amplitude loading and long-duration, low-amplitude loading.The first represents an obvious acute trauma—the classic automobile collision from the rear with whiplash injury.The second is a chronic sprain of soft tissues that occurs inconspicuously and gradually, usually with some final event that precipitates a more acute syndrome superimposed on a chronic condition.

[edit] Pharmacologic Treatment

Drugs have a relatively small role in the management of cervical spine syndromes unless specifically indicated.

[edit] Rest and Exercise

Stretching exercises for the cervical spine are used for the same reasons they are used elsewhere in the body: to prevent contracture, to increase range of motion if contracture has occurred, and to maintain biomechanical function of the supporting structures in the cervical spine.Range of motion exercises maintain or increase a limited range.Strengthening exercises are especially important because the cervical spine is extremely mobile compared with other areas of the body.

[edit] INDICATIONS FOR CONSULTATION

Neurologic consultation is indicated if the patient has rheumatoid arthritis (RA) of the cervical spine and subluxationsassociated with neurologic symptoms and signs.If these signs are progressive, the indication becomes urgent.Unidentified peripheral neuropathy or entrapment neuropathy at the thoracic outlet, at the elbow, and associated with carpal tunnel syndrome at the wrist may indicate cervical myelopathy.Neurologic consultation also may be necessary when neurosurgical or orthopedic surgery (e.g., facetectomy, laminectomy, chondroosteophyte removal) is being contemplated for a patient with cervical osteoarthritis and when progressive inflammatory muscle disease (e.g., polymyositis, dermatomyositis) is present.

Neurosurgical consultation may be needed in RA patients with cervical spine subluxations who require surgical stabilization of the spine or have RA signs and symptoms of myelopathy, radiculopathy, and peripheral neuropathy.Other indications for neurosurgical consultation include osteoarthritis of zygapophyseal joints, overproduction of osteophytes in the uncinate processes, or vertebral chondral osteophytes with progressive symptoms; cervical spine fractures, particularly in ankylosing spondylitis, RA with subluxations, or juvenile polyarthritis with soft tissue injury; and any trauma with fracture, dislocation, or both.

Consultative services provided by the orthopedic surgeon and the neurosurgeon overlap.In general, orthopedic consultation is indicated when reconstructive surgery is being considered, as in ankylosing spondylitis; in the hip, lumbarspine, and cervical spine; and with surgical subluxations in RA, with fusions and wiring techniques to stabilize the cervical spine.^[9]

[edit] CERVICAL SPONDYLOSIS (OSTEOARTHRITIS OF CERVICAL SPINE)

Osteoarthritis describes all joint involvement in the cervical spine, including all secondary manifestations in vertebrae, tendons, ligaments, capsules, muscles, and hyaline cartilage.^[4][10] Primary generalized osteoarthritis has strong genetic implications.This disorder is dominant in women and recessive in men.Further hereditary factors occur in ochronosis, calcium pyrophosphate dihydrate (CPPD) crystal disease, gout, and RA, all of which may play a role in secondary osteoarthritis.Cervical spine osteoarthritis affects virtually all persons age 50 and older.Clinical syndromes, symptoms, and signs in osteoarthritis of the cervical spine are divided into five general categories, with considerable overlapping: (1) involvement of the joints, or intraarticular and extraarticular structures, with clinical reflections; (2) involvement of nerve rootlets, or anterior and principally posterior nerve roots; (3) compression of the spinal cord, or cervical myelopathy; (4) involvement of the vertebral artery by the osteoarthritic process, notably at the atlas-axis-occipital level; and (5) esophageal involvement.

Attacks occur approximately once a year.The patient awakes with severe unilateral pain in the neck; the neck is sometimes fixed by definite deformity; acute torticollis with constant severe pain may last 2 to 3 days, with recovery in 7 to 10 days.Pain caused by joint involvement is more likely to arise from the upper cervical spine, whereas pain caused by intervertebral disk osteoarthritis is more likely to arise from the lower cervical spine.These attacks occur from about ages 35 and 40 to 55 and 60 and gradually become more frequent, depending on the progression of the pathologic events.Pain may be variably severe and referred to the occipital, retroorbital, and forehead areas.Pain is usually worse in the morning and associated with stiffness, making neck rotation difficult.Moderate to severe unilateral cervical posterior root pain may occur after age 35; it is worse at night, with paresthesias in the hands.Arm pain is maximal for 2 to 3 weeks, lasts for 1 to 2 months, and subsides gradually.A pain episode may last about 3 months.When bilateral disk protrusion occurs, pain is present in both upper limbs, and paresthesia occurs in the digits of both hands.Central protrusion may press on the posterior longitudinal ligament and dura mater, becoming adherent, fibrotic, and adhesive and resulting in constant bilateral aching from occiput to scapula.Bilateral disk protrusion occurs primarily in patients age 60 and older.Motion is usually in only one to three of the six classic movements of the cervical spine; flexion is usually preserved, with limited lateral flexion, extension, and rotation.Painless restriction (painless stiffness) is interpreted as resulting from osteoarthritis.Manual compression of the zygapophyseal joints elicits tenderness.Osteoarthritis of zygapophyseal, atlantoaxial, and atlantooccipital joints causes ligamentous contracture.

Radiologic characteristics of cervical spondylosis include zygapophyseal and uncinate processes, with increased density of bone, varying degrees of chondroosteophytosis, irregular narrowing of joint spaces, and sometimes pseudocysts.There are no specific laboratory findings.Occasionally, routine radiologic studies are supplemented by CT or MRI.

[edit] Management

The patient is taught the natural history of osteoarthritis of the cervical spine.The majority of patients continue to be functional and effective.Daily stretching and range of motion exercises are emphasized, including cervical, thoracic, and lumbar portions.Physical therapy involves heat, ultrasound, diathermy, heating pads, infrared lamps, hot wet packs (hydrocollator), hot tub baths, Hubbard tank, and special pillows.Analgesic, antiinflammatory, and muscle relaxant drugs may be helpful.Special attention is needed for patients with complications of cervical spine osteoarthritis: radiculopathy, peripheral neuropathy, myelopathy, esophageal involvement by osteophytes, and vertebral artery compressive syndromes, with appropriate neurologic, neurosurgical, or orthopedic consultation.Other strategies include traction in select patients; relaxation techniques two or three times a day, particularly at night; and cervical massage.The prognosis is generally good.^[11]

[edit] NEUROLOGIC DISORDERS

The clinical manifestations of nerve root involvement include compression of the posterior root and dorsal root ganglia infection by viruses such as herpes zoster.The anterior or motor root is well protected and anatomically low in the intervertebral foramen and thus rarely involved.Most of these syndromes are sensory, involving the posterior nerve root and the dorsal root ganglia.Sensory changes include functional disturbances, pain, paresthesia, anesthesia, hypesthesia, and hyperesthesia, which are confined to the dermatomes (skin areas supplied by specific cord segments, dorsal roots, or ganglia).Symptoms of nerve root irritation, termed radicular, are increase exacerbated by motion, coughs, sneezes, strain, nerve root stretching, and increased intraspinal pressure.The pain is lancinating in character, intermittent, and rarely constant.Etiologies for nerve root involvement are osteoarthritis, pachymeningitis, extramedullary tumors, protruded intervertebral disks, extradural abscesses, and a variety of viral disorders and active inflammation (e.g., nonspecific, noninfectious granuloma of RA).Muscle spasm alone can cause nerve root compression.

[edit] Cervical Radiculopathy

Cervical radiculopathy of osteoarthritis may be single or multiple, bilateral, symmetric, or asymmetric, with varying degrees of involvement of each separate root, and is often associated with myelopathy.Clinical syndromes are divided into acute, subacute, and chronic radiculopathies.

[edit] Acute Type.

Acute radiculopathy is characterized by an abrupt onset of severe pain and aching in the dermatomal distribution of the cervical root involved.Pain perception affects bone, joints, muscles, blood vessels, and skin, with wide radiation involving the neck, shoulder, down the arm and forearm, and to the digits.Pain may extend into the chest anteriorly and posteriorly, especially with C5 to C7 nerve root involvement.Pain is altered by head or neck position.Scalp, retroorbital, and cervical pain worsens with both active and passive rotation; lateral flexion, extension, and rotation are most painful.Pain is not exacerbated by coughing unless there is acute intervertebral disk protrusion.In a few patients, muscular weakness or decreased to absent reflexes are seen, reflecting involvement of the motor and sensory root.Atrophy may occur rapidly with fasciculations.Tendon reflexes are diminished or lost.

[edit] Subacute Type.

With subacute radiculopathy, or typical “brachial neuritis,” usually more than one root is involved.It is characterized by pain in the neck with associated paresthesias and severe muscle spasm.Mild muscle atrophy, hypotonia, and muscle weakness are uncommon.Frozen shoulder is a frequent complication, as are tennis elbow and carpal tunnel syndrome.

[edit] Chronic Type.

Chronic radiculopathy usually follows unaccustomed exercise or work in an awkward position.Symptoms and signs develop insidiously, only partially clearing after an acute attack with lingering pain.Radiologic characteristics include narrowing of intervertebral disk spaces and zygapophyseal joints, along with chondroosteophytes of the uncinate processes.Special studies include electromyography and special radiologic views to identify narrowed intervertebral foramina.Occasionally, MRI is required.

[edit] Management.

Patient education focuses on outcome, usually a good prognosis with optimum management.Physical therapy includes heat, cold therapy occasionally, and both alternating at times; gentle stretching and strengthening exercises; range of motion exercises; and intermittent use of a soft or hard plastic collar.Antiinflammatory drugs and occasional analgesics are helpful, but with little or no role for narcotic or potentially addictive drugs.Traction is judiciously applied with close follow-up and monitored according to specific results.Other therapies include a cervical spine pillow, massage, occasional lidocaine and corticosteroid injection in areas of pain and spasm, and hydrotherapy.

[edit] Cervical Myelopathy.

Symptoms of cervical myelopathy are related to ischemia and compression of the spinal cord by osteoarthritic bars, hypertrophied ligamenta flava (posteriorly), cervical disk material anteriorly, and surrounding structures.Clinical symptoms vary greatly.Disability increases subtly, often preceded by a history of radicular symptoms and recurrent attacks of brachial neuritis.The patient also may experience paresthesias and dysesthesia of the hands, weak and clumsy hand functioning, weakness in the lower limbs, and vague deep pain in the lower extremities.Numbness and tingling occur in the finger tips.The pain is often radicular.Touch perception is usually not compromised, but the patient may have vague impairment of light touch and tactile discrimination, with pinprick sensation diminished to absent.Sensory loss may be one or two dermatomes above the upper segmental level of spinal compression.Vibration sense is impaired or lost below the iliac crest or costal margin; some loss may occur over the digits of the hands.Perception of passive movement in fingers and toes is slightly impaired.Acute cervical disk protrusion may involve sudden spinal cord compression, severe disabling neck pain and weakness, and paresthesias of the upper or all four extremities.Paresthesias in the soles of the feet are increased by neck flexion.

Onset of myelopathy may be painless and slow, with difficulty in gait and upper motor neuron signs affecting both legs.Both hands and feet are paresthetic, and the patient experiences the sensation of pins and needles from the anterior knees to all toes.Myelography shows often multiple protrusions, with several sites of spinal cord compression, and both chondroosteophyte formation and disk herniation, distinguishable only at laminectomy.The posterior longitudinal ligament has adhesions to the dura mater resulting from proliferative, thick fibroses.Neck flexion causes overstretching and further damage to the spinal cord.Pressure on the anterior spinal artery may cause widespread ischemia and cord infarction with paraplegia.

Atrophy of the upper limbs is variable.If upper cervical enlargement is compromised, the supraspinatus and infraspinatus muscles and the deltoid-triceps-biceps–greater pectoral muscles may be involved, as well as the dorsiflexors of the wrists and fingers.If the lower part of the cervical enlargement is involved, most wasting is in the flexors of the wrist and fingers and intrinsic muscles of the hands; wasting is variable.Corticospinal tract involvement is below the level of other involvement if motor radiculopathy coexists.If only the corticospinal tract is involved, symptoms are limited to the lower limbs, with spastic paraplegia and no upper limb symptoms.Rarely, symptoms are motor only, with muscular wasting of the upper limbs and spastic weakness of the lower limbs simulating motor neuron disease.Severe paraplegia or quadriplegia and loss of sphincter control also occur rarely.Muscular wasting and pain may be associated with concomitant osteoarthritis of the lumbar spine.

Tendon reflexes have diagnostic importance.A normal jaw jerk with exaggerated tendon reflexes of the upper extremity suggests that the lesion is below the level of the foramen magnum.An exaggerated, diminished, or absent jaw jerk suggests a lesion above the level of the pons.Tendon reflexes in myelopathy are a function of both upper and lower motor neuron lesions.Compression of the anterior horn cells causes lower motor nerve dysfunction, whereas compression of the corticospinal tract causes upper motor neuron dysfunction.Ultimately, reflexes disappear, but this is preceded by an exaggeration of reflexes, inverted radial reflex, extreme flexor finger jerks, and positive Hoffmann's and Babinski's reflexes.Abdominal reflexes diminish but are rarely lost; clonus, bowel, and bladder symptoms and signs rarely if ever disappear.

Cerebrospinal fluid often shows increased protein content (18 to 125 mg/dl).Pressure may be elevated, and Queckenstedt's test may be positive.Passive extension of the neck may raise the pressure, indicating partial but not complete block.Laboratory data are not usually helpful.Radiologic studies reveal the usual changes of osteoarthritis.Special studies show narrowing of the sagittal diameter of the spinal canal, as measured on standard radiographic films.MRI may be required for precise diagnosis.

[edit] Management

Special adaptations are provided for patients with problems of cervical cord compression.Surgical therapy is indicated only in unusual circumstances.Extensive laminectomy, foraminotomy, and excision of osteophytes are often unsuccessful.The natural history of cervical osteoarthritic myelopathy is one of mild disability.After initial deterioration, a static period may last for several years.

[edit] FRACTURES

As a rule of thumb, any patient with a severe head injury should also be evaluated for possible neck injuries.Cervical spine fractures must be ruled out in any patient who hasmultiple trauma or is unconscious.Every patient holding the head and complaining of neck pain should also be treated for a fracture until proved otherwise.The head and neck are stabilized first to prevent further spinal cord damage.Patients with head injuries, in shock, or with multiple trauma are frequently combative, requiring restraints.Every emergency room (ER) should be equipped with rigid and adjustable cervical collars to stabilize the spine until radiographs are obtained.

Fractures of the cervical spine are usually the result of severe trauma to the head or head and neck, usually from an axial load or flexion and rarely from an extension force on the head and neck.These forces may have a rotatory component that adds to the displacement.The neurologic examination should be properly documented as soon as the patient arrives at the ER.Radiographs should include an AP or swimmer's view of all the vertebrae, including C7.In a swimmer's view, while one arm is abducted 180 degrees, the other arm is pulled down and a radiograph taken at T1.Oblique views, tomograms, or CT scan may also be necessary.

C1 trauma may result in fracture of the posterior arch and anterior tuberosity that constitute the C1 vertebral body.If no subluxation or dislocation occurs, C1 fracture does not involve spinal cord damage.The diagnosis can be overlooked if the posterior arch of C1 is not properly visualized.CT scans or tomograms are helpful, and immediate treatment is immobilization of the spine (Fig.124-5).Cranial-skeletal traction is preferable until swelling and muscle spasm subside.The neck can then be immobilized in a cervical brace until bony union occurs.

Figure 124-5 CT scan of first cervical (C1) vertebra, or atlas, showing fracture of ring structure without compression of internal neural structures.

[edit] Odontoid Fractures

Fractures of the odontoid are increasingly recognized, usually associated with motor vehicle accidents.Different classifications exist for this fracture, which can be high or low on the odontoid process.Lower fractures, where the odontoid is essentially part of the C2 vertebral body, have a greater incidence of bony union.Fractures at or above the “waistline” of the odontoid have a high incidence of nonunion.These fractures should be differentiated from a congenital os odontoideum, a failed union between separate ossification centers.

With the exception of the lower type, the preferred treatment for odontoid fractures is fusion of C1 and C2.Immediate treatment consists of rigid immobilization with a cervical brace, cranial-skeletal traction, or a halo vest, depending on the associated soft tissue injuries.This helps protect against further spinal cord injury.

[edit] Hangman's Fracture

Hangman's fracture occurs through the pedicles of C2 and is associated with capital punishment.To eliminate the slow deaths from asphyxiation, the long drop was employed at hangings in London first in 1784.This resulted in a C2 fracture.The submental knot, applied in judicial hangings, causes a traumatic spondylolisthesis of the axis (C2).This injury can also occur in head-on automobile collisions with the victim's head hitting the windshield, causing extension with fractures of the pars of C2.When these fractures are associated with severe displacement, the spinal cord is damaged and the patient cannot survive (Fig.124-6).Undisplaced fractures, however, frequently cause no neurologic symptoms.Occasionally, pain occurs along the greater occipital nerve, but more often, neck pain and muscle spasm are the presenting symptoms.

Figure 124-6 A, CT scan of second cervical (C2) vertebra, or axis, showing fracture and discontinuity of ring structure. B, Lateral view showing C2 fracture (arrow) complicated by almost total ligamentous disruption between C2 and C3.

Treatment should be cranial-skeletal traction and then rigid immobilization, usually in a halo vest.The traction may need to realign minor displacement of the fragments.Surgery is rarely if ever indicated.

[edit] Fractures and Dislocation of C3 to C7

Injuries to the area of C3 to C7 can be devastating and are frequently associated with spinal cord injuries.Depending on the level of paralysis, the extent of the neurologic loss can vary from complete quadriplegia involving paralysis of the upper and lower extremities to high paraplegia with sparing of the upper extremities.The neurologic deficit results from ischemia, bleeding, decreased blood supply, or contusion of the cord, followed by swelling and oligemia, which result in cord necrosis with complete paralysis below the level of injury.The diagnosis is established after careful neurologic evaluation confirmed by radiologic findings.

The first treatment for fractures of the lower cervical spine is immediate immobilization with cranial-skeletal traction to provide temporary stabilization and alignment of the fracture.Patients may require surgical stabilization of the fracture and rarely a decompression laminectomy later, when their condition has improved.Spinal stabilization permits earlier rehabilitation and less time on bed rest or in a surgical orthosis.Surgery does not alter or lessen the neurologic deficit.

Minor, less devastating injuries to the cervical spine include stable fractures without neurologic deficit.The clay shoveler's fracture, for example, is an avulsion injury of the posterior spinous process.

[edit] ESOPHAGEAL COMPRESSION IN OSTEOARTHRITIS

Osteoarthritis can cause esophageal compression by osteoarthritic chondroosteophytes or by subluxated cervical vertebrae (atlantoaxial subluxation or subaxial subluxation in RA).Dysphagia may manifest as difficulty swallowing (atlantoaxial subluxation), discomfort or pain during swallowing, and pain from the esophagus or gastroesophageal junction referred to the chest.Evidence of radiologic esophageal compression by anterior chondroosteophytes in osteoarthritisis noted on lateral cervical spine films.Some lesions may be asymptomatic even though they appear grossly compressive.Esophageal compression also can be demonstrated by barium swallow, lateral views of the cervical spine (neutral, flexion, extension), and esophagoscopy or gastroscopy if ulceration is suggested at sites of pressure by chondroosteophytes.

No treatment is indicated unless the patient has symptoms (see therapeutic maneuvers listed earlier).Surgical removal of anterior osteophytes may be necessary.

[edit] REFERENCES