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JOHN H. BLAND
The cervical spine is surely the most complicated articular system in the body; there are 37 separate joints whose function it is to carry out the myriad movements of the head and neck in relation to the trunk, and subserve all special sense organs, e.g., eyes, ears, nose, taste, touch, and proprioception. The 7 small cervical vertebrae with their ligamentous, capsular, tendinous, and muscle attachments appear poorly designed to protect their contents, compared with the skull above and the thorax below. The contents of this anatomical cylinder interposed between the skull and thorax include carotid and vertebral arteries, the spinal cord and all anterior and posterior nerve roots, and, in its uppermost portion, the brain stem. The extremely flexible cervical spine balances a 4.5-5.5 kg (10-12 pound) "ball," the head, on the lateral masses (zygapophyseal joints) of the atlas. The head acts as a cantilever on top of the highly mobile neck.
Normally, the neck moves over 600 times an hour, awake or asleep; no other part of the musculoskeletal system is in such constant motion. The cervical spine is subject to stress and strain in ordinary everyday activities--speaking, gesturing, rising, sitting, walking, turning about, even at rest lying down. The position of the cervical spine discloses mood, attitude, how you feel about yourself and the world about you. The cervical spine in flexion suggests depression, withdrawal, sadness, and mourning--sometimes prayer, as in bowing the head in prayer and supplication--while chin up extension of the cervical spine expresses optimism, confidence, savoir-faire, "all's right with the world." This section of the spine is constantly communicating with myriad subliminal gestures, poses, questions, and answers. A "pain in the neck" is such an unpleasant experience that it is used as an invective for any annoying event or person (how about the verb "to neck," i.e., kissing and caressing, the terminology currently out of style). Normal function requires that all movement be made without damage to the spinal cord, the entire vascular supply to the head and neck, with many millions--or perhaps billions--of nerve fibers passing through it and the intervertebral foramina.
Is the cervical spine clinically important? In one epidemiologic study, over 10% of the population recalled at least 3 episodes of neck pain within a 3-year period. Another reports that at any one time as much as 12% of the adult female population and 9% of adult males experience pain in the neck with or without associated arm pain; 35% of people report that they can recall an episode of neck pain. A most important clinical epidemiologic study of cervical spine pain disclosed that a history of stiff neck and arm pain was elicited in 80% of a population of male industrial and forest workers. Seventy percent of adults who visited their doctors for neck pain were well or improving within one month. Neck pain is a recurring ubiquitous clinical event, a mild to modest transitory nuisance to most of us, but occasionally quite serious!
The nucleus pulposus, present at birth, gradually disappears between the ages of 12-14 years and 35-40 years. Little if any nucleus pulposus remains in any of the discs of the cervical spine. Thus, persons over age 40 cannot herniate the nucleus pulposus--it just isn't there (Figure 1). The uncinate process is a bony development posterolaterally on the vertebral body that enlarges with increasing age and presents a bulwark that prevents herniation of the intervertebral discs posterolaterally.
From the level of C3-4, the posterior nerve root exits are below the level of the discs. Thus, the nerve roots are found regularly with increasing obliquity from above downward. Clinically, it seems impossible for the disc to compress nerve roots within the spinal canal because the nerve exit zone is below the level of the disc (Figure 2).
After age 40-45, all dural root sleeves (exit sites) become fibrotic and stiff. All zygapophyseal joints (posterior joints) have menisci capable of proliferation into a pannus-like structure over the surface of the cartilage. This structure has clinical significance (Figure 3).
The anterior nerve root is low in the intervertebral foramen and is unlikely to be subject to compression. The posterior root is well protected from the point of view of any disc herniation; however, the zygapophyseal joints can become enlarged and develop osteophytes that can compress the posterior nerve roots. Any radiculopathy (although radiculopathy itself is rare) is a consequence of zygapophyseal joint abnormality, not of the uncinate process or the alleged joints of Luschka. There is considerable disparity 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. There are "fat" cords and "thin" cords--seemingly a genetic endowment. The ideal is a thin cord and a capacious spinal canal, a constitutional characteristic.
The anterior portion of the spinal canal is characterized universally by bars of osteophytes at the level of the intervertebral discs, sometimes compressing the cord to varying degrees. The ligamentum flavum is hypertrophic and hyperplastic, in most instances, projecting into the posterior spinal canal (Figure 4).
A 30° turn of the head normally kinks the ipsilateral vertebral artery. A 45° turn kinks both vertebral arteries. In the presence of osteoarthritis, disc 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. Any part of the musculoskeletal system that is put to complete rest will result in an unfortunate series of events culminating in destruction of a joint within approximately 4-6 months. Wherever there is the least motion, there will be the greatest degree of pathophysiologic changes in the involved tissue. 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 predictably results in stiffness, pain, and limited motion. Immobilization, partial or total, should be avoided as much as possible. The cervical spine is by far the most mobile portion of the entire spine.
Knowing the patient's age and occupation is extremely important. Cervical osteoarthritis and its 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 they usually require the patient to extend the occiput, atlas, and axis complex and flex the lower cervical spine. Inquiry about the type of pillow the patient uses, if any, frequently reveals useful information about neck and arm position during sleep. These historical details must be placed in the context of coexistent systemic illnesses that may be contributing to or even causing the neck pain. Psychosocial factors are especially important to assess as potential contributors to chronic neck pain.
Physical characteristics such as neck length, receding mandible, high arched palate, crooked teeth, and asymmetry of the facial bones and muscles should be noted. Information about temporomandibular joint function is important. Investigation of a painful bite, limited jaw opening, or swelling of the temporomandibular joint area may lead to a proper and accurate diagnosis, because temporomandibular joint abnormalities may mimic or accompany cervical spine syndromes.
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. A differential diagnosis of neck and shoulder pain is given in Table 1. Figures 5 and 6 are schematic representations of the pertinent anatomy. Head pain is common in and characteristic of cervical syndromes. Stiffness with limitation of motion can be due to muscle spasm, articular involvement, or nerve root irritation. A lesion at the level of C6-7 may occasionally cause neurologic or myalgic pain and very significant muscular tenderness in the precordial or scapular region, suggesting angina pectoris.
Numbness and tingling occur in the segmental distribution of the nerve roots, often with no demonstrable objective sensory change. Weakness is uncommon. Patients who have trouble balancing their heads because of muscle weakness have clearly lost power.
Eye symptoms and signs may occur in cervical syndromes. These signs and symptoms include blurring of vision, frequent change of glasses without improvement, relief of pain by changing neck position, retro-orbital pain, and a strange description of the eyes "being pulled backward or pushed forward." The etiology of these signs and symptoms is likely the result of irritation of the cervical sympathetic nerve supply to eye structures. Change in equilibrium may occur because of irritation of sympathetic plexuses surrounding the vertebral arteries or as a result of vascular insufficiency.
Dysphagia may be an occasional symptom in cervical syndromes and can be caused by muscle spasm and anterior osteophyte compression of the pharynx and esophagus (Figure 7). A large group of bizarre symptoms, some of which are unrelated, are explicable in terms of multivalent pathogenetic mechanisms. A patient comment such as "I can't get a deep breath" may be due to a C3-5 lesion whose roots innervate the diaphragm and other respiratory muscles. Cardiac palpitation and tachycardia may result from unusual positions or hyperextension of the neck due to irritation of the C4 nerve root supplying the diaphragm and pericardium, or by irritation of cardiac sympathetic nerve supply. Nausea and vomiting, ill-defined pain, and paresthesia may be caused by cord compression. Drop attacks (rare), i.e., collapse without loss of consciousness, often with the ability to rise and continue with previous activity, may be caused by abrupt loss of proprioception.
Differentiating somatoform disorders or psychoneurosis from other cervical syndromes is a common problem, partly related to the overlapping symptoms and signs in both conditions. Attention must be paid to psychosocial issues in patients presenting with chronic neck pain.
Most patients with cervical spine syndromes require a complete physical examination in addition to a thorough musculoskeletal examination with appropriate regional focus.
The patient should be gowned. Range of motion of the cervical spine can be determined with the patient sitting upright and lying (to lessen the effect of antigravity musculature). Posture is observed from the front, back, and side while the patient is sitting, standing, and walking. Anatomical details such as scapular height, spinal curve, head tilt, and head position are noted. The cervicothoracic and thoracolumbar junctions and the sacral area are examined. The presence of cervical lordosis, kyphosis, and lumbar lordosis is specifically investigated.
The patient's ability and willingness to move should be observed, looking particularly for head or neck guarding. The acuteness of the problem is assessed.
The patient is observed for any abnormal appearance such as unusual height or shortness, long or short neck, retracted mandible, crooked teeth, or a 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.
Table 2 describes clinical neurologic screening tests.
With the patient standing, movement of the entire spine in order--cervical spine first, flexion, extension, lateral flexion, and rotation--are done, followed by the same motions against resistance. Passive ranges of motion are determined, then an attempt is made to actively increase them. All 4 motions are tested against resistance to observe motor power and 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.
The examiner should do a systematic examination of the shoulder and structures within it, questioning whether there is any contribution to pain in the neck arising in the shoulder.
Head extension is tested first, so the inferior facets of the vertebra above glide posteriorly on the facets of the vertebra below, thereby narrowing the foramina. If this maneuver produces shoulder pain, paresthesia, or numbness, the nerve root is compressed in the foramen. Other maneuvers should not be attempted. If the patient does not experience symptoms, lateral flexion is tried, closing the foramina toward the side of the flexion and opening it on the opposite side. If this maneuver produces the syndrome, other maneuvers need not be made. If the maneuver does not produce pain or dysesthesia, full rotation is added which maximally closes the foramina on one side, opening it on the opposite.
Compression of the head, causing forced 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 examination is performed with the patient sitting. The physician places one hand over 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 both sides, backward, and then forward increases the sensitivity of the test.
This test predicts the effect of cervical spine traction in relieving pain or paresthesia. If the intervertebral foramina are opened or disc spaces extended, nerve root compression may be relieved with disappearance of symptoms and signs. Pressure on joint capsules of the apophyseal joints is decreased by distraction. Muscle spasms 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, discs, and joints. The test is continued for 30 to 60 seconds.
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 even the third vertebra in a very lean patient. In the anterior triangle, the landmarks should be identified, helping in clinical orientation such as in the identification of a fractured cervical vertebra. The hyoid bone is at the level of C3. If there are signs and symptoms related to C3, tenderness may be present at this level. The thyroid cartilage is at the upper level of C4, and the thyroid level is at the lower level of C5. The first ring of cricoid cartilage is at the level of C6.
The levator muscle of the scapula, the trapezius, rhomboid, and scalene muscles, and the superior angle of the scapula are observed, checking for symmetry, atrophy, weakness, and neurologic signs. The deltoid, supraspinatus, and infraspinatus muscles are observed for atrophy. The skin is examined for thickness, color, scars, temperature, and old incisions. The carotid arteries are palpated for tenderness and temperature. The sternocleidomastoid muscle and its function are examined. Sites of tenderness are marked with a felt pen and correlated, if possible, with the local structure.
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 atlanto-occipital or atlanto-axial joints. The second AP view includes the lower cervical spine from C3 to T1.
A lateral cervical spine film should show the base of the skull, 7 cervical vertebrae, and the endplate of the first thoracic vertebra. If shoulders prevent clear imaging of the lower vertebral bodies, a coned-down or "swimmers" view of the cervicothoracic junction is obtained. Oblique views illustrate the neural foramina, pedicles, and the superior and inferior articulating facet joints. There is a lack of correlation between radiologic cervical osteoarthritis and clinical symptoms, a situation analagous to patients with back pain.
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 and 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 computed tomography (CT) scan. CT scanning accurately demonstrates fractures and displaced bone fragments that could cause serious neurologic injury by compromising either the spinal canal or the neural foramina.
Magnetic resonance imaging (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 CT scanning, bone artifact does not degrade MRI imaging. Multiple imaging planes, e.g., sagittal, axial, coronal, and 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 studies require a cooperative patient. Disadvantages include striking motion sensitivity. In addition, dense cortical or compact bone has very few hydrogen protons, therefore it is seen as a signal void in MRI with limited spatial resolution. Thus, MRI can fail to delineate fractures and poorly defines bone spurs and calcifications. MRI is a more expensive imaging method than CT scanning, and patients occasionally are too claustrophobic to endure the study. In patients with nontraumatic neck pain, MRI should be reserved for situations where intervertebral disc herniation with radiculopathy or spinal stenosis with cervical myelopathy is suspected by history and physical findings (Figure 8).
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. Patient education is a major contributor to the success of management (see the following patient education report). Patient education classes about various kinds of arthritis are available through the Arthritis Foundation. Patient handbooks and educational materials are also useful.
Physical therapy modalities are clearly helpful for many aspects of cervical spine management. Modalities of physical therapy can be categorized as follows: cryotherapy (the use of physical cold); thermotherapy (both superficial and deep heat); the use of heat by any method that provides heat; mechanical therapy (use of massage, whirlpool, methods that move the tissues about in a variety of ways); and electrotherapy (stimulation of nerve and muscle by electric current).
Cervical collars play a relatively small role in stabilizing the spine, but they may 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, psychological benefits, and marginal control of movement.
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 report in cervical spine patients is night pain. Correction of poor sleeping posture is often successful in alleviating discomfort. Most people sleep on one or more pillows, promoting 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 a long period. When poor sleeping posture results in head and neck pain, the use of a pillow is 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 (Cervi-Pillow), to a multi-purpose pillow (Wal-Pil-O). Wal-Pil-O provides 4 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 4 pillows in all, with soft and medium centers for heads narrow and wide, and firmer borders for the neck. Another pillow, "The Shape of Sleep," features a neck support ridge that fits under the neck and is a physiologic, biomechanically sound model. A bolster-type pillow is available in several different diameters, and pillows with a contour cutout for the head are also obtainable.
The usefulness and effectiveness of cervical spine traction have been questioned, but it is still widely used to relieve pain; it does not cause vertebral distraction. About 75% to 80% of patients with radicular symptoms have some pain relief, sometime lasting months to years, from optimally applied traction. Prior to the use of traction, radiographs should be obtained to exclude fracture, tumor, infection, and instability.
Intermittent traction is the best initial application. The weight applied ranges from a minimum of 10 pounds to a maximum of 50 pounds (the latter only very rarely) over 15-20 minutes. If significant improvement does not occur over 8-10 sessions of optimally administered traction, it should be discontinued. If symptoms have clearly worsened, there is little point in continuing traction, and the physician should identify why the therapy was not successful. The amount of weight used in traction is a function of size of the patient, 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 traction equipment and continue traction under those circumstances until all symptoms resolve. In such cases, the patient should maintain close contact with a medical authority. Continual traction does not permit the use of as much weight as that permitted in intermittent traction. Increments of weight are added with each traction session, usually beginning with about 10 pounds, depending on the degree of the patient's personally reported progress, or lack of it. Trial and error method is the best way to deal with variables such as the distance that the patient sits from the traction pulley, the direction of traction, and the position of the patient during traction. An average level of traction is 15-20 pounds for 20 minutes. The patient sits in slight cervical spine flexion, placing the door or apparatus and the angle of the rope 20-30° from vertical (Figure 9). This is a physiologic position. Self-administered or home traction should always be undertaken initially in a supine or sitting position. The application of warm moisture before traction is recommended.
In general, the relief of pain occurs sooner and more completely in patients with radicular symptoms than in those with symptoms arising from the connective tissue structures of the neck itself--ligaments, tendons, muscles, and joints. Traction is not indicated for an acute whiplash syndrome.
Drugs occupy a relatively small place in the management of cervical spine syndromes. Simple analgesics may be helpful in acute pain, as may short courses of nonsteroidal anti-inflammatory drugs. Small doses of tricyclic antidepressants taken at night may enhance pain-free sleep.
Stretching exercises for the cervical spine are used for the same reason 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 of motion. Strengthening exercises are especially important because the cervical spine is extremely mobile compared with all other areas of the body.
In the interest of maintaining optimum fitness and function of the proprioceptive nervous system, a series of 24 stretches have been developed, which have been exceptionally beneficial in cervical spine clinical disorders. Each stretch is held for 20 seconds. Stretch no. 15 is that of the cervical spine. Virtually all receptors in the proprioceptive nervous system are "fired off" by these maneuvers and constitute important aspects of cervical spine management (see Information for Patients).
The persistence of nonspecific neck strain longer than a few weeks, the presence of systemic symptoms or a systemic disorder such as rheumatoid arthritis, or the suspicion of a more generalized pain disorder such as fibromyalgia may warrant referral to a rheumatologist. Neurologic consultation may be indicated in the following general clinical circumstances: rheumatoid arthritis of the cervical spine with subluxation and definite neurologic symptoms and signs; entrapment at the thoracic outlet, the elbow, or carpal tunnel; neurosurgical or orthopedic surgical operation contemplated for treatment and management of a patient with cervical arthritis, such as facetectomy, laminectomy, or chondro-osteophyte removal; severe and progressive inflammatory disease of muscle, such as polymyositis and dermatomyositis. Neurosurgical or orthopedic consultation may be needed for: 1) rheumatoid arthritis of the cervical spine with subluxation, signs and symptoms of myelopathy, radiculopathy, and peripheral neuropathy; 2) osteoarthritis of zygapophyseal joints or overproduction of osteophytes in the uncinate process or vertebral chondral osteophytes with progressive myelopathic symptoms and signs suggesting spinal stenosis; 3) cervical spine fractures, i.e., ankylosing spondylitis, rheumatoid arthritis, juvenile polyarthritis; 4) any circumstances of trauma with fracture dislocations.
Osteoarthritis describes all joint involvement in the cervical spine including all secondary manifestations in vertebrae, tendons, ligaments, capsules, and hyaline cartilage.
The following topics are essential in the management of cervical spondylosis. 1) Patient education. The patient is taught the natural history of osteoarthritis of the cervical spine. The majority of patients continue to be functional and effective, although the pain may be recurrent. 2) Exercises. Emphasis should be placed on daily stretching and range of motion exercises. Cervical, thoracic, and lumbar portions of the spine should be included. (See Information for Patients.) 3) Physical therapy. Modalities to consider are: heat, ultrasound, diathermy, heating pad, infrared lamps, hot moist packs (hydrocollator), hot tub baths, Hubbard tanks. 4) Special pillows. 5) Analgesic and anti-inflammatory drugs, tricyclics in low doses. Special attention should be paid to patients with complications of cervical spine osteoarthritis, radiculopathy, peripheral neuropathy, myelopathy, esophageal involvement by osteophytes, and vertebral artery compressive syndrome. 6) Rheumatology, neurology, neurosurgical, or orthopedic consultation, if necessary. 7) Traction in selected instances, especially with radiculopathy. 8) Relaxation techniques 2-3 times daily with a session especially at night. 9) Cervical massage.
The management includes: 1) Patient education regarding the likely ultimate outcome--usually good prognosis with optimum management. 2) Physical therapy: heat, occasional cold therapy, occasionally one following the other; gentle stretching and strengthening exercises; range of motion exercises; intermittent soft or hard plastic collar. 3) Analgesic and anti-inflammatory drugs (little or no role for narcotic or potentially addictive drugs). 4) Traction judiciously applied with close followup; monitor traction according to specific results obtained. 5) Cervical spine pillow. 6) Massage. 7) Occasional lidocaine and corticosteroid injection in areas of pain and spasm. 8) Hydrotherapy.
Management includes all features previously discussed, with special adaptations for 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 osteoarthritis myelopathy is one of mild disability; after an initial period of deterioration, a static period may last for several years.
Osteoarthritis can cause esophageal compression by osteoarthritic chondro-osteophytes, extensive bony bridging from diffuse idiopathic skeletal hyperstosis (Figure 7), or by subluxated cervical vertebrae (atlantoaxial subluxation or subaxial subluxation in rheumatoid arthritis). Dysphagia may manifest as difficulty in initiating the act of swallowing (atlantoaxial subluxation), perception of discomfort or pain during swallowing, and referred pain from esophagus or gastroesophageal junction to the chest.
Evidence of radiologic esophageal compression by anterior chondro-osteophytes in osteoarthritis is noted in lateral cervical spine film. Some lesions may be asymptomatic, even though they appear grossly compressive. Esophageal compression also can be demonstrated by barium swallow, lateral view of the cervical spine in neutral, flexion, and extension positions, and esophagoscopy or gastroscopy if there is any suggestion of ulceration at sites of pressure by chondro-osteophytes.
Management strategies include: 1) No treatment is indicated unless the patient has symptoms. 2) Apply the many possible therapeutic maneuvers previously listed. 3) Surgical removal of anterior osteophytes.
In conclusion, acute neck strain is usually a self-limited benign disorder. Even disc herniation with radiculopathy usually remits after a course of conservative therapy, often including cervical traction. On the other hand, chronic neck pain has multiple etiologies from benign to malignant. A thorough history and physical examination coupled with appropriate imaging when indicated will reveal the cause of chronic neck pain in most instances. The primary care physician must be aware that commonly psychosocial factors or generalized pain syndromes such as fibromyalgia may contribute greatly to the chronicity of the pain. Cervical spondylosis, the most common cause of chronic neck pain, requires a multipronged approach with an emphasis on patient education and physical modalities including exercise. Many of the physical modalities used in chronic neck pain are of scientifically unproven value (e.g., ultrasound, diathermy) but may provide safe, mild analgesia. Surgery is rarely indicated and is reserved for those few with progressive neurologic involvement, usually myelopathy due to spinal stenosis.
John H. Bland, MD: Professor Emeritus of Medicine-Rheumatology, Rheumatology and Clinical Immunology Unit, University of Vermont College of Medicine, Burlington.
1. Bland JH. Disorders of the cervical spine, diagnosis and medical management. 2nd ed. Philadelphia: WB Saunders; 1994.
2. Bland JH. Anatomy and physiology of the cervical spine. Semin Arthritis Rheum 1990;20:1-20.
3. Kapandji I. Physiology of joints, the trunk and vertebral column. Vol. 3. 2nd ed. Edinburgh: Churchill Livingstone; 1977.
4. The Cervical Spine Research Society. The cervical spine. 2nd ed. Sherk HM, editor. Philadelphia: JB Lippincott; 1989.
5. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc 1997;10:5236-45.
6. Giles LGF, Singer KP. Clinical anatomy and management of cervical spine pain. Vol. 3. Oxford: Butterworth Heinemann; 1998.
7. Bland JH. Cervical and thoracic outlet syndrome and brachial neuritis. Curr Opin Rheumatol 1990;2:242-52.
8. Herns TEJ, Glasby MA. Prospects for the treatment of cervical spinal cord and peripheral nerve injury. J Bone Joint Surg Br 1996;78-B:176-7.
9. Mikawa Y, Yamaoka T, Watanabe R. Compression of cervical spinal cord due to destructive spondyloarthropathy of the atlanto axial joints. J Bone Joint Surg Am 1996;78-A:1911-4.
Clinical Approach to Cervical Spine Pain: Patient Education
1. Emphasize normal extreme mobility of the cervical spine and the therapeutic necessity to continue to increase and stretch to whatever the constraints of cervical pain permit.
2. Maintain an optimistic prognostic outlook to the patient. As recently as 1987, no books were available on the cervical spine from the medical and rheumatologic point of view--only surgical, neurosurgical, and orthopedic. Ninety percent of diagnosis and management is medical. Cervical spine medical disorders are the third most important cause of pain overall. Stress the enormous advances in knowledge of basic physiology, anatomy, and pathophysiology of the cervical spine.
3. Teach the patient the mechanisms of physical therapeutic methods and the rationale for extensive application day to day.
4. Teach the patient the great importance of your eliciting accurate and full historical and physical data leading up to your studying the clinical problem with the cervical spine. Historical elicitation and physical examination are the major means of data gathering.
5. Educate the patient on the issue that drugs are not the most important aspects of management. Dependence on heavy analgesic use is discouraged. Reassure the patient regarding the pathophysiologic goals in optimum accurate diagnosis and consequent therapy.
6. Teach the patient the mechanism of stretching exercises and how they contribute to the achievement of optimum proprioceptive function.
7. If traction is to be used, the patient will need and require full explanation of the function of therapeutic traction as it relates to their pathophysiologic mechanisms of production of symptoms and signs. Explain the reason for preheating the cervical spine prior to applying traction method.
8. Emphasize the requirement for a balance of rest and exercise. Absolute bed rest has no place in the management of rheumatic diseases generally--most emphatically never in cervical spine disorders! Manipulation coupled with both active and passive exercise result in a decrease in the inflammatory process, even in severe inflammatory disease.
9. Educate the patient in the many current relaxation techniques. All relaxation skills are easy to teach, require a change in lifestyle, are pleasant and simple, and the price is right. The greatest natural resource the patient has is his or her own mind, which does require some training. General terms and types of relaxation techniques include relaxation training, transcendental meditation, psychocybernetics, biofeedback, self-hypnosis, yoga, Jacobsen progressive relaxation, and Herbert Benson's Relaxation Response (see p. 278-82 in Bland JH. Disorders of the cervical spine, diagnosis and medical management. 2nd ed. Philadelphia: WB Saunders; 1994.).
10. Teach the patient the realities of manipulative therapy. There are testimonies of thousands of patients, chiropractors, osteopathic physicians, and various other therapeutic manipulators supporting the efficacy of therapeutic manipulation. However, there exists little, if any, scientific evidence of a cause and effect relationship between the use of manipulation and relief of symptoms. Some physicians have enormous confidence in manipulative programs and ask, "Can we justify not manipulating?" Manipulating therapy is far from completely safe, yet it is widely practiced, and catastrophic events do occur. Certainly, a manipulator should be highly trained, have the knowledge and skill required for making an appropriate decision regarding manual therapy, and be aware of the dangers involved.
Figure 1. A, Anatomic specimen of a cervical spine from a calendar age of 48 years. In the lower 3 vertebrae the posterior longitudinal ligament has been cut displaying the intervertebral disc area where very little disc substance remains. The same is noted in the upper 4 vertebrae. Incidentally, note the exiting spinal nerves into the intervertebral foramina. B, A coronal section of a cervical spine from a 72-year-old man. Note the intervertebral discs are virtually gone save for a few shreds in the two lowermost discs.
Figure 2. A coronal section of a whole human cervical spine. The existing spinal nerves at vertebrae 4 and 5 (viewer's right) are below the level of the intervertebral discs.
Figure 3. An oblique section of a whole human cervical spine cut through 4 zygapophyseal joints. Note the meniscus (normal) in the lowermost joint and proliferating meniscal pannus in the 3 joints above.
Figure 4. A, Cervical spine split laterally showing gross osteophytic bars, all of which compressed the spinal cord. B, Lateral x-ray of the cervical spine showing posterior longitudinal ligament enormously hypertrophied, also compressing the spinal cord.
Figure 5. Sagittal view of the whole cervical spine showing relationship among structures on that plane.
Figure 6. Sagittal view of cervical spine showing relationships among the brain stem, the medulla oblongata, and the spinal canal.
Figure 7. Cervical spine from a patient with the diffuse idiopathic skeletal hyperostosis syndrome, showing gross overgrowth of bone compressing the esophagus with resulting clinical dysphagia.
Figure 8. Spinal stenosis: cervical spine (magnetic resonance image). The T2-weighted sagittal image shows a high-grade spinal stenosis most marked at the C3-4 interspace, due to extradural compression anteriorly and posteriorly. The cervical cord is markedly compressed. The patient also had degenerative disease of C3-4 and C4-5. (Reprinted from the American College of Rheumatology Clinical Slide Collection on the Rheumatic Diseases.)
Figure 9. Cervical traction, sitting position.
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