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Chapter 5:
The Posterior Neck and Cervical Spine
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Symptomatology and Differential Diagnosis”
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Introduction Anomalies and Deformities Inflammatory Musculoskeletal Syndromes Intervertebral Disc Syndromes Postural Syndromes Postural Syndromes Subluxation/Fixation Syndromess Trauma: Cervical Spine SyndromesChapter 5: The Posterior Neck and Cervical Spine
IntroductionWith the important exception of neurologic and vertebral artery syndromes, most of the disorders witnessed in the osterior aspect of the neck are musculoskeletal conditions. Of particular significance are the symptom complexes of cervical arthritis, deformities, disorders of muscle tone, IVD syndromes, spondylosis, vertebral subluxation, tumors, and the effects of trauma. It is helpful to keep in mind that tumors of the cervical spine are usually secondary and that chronic degenerative disc disease and congenital anomalies may be asymptomatic for many years.
Functional Considerations
Nowhere in the spine is the relationship between the osseous structures and the surrounding neurologic and vascular beds as intimate or subject to disturbance as it is in the neck. Many peripheral nerve symptoms in the shoulder, arm, and hand will find their origin in the brachial plexus and cervical spine.
The gross mechanical function of the neck is determined by analysis of joint motion and muscle strength.
EVALUATING JOINT MOTION OF THE NECK
Gross joint motion is roughly screened by inspection during active motions. When a record is helpful, it is usually measured by goniometry. The prime movers and accessories responsible for voluntary joint motion in the cervical region are shown in Table 5.1.
Table 5.1. Neck Motion and Responsible Movers
Joint Motion Prime Movers AccessoriesExtension Trapezius, upper Transverse spinalis group Splenius capitis Levator scapulae Splenius cervicis Semispinalis capitis Semispinalis cervicis Erector spinae capitis Erector spinae cervicis Flexion Sternocleidomastoid Scalenes Longus colli Hyoid muscles Longus capitis Rectus capitis anterior Rectus capitis lateralis Lateral Scalenes Transverse spinalis group flexion Levator scapulae Rectus capitis lateralis Rotation Sternocleidomastoid Scalenes Trapezius, upper Transverse spinalis group Splenius capitis Splenius cervicisEVALUATING MUSCLE STRENGTH OF THE NECK
Muscle strength is recorded as from 5 to 0 or in a percentage and compared bilaterally whenever possible. The major muscles of the neck, their primary function, and their innervation are listed in Table 5.2.
Table 5.2. Function and Innervation of the Major Muscles of the Neck
Spinal Muscle Major Function SegmentsErector spinae, upper Extension, rotation C1–T1 Longus capitis Flexion C1–C3 Longus colli Flexion C2–C6 Rectus capitis anterior Flexion C1–C2 Rectus capitis lateral Flexion C1–C2 Scalenes Flexion, rotation C4–C8 Semispinalis capitis Extension, rotation C1–T1 Semispinalis cervicis Extension, rotation C1–T1 Splenius capitis Extension, rotation C1–C8 Splenius cervicis Extension, rotation C1–C8 Sternocleidomastoid Flexion, rotation C2, XI Trapezius, upper Extension, rotation C3–C4
Gross anomalies are rarely seen in chiropractic practice unless well adapted to the individual's life-style. Those cases that have biomechanical significance vary in severity from minor to severe and occur multiply or singly. The cause is purely genetic transmission in about 35% of cases, and the remainder is due to environmental factors or a mixture of genetic and environmental factors.
(1) in acquired fusions, the margins of the vertebral body tend to be irregular, disc lines are wider than the adjacent vertebral bodies, the posterior arches are frequently subluxated,
Excessive hypertonicity of a muscle, confirmed by palpatory tone and soreness, will tend to subluxate its site of osseous attachment. The major effects of cervical hypertonicity are shown in Table 5.8.
Rheumatoid arthritis, ankylosing spondylitis, and various infectious diseases may attack the cervical spine during infancy, childhood, or adulthood.
The two most common disorders of cervical intervertebral discs are degenera-
tive disease processes and disc protrusion. These disorders may manifest singularly or be combined.
Autonomic Involvement. Vague autonomic symptoms may be exhibited such as
dizziness, blurred vision, and hearing difficulties. These can usually be attributed to involvement of the plexus around the vertebral artery or intermittent disruption of the blood flow.
There are several syndromes to consider under the classification of neurovascular compression syndromes (also termed thoracic outlet or inlet syndromes), each of which may produce the symptom complex of radiating pain over the shoulders and down the arms, atrophic disturbance, paresthesias, and vasomotor disturbances. These syndromes, however, do not necessarily indicate the specific cause of the problem.
Neurologic vs Vascular Compression. Compression of nerve tissue results in
numbness, pain, paralysis, and loss of function. Compression of vascular structures results in moderate pain, edema, swelling, and obstruction of circulation that may result in clotting within the vessels with possible consequent infarction in the tissues supplied. Adson's and similar signs will be positive. These unilateral phenomena are limited to the cervicobrachial distribution.
Active Cervical Rotary Compression Test. With the patient seated, he or she
should be observed while voluntarily laterally flexing the head toward the side
being examined. With the neck flexed, the patient is then instructed to rotate
the chin toward the same side, which narrows the IVF diameters on the side of
concavity. Pain or reduplication of other symptoms probably indicates a physiologic narrowing of one or more IVFs.
BASIC LABORATORY WORKUP CONSIDERATIONS
The two most common gross reflections of postural distortion in the cervical
spine are curve reversal and scoliosis. These disorders many occur singularly or
be combined.
(1) flattening of the cervical spine from muscular spasm and adhesion development;
Structural and Neurologic Considerations
The healthy posterior neck provides stability and support for the cranium, a flexible and protective spine for movement, balance adaptation, and housing for the spinal cord and vertebral artery. From a biomechanical viewpoint, primary cervical subluxation syndromes may reflect themselves in the total habitus; from a neurologic viewpoint, insults may manifest throughout the motor, sensory, and autonomic nervous systems. Unlike the lumbar region, cervical disc herniations are not frequently associated with severe trauma; however, traumatic nerve root or cord compression has a high incidence in this area.
A general classification of musculoskeletal disorders of the neck is shown in Table 5.3, and the function of the nerves of the cervical plexus and the brachial plexus is shown in Tables 5.4 and 5.5.
Table 5.3. Classification of Musculoskeletal Disorders of the Neck
Adulthood Cervical Disorders Childhood Cervical Disorders
Congenital anomalies Acquired torticollis
Cervical ribs Congenital deformities
Congenital stenosis Inflammatory disease
Degenerative disc disease Ankylosing spondylitis
Geriatric Juvenile rheumatoid arthritis
Spondylosis Vertebral/disc infections
Traumatic Metabolic disease and bone dysplasias
Inflammatory diseases Central disc calcification
Ankylosing spondylitis Diastrophic dwarfism
Infections Morquio's disease
Rheumatoid arthritis Spondyloepiphyseal dysplasia
Systemic disease causing bone texture Trauma
alterations Cervical sprain
Anemia Cervical strain
Hodgkin's disease Fracture or dislocation
Leukemia Soft tissue or disc injury
Osteoporosis Subluxation
Paget's disease Tumors of the cervical spine
Trauma of the cervical spine and cord Primary (uncommon)
Acute herniated disc Secondary (rare)
Fracture or dislocation
With neural deficit
Complete quadriplegia Infantile Cervical Disorders
Incomplete quadriplegia Birth Injuries
Anterior cord syndromes Bone injuries
Brown-Sequard syndrome Cord injuries
Central cord syndromes Delivery-related subluxations
Nerve root injury Epidural hemorrhages
Without neural deficit Nerve injuries
Stable Congenital disorders of cervical spine
Unstable Atlanto-occipitalization
Soft tissue or disc injury Basilar invagination
With neural deficit Congenital torticollis
Cord signs Odontoid process dysplasia
Root signs Spinal dystrophia
Without neural deficit Vertebral fusion
Subluxation-fixation
Tumors
Primary, of bone
Secondary, metastatic
Men: lung, prostate
Women: breast
Table 5.4. The Cervical Plexus
Segment Function
C1 Motor to head and neck extensors, infrahyoid, rectus capitis
anterior and lateral, and longus capitis.
C2 Sensory to lateral occiput and submandibular area; motor,
same as C1 plus longus colli.
C3 Sensory to lateral occiput and lateral neck, overlapping C2
area; motor to head and neck extensors, infrahyoid, longus
capitus, longus colli, levator scapulae, scaleni, and trapezius.
C4 Sensory to lower lateral neck and medial shoulder area; motor
to head and neck extensors, longus coli, levator scapulae,
scaleni, trapezius, and diaphragm.
Nerve Function
Cervical cutaneous Sensory to skin over anterolateral portion of neck.
Greater auricular Sensory to skin over parotid, jaw angle, ear lobe,
and front of mastoid process.
Lesser occipital Sensory to skin behind ear and mastoid process.
Muscular branches Motor to capitus anterior and lateralis, longus
capitus, longus colli, hyoid muscles,
sternocleidomastoideus, trapezius,
levator scapulae, scalenus medius.
Phrenic Sensory to costal and mediastinal pleura
and pericardium.
Motor to diaphragm.
Supraclaviculars Sensory to skin over medial infraclavicular area,
pectoralis major and deltoid.
Table 5.5. The Brachial Plexus
Segment Function
C5 Sensory to clavicle level and lateral arm
(axillary nerve); motor to deltoid, biceps;
biceps tendon reflex. Primary root for shoulder
abduction, exits between C4–C5 discs.
C6 Sensory to lateral forearm, thumb, index and
half of 2nd finger (sensory branches of
musculocutaneous nerve); motor to biceps, wrist
extensors; brachioradialis tendon reflex.
Primary root for wrist extension, exits
between C5–C6 discs.
C7 Sensory to second finger; motor to wrist flexors,
finger extensors, triceps; triceps tendon reflex.
Primary root for finger extension, exits
between C6–C7 discs.
C8 Sensory to medial forearm (medial antebrachial
nerve), ring and little fingers (ulnar nerve);
motor to finger flexors, interossei; no reflex
applicable. Primary root for finger flexion,
exits between C7–T1 discs.
T1 Sensory to medial arm (medial brachial cutaneous
nerve); motor to interossei; no reflex applicable.
Primary root for finger abduction, exits
between T1–T2 discs.
Nerve Function
Axillary Motor to deltoid muscle; sensory to lateral arm
and deltoid (silver dollar) patch on upper arm.
Median Motor for thumb opposition and abduction;
sensory to distal radial aspect of index finger.
Musculo- Motor to biceps muscle; sensory to lateral forearm.
cutaneous
Radial Motor for wrist and thumb extension; sensory to
dorsal web space between thumb and index finger.
Ulnar Motor for little finger abduction; sensory to
distal ulnar aspect of little finger.
Miscellaneous-Syndromes Involving the Posterior Neck
See Table 5.6.
Table 5.6. Miscellaneous-Syndromes Involving the Posterior Neck
Name of Syndrome Symptom Complex
Costoclavicular Compression, irritation, or stretching on the nerves or vessels
at the cervicobrachial outlet resulting in pain or other
disturbances in the arm and/or hand.
Klippel-Feil's Limited neck motion, low hairline, and shortness of neck as a
result of a reduction in the normal number of cervical
vertebrae or fusion of multiple hemivertebrae into one mass.
Radicular Restricted mobility of the spine and root pain as the result
of lesion of the roots of the spinal nerve.
Rust's Stiff neck, restricted head carriage, and the necessity of
grasping the head with both hands in lying down or arising
from a recumbent position. It occurs in phthsis, cancer, spinal
fracture, rheumatism, arthritis, and syphilitic periostitis.
Sudeck-Leriche's Osteoporosis and vasospasm following trauma.
Weinberg's This syndrome of spinal cord tumor at the foramen magnum is
characterized by the presence of pain in the cervical or
occipital regions, tending to extend down both arms to the
elbows and aggravated by coughing, sneezing, and other extreme
movements. The evolution of other symptoms epends on the extent
of the tumor and direction of its growth. Tumors projecting
into the posterior fossa produce symptoms of intracranial
pressure such as nystagmus, papilledema, vertigo, ataxia,
past pointing, and asteriognosis. Signs occurring in this
syndrome, not specifically characteristic of spinal cord tumors,
are paresis of infrabuccal facial nerves, atrophy of the muscles
of the upper extremities, and speech difficulties.
Anomalies and Deformities
BASIC INVESTIGATIVE APPROACH
Subtle and asymptomatic anomalies in the cervical area frequently predispose subluxations from minor stress and underlie a pathologic process. Many anomalies do not become symptomatic unless the effects of trauma or degeneration are added. The primary concerns are whether the deformity will increase with growth and normal activity and how much does the deformity contribute to the degree of cervical instability and neurologic deficit present.
ETIOLOGIC PICTURE
A listing of the bony anomalies of the cervical spine of which all practitioners should be acquainted is shown in Table 5.7.
Table 5.7. Types of Bony Anomalies of the Cervical Spine
Region of Anomaly Type of Defect
Atlas and Axis Atlas arch dysplasia Odontoid dysplasia
Cranio-occipital Atlantoid assimilation Occipital dysplasia
Basilar coarction Occipital vertebrae
Condylar hypoplasia
Lower Cervical Cervical rib Fusion failure (eg, spina
Failure of segmentation bifida, spondylolisthesis)
(eg, Klippel-Feil
syndrome)
BASIC LABORATORY WORKUP CONSIDERATIONS Blood smear Serum alkaline phosphatase Tuberculin test
CBC and differential Serum calcium Urinalysis
EEG Serum growth hormone Urine amino acids
R-A text Serum parathyroid hormone Urine mucopolysaccarides
Sedimentation rate Skull x-ray
Serum acid phosphatase Spinal roentgenography
Cervical Rib and Related Syndromes
Anomalous development of extra ribs in the region of the cervical vertebrae may be found singularly, bilaterally, or multiple bilaterally. The condition is usually seen at C7, and the cause is a variation in the position of the limb buds. It may vary from a small nubbin to a fully developed rib. A small rudimentary rib may give rise to more symptoms than a well-developed rib because of a fibrous band attached between the cervical rib and sternum or 1st thoracic rib. The incidence of cervical rib is more frequent in women in the ratio of 3 to 1.
BASIC INVESTIGATIVE APPROACH
A cervical rib rising from C7 and ending free or attached to the T1 rib appears in the neck as an angular fullness that may pulsate because of the presence of the subclavian artery above it. It rarely produces symptoms, and it is usually first noticed when percussing the apex of the lung. The bone can be felt behind the artery by careful palpation in the supraclavicular fossa. It can also be readily demonstrated by roentgenography. Pain or wasting in the arm and occasionally thrombosis may occur from the impaired circulation effected.
Grieve points out that some clinicians are far too anxious to blame upper limb paresthesiae on the presence of a cervical rib just because it is there. Many patients with a cervical rib have no complaints, many without a cervical rib have similar complaints, and many with complaints have symptoms on the contralateral side of a unilateral cervical rib. However, when any anomaly such as a cervical rib is seen roentgenographically, the examiner should be suspicious that other anomalies not as evident may be associated.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
The 4th and 5th decades mark the highest incidence of the cervical rib syndrome, probably because of regressive muscular changes. Trauma is a common precipitating factor. Associated aneurysms of the subclavian artery are rare.
Symptoms usually occur at age 12 or later, after the ribs have ossified. Two groups of symptoms are seen, those of scalenus anticus syndrome and those due to cervical-rib pressure. Also see Neurovascular Compression Syndromes.
When symptoms are exhibited, they are usually from compression of the lower cord of the brachial plexus and subclavian vessels such as numbness and pain of varying intensity in the ulnar nerve distribution. This pain is worse at night because of pressure from the recumbent position. Tiredness and weakness of the extremity, finger cramps, numbness, tingling, coldness of the hand, areas of hyperesthesia, muscle degeneration in the hand, a lump at the base of the neck, tremor, and discoloration of the fingers are also characteristic. Work and exercise accentuate these symptoms, while rest and elevation of the extremity relieve them.
Congenital Spinal Stenosis
A degree of congenital narrowing of the cervical vertebral canal, for some reason seen only in males, will easily mimic cervical spondylosis in the young. Progressive thickening of the laminae is often initially diagnosed in error as multiple sclerosis because of the progressive tetraplegic spasticity produced.
Craniovertebral Malformations
A large number of varied anomalies arise from occipital malformations. They are usually characterized by an abnormal shift upward of the atlas and axis with the odontoid protruding above Chamberlain's line. Such anomalies are frequently associated with congenital neural malformations and with other osseous deformities (eg, Klippel-Feil syndrome). As they may remain asymptomatic unless precipitated by compressive forces following trauma or of degeneration, a concern is that these anomalies may easily be confused with the root/cord signs and symptoms of lower cervical spondylosis. Headache, sensory loss, limb pain, and ataxia are often associated.
APLASIA OF THE ARCH OF THE ATLAS
This rare deformity may vary from a slight opening to a complete loss of the anterior arch. Quite often the anomaly is asymptomatic unless precipitated by trauma.
BASILAR IMPRESSION AND PLATYBASIA
Basilar impression is the result of a congenital or an acquired invagination of the odontoid process into the foramen magnum, as measured by the height of the odontoid above Chamberlain's line or McGregor's line on a lateral film. The diagnostic A-P line of Fischgold-Metzger is used to differentiate basilar impression from an abnormally long dens and/or high palate.
In basilar impression, the atlas appears to indent the base of the skull on an A-P film as the odontoid approaches the brain stem. During inspection, the ears will be closer to the shoulders even though the length of the cervical spine is normal. The congenital form is usually associated with other defects such as atlanto-occipital fusion, aplasia of the posterior arch of the atlas, and atlantoaxial dislocation. The acquired form is seen in Paget's disease and bone weakening (eg, osteomalacia, rickets). It is then the result of head weight superimposed on softened structures at the base of the skull. Symptoms do not often appear until later life, and then they can mimic a number of acquired neurologic disturbances.
Basilar impression should not be confused with platybasia, an anthropometric flattening of the base of the skull. It is often associated with congenital atlantoaxial subluxation and occurs in 20% of mongoloid children. Platybasia is found by measuring the angle extend°ing from the clivus and the episthion and finding that it is greater than 130°.
CONGENITAL ATLANTOAXIAL INSTABILITY
Various precipitating factors may be involved in congenital predisposition to atlantoaxial instability. Most common are an abnormal odontoid, a loose cruciate ligament, and atlanto-occipital fusion -- all of which can produce transient narrowing of the spinal canal and compression of its contents.
The normal anterior atlas-dens interval is 3 mm in the adult and 4 mm in the child, particularly during flexion. A distance greater than this indicates a ruptured or stretched transverse cruciate ligament following acute trauma. It should be kept in mind that a hypermobile odontoid is also seen in mongoloids and rheumatoid arthritis. Of equal importance is the corresponding posterior dens-atlas interval that indicates the space available for the tissues within the spinal canal. It is rare to find an adult patient with less than 19 mm of posterior dens-atlas space who is asymptomatic, and cord compression is possible when the space is less than 17 mm.
OCCIPITALIZATION
Atlanto-occipital fusion (atlantal assimilation) is the most common anomaly of this joint, and C2–C3 fusion is associated in 70% of the cases. The gross features are those of Klippel-Feil syndrome.
ODONTOID ANOMALIES
These rare deformities vary from an abnormally small size (hypoplasia) to a bifid odontoid, os odontoideum (suggesting congenital dysplasia or traumatic nonunion), or complete absence (agenesis). It is easy to confuse congenital absence to that of absorbed nonunion after fracture in early life.
Klippel-Feil Syndrome
This symptom set, which varies in degree of severity, classically consists of a short neck, a low hair line, and severe neck stiffness associated with fusion of the cervical (and possibly upper thoracic) vertebrae into bony blocks. It is sometimes referred to as congenital cervical synostosis. A case may be structurally severe yet asymptomatic of commonly associated neurologic signs (eg, paresthesia, mirror movements of hands from an underlying neural defect) unless precipitated by trauma. Idiopathic deafness occurs in 30% of cases.
Associated deformities frequently include degrees of scoliosis and kyphosis; hemivertebrae; cervical rib; spina bifida; Sprengel's deformity, which is a small, elevated scapula often connected to the cervical spine; and Turner's syndrome, featuring webbing of the neck, gonadal hypoplasia, and cubitus valgus.
Acquired fusions are differentiated by the facts that
(2) congenital fusions are narrow, the disc remnants are no wider than the adjacent bodies, bony trabeculae tend to cross the disc line, and
(3) associated deformities are not found.
Torticollis: Congenital
Congenital torticollis is a counterpart of club foot. It is due to shortness of cervical muscles and not spasm. For an unknown reason, it is almost always right-handed. The clinical picture of this deformity is one of contracture of the sternocleidomastoideus, where the head tilts toward the involved side and the chin rotates towards the contralateral side. There is usually a palpable mass of fibrous tissue in the midline of the affected muscle in the infant. The congenital form of torticollis is commonly associated with Klippel-Feil syndrome, atlanto-occipital fusion, and pterygium colli.
Exclusion should be made from acquired muscular torticollis. The birth history will often portray a forceps delivery, and a related, progressing facial deformity is often exhibited in later life. In skeletal torticollis, compensatory scoliosis below the defect may hide the physical picture or asymmetry of the occipital condyles that produces tilting of the atlanto-occipital and atlantoaxial joints. Also see Torticollis: Acquired.
Hypertonicity
Table 5.8. Selected Effects of Cervical Area Hypertonicity
Muscle Effect of Prolonged Hypertonicity
Interspinales Excessive muscle tone between the spinous processes
tends to hyperextend the motion unit.
Obliquus capitis Increased tone tends to produce a rotary torque of the
inferior atlas-axis motion unit.
Obliquus capitis Contraction tends to roll the occiput anterior and
superior inferior and pull the atlas posterior and superior to
produce a lateral occiput tilt and condyle jamming.
Rectus capitis Hypertonicity tends to pull the occiput posterior,
posterior major inferior, and medial and the spinous of the axis
superior, lateral, and anterior. Strong hypertonicity
will lock the occiput and axis together so that they
appear to act as one unit even though they are not con-
tiguous.
Scalenus anterior Contraction tends to pull the C3–C6 transverse pro-
cesses inferior, lateral, and anterior and the 1st rib
superior and medial.
Scalenus medius Excessive tone tends to pull the C1–C7 transverse pro-
cesses inferior, lateral, and anterior and the 1st rib
superior and medial.
Scalenus posterior Hypertonicity tends to pull the C4–C6 transverse pro-
cesses inferior, lateral, and anterior and the 2nd rib
superior and medial.
Splenius capitis Increased tone tends to pull the C5–T3 spinous pro-
cesses lateral, superior, and anterior and to subluxate
the occiput inferior, medial, and posterior.
Sternocleidomas- Contraction tends to pull the sternum and clavicle
toideus posterior and superior and the occiput inferior and
anterior.
Upper trapezius Hypertonicity tends to pull the occiput posteroinferior,
the C7–T5 spinous processes lateral, and the shoulder
girdle medial and superior.
Inflammatory Musculoskeletal Syndromes
Cervical Ankylosing Spondylitis
Ankylosing spondylitis is a common adolescent and adult arthritic disorder, attacking the spine and larger joints. It is characterized by ankylosis, joint deformity, spinal pain and rigidity, muscle spasm, and loss of chest expansion. There may be loose ligaments above a rigid axis leading to atlantoaxial dislocation. Disc spaces are rarely narrowed as the ligaments and discs ossify. The patient moves as if his spine were a metal rod, with head and shoulders moving as a unit. A related fracture (usually lower cervical) through an ossified disc produces a characteristic chin-on-chest deformity, without or with paralysis from an associated epidural hemorrhage.
In ankylosing spondylitis, the tissues subjacent to articular cartilage are the first to be affected. Thus, the cartilage is invaded and erodes from below as contrasted to the surface erosion of rheumatoid arthritis. Early diagnosis and management are important to reduce gross deformity. The first signs are not often cervical but found in the dorsal spine (reduced chest expansion), lumbar spine (vertebral body "squaring"), and sacroiliac joints (erosion). The first cervical sign is usually that of reduced lateral flexion, followed by increasing gross neck flexion at rest and upper cervical subluxation. Deformity is usually greatest at the lumbar spine and hips, but spinal motion is lost in the lower cervical region first.
In addition to the disease process itself, a great danger in the ankylosing spine is the addition of trauma. Because the neck is unable to properly extend, any anteriorly directed force to the head can easily inflict a vertebral fracture. This usually occurs through a fused disc area, with or without residual displacement. Regardless, instability is great. Cord damage can readily result from impact if the shear forces produce posterior displacement.
Cervical Pott's Disease
Cervical tuberculosis has the characteristics of joint tuberculosis elsewhere; viz, stiffness due to muscular spasm, malposition of the bones and of the head, and abscess formation. Physical diagnosis depends greatly on wry neck with stiffness of the muscles of the back and neck and pain in the occiput -- a characteristic symptom group. The patient is very protective of neck motion. The chin is often supported by the hand if an abscess is present. Tenderness is present posteriorly on percussion and anteriorly on palpation where an abscess may be felt. Neck pain exists both day and night. It is often relieved somewhat when recumbent and frequently radiates to the occiput and shoulders. Rheumatic or traumatic torticollis, however, may present all these symptoms, and diagnosis may be impossible without the aid of other tests and roentgenology. If in Pott's disease of bone the abscess causes pressure on the anterior spinal cord, a usually spastic paralysis occurs that is characterized by hyperactive reflexes, a positive Babinski, sustained clonus, and difficulty or inability to void.
Cervical Pyogenic Infection
Pyogenic infection, most common in middle age, produces an exudative inflammation with hyperemia leading to osteoporosis and osteomyelitis. Early diagnosis is vital. The first clues are neck pain (possibly referred to the scapula or shoulder), fever, muscle spasm, and sometimes dysphagia with a large prevertebral abscess that may be palpable. In time, the end-plate becomes involved and the infection enters the disc space. Bone destruction leads to collapse. The abscess may enter the cord or a paravertebral abscess may extend into the thorax, or vice versa.
Cervical Rheumatic Disease
This common and highly deforming disorder is a generalized disease of connective tissue that begins in joint synovium. It manifests as neck pain, severe but paroxysmal, that is associated with a mono- or poly-arthritis. In time, ankylosis develops, especially in the upper cervicals, and is demonstrated by restricted motion from ossification of the posterior facets and interspinous igaments. During this process, ligaments loosen in the upper and lower cervical areas encouraging gross vertebral subluxations and dislocations that may possibly be asymptomatic. In late stages, the odontoid may migrate into the foramen magnum and produce cord pressure with various neurologic signs.
The length of the cervical cord and cervical discs is greatest during flexion and least during extension in the normal spine. The opposite is true in the
rheumatic spine due to loss of disc and vertebral body height from destruction
and absorption.
Even when cervical symptoms are absent, periodic cervical roentgenographs
should be taken to assess progress. The initial target areas in the cervical
spine are the apophyseal joints and the synovial tissues anterior and posterior
to the dens where it articulates with the anterior arch of the atlas and the
cruciate ligament. Other tissues affected include the IVDs, spinal ligaments,
and extradural alveolar tissue. A genetic susceptibility factor has been shown
to be involved in most cases.
DIFFERENTIATION FROM SPONDYLOSIS
In both degenerative and rheumatic spondylosis, involvement of the cervical
cord first involves the anterolateral tracts and central gray matter of the
cord. The effect is signs of an upper motor (pressure ischemia) lesion with a
degree of tetraparesis produced by the reduced A-P dimension of the vertebral
canal. Degenerative spondylosis is differentiated from rheumatoid spondylosis in
that the latter frequently involves the upper cervical area. Osteophyte formation and end-plate sclerosis are usually absent in rheumatoid spondylosis, unless the two disorders are superimposed. The small peripheral joints are
usually also involved in rheumatoid arthritis.
NEUROLOGIC DAMAGE
Nerve roots may become entrapped within one or more IVFs from a combination
of subluxation, perivascular adhesions, dural adhesions, rheumatoid nodules,
granulation tissue, and sequestrated disc tissue. Neck pain, with or without
radiation to the arms, weakness, feelings of instability, ataxia, and paresthesiae are common symptoms. However, these cervical symptoms are difficult to differentiate if the disease initiates in the peripheral joints where signs of peripheral entrapment, myositis, tenosynovitis, and subluxated joints from tendon rupture exist. Related giddiness and fainting spells suggest an associated vertebral artery ischemia that is usually associated with the upward migration of the dens that produces a kinking of the vertebral artery at the atlas level.
RHEUMATIC ATLANTOAXIAL SUBLUXATION
Orthopedic subluxation is always a danger, proceeding from the synovitis,
apophyseal erosion, and erosion of the vertebral bodies involved that lead to
instability from joint destruction and ligamentous laxity. As apophyseal erosion
progresses, the dens migrates into the foramen magnum and the atlas becomes
fixed to the axis to reduce the possibility of dislocation. These signs determine the severity and prognosis of the general disease.
The characteristic anterior subluxation of the atlas on the axis is generally considered to be an adaptation change to help increase the capacity of the
spinal canal as rheumatoid tissue accumulates. If this is true, the decision for
clinical reduction presents a dilemma. This anterior subluxation usually occurs
only in flexion unless granulation tissue between the atlas and dens prevents
reduction during extension. Thus, direct reduction of the orthopedic rheumatic
subluxation by either manipulation or traction is usually contraindicated.
Jeffreys states: "The incidence of neurological damage in subluxated (rheumatic)
spines is very low" and "not infrequently the cord only becomes compromised when
the subluxation is reduced."
Intervertebral Disc Syndromes
The clinical picture of cervical disc disorders, states Grieve, is typically
a combination of "a hard osseocartilaginous spur, produced by the disc together
with the adjacent margins of the vertebral bodies." Furthermore, “the mechanism
by which pain and disability originate in the neck region,” contends Cailliet,
“can be considered broadly to result from encroachment of space or faulty movement in the region of the neck through which the nerves or blood vessels pass.” This encroachment of space or faulty movement commonly comprises apophyseal subluxation with osteophyte formation, contributing to, or superimposed upon disc degeneration and/or protrusion. This occurs most frequently in the C4–C6 area.
Degenerative Disc Disease
The cervical spine is readily subject to degenerative disc disease because
of its great mobility and because it serves as a common site for various congenital defects. Cervical degenerative changes can be demonstrated in about half
the population at 40 years of age and 70% of those at 65 years, many of which
may be asymptomatic. Bone changes are more common posteriorly in the upper cervicals and anteriorly in the lower cervicals.
ETIOLOGIC PICTURE
Various situations, individually or in combination, may be involved in initiating the process. Typical factors include trauma, postural and occupational
stress, biochemical abnormalities (eg, hydration, mucopolysaccharide, collagen,
lipid changes), biologic changes (eg, aging), autoimmune responses, psychophysiologic effects (eg, the sodium retention of depression), and genetic predisposition (eg, identical development in twins).
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
Cervical stiffness, muscle spasm, spinous process tenderness, and restricted
motion are common features. When pain is present, it is usually poorly localized
and often referred to the occiput, shoulder, between the scapulae, arm or forearm (lower cervical lesion), and may be accompanied with paresthesias. Radicular
symptoms rarely manifest unless a herniation is present.
Disc Protrusion or Herniation
The discs below C3 exhibit a higher incidence and the greatest severity of
herniation. The C5 disc is the most frequently involved, followed by the C6
disc. The C2 disc is the least frequently involved. Pure encroachment of a disc
upon the spinal canal or IVF as seen in the lumbar region is not frequently seen
in the cervical area.
ETIOLOGIC PICTURE
In acute disorders, interspace narrowing, straightening of the cervical
curve, and instability may be the only roentgenographic signs present. Instability will be most evident as aberrant segmental movement in comparative lateral
films made during full flexion and extension.
Several structural changes occur in chronic disorders. The vertebral bodies
involved become elongated, the normal cervical lordosis flattens, the anterosuperior angle of the vertebral bodies becomes rounded, the involved body interspace narrows, the total height of the neck is reduced, and the inferior apophyseal facet above tends to subluxate posteriorly on the superior facet below and erode the lamina.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
Generally, central herniation produces local neck pain while lateral herniation produces upper extremity pain. If the protrusion is central, cord signs and symptoms exhibit as lower extremity spasticity and hyperactive reflexes. Sensory changes are rarely evident, but the gait may be ataxic. If the protrusion is posterolateral, the nerve root will be involved rather than the cord.
Posterior osteophytes form at the disc attachment peripherally, often compromising the IVFs and vertebral canal. This may be noted by narrowing of the
A-P dimension of the spinal canal in lateral films and foraminal encroachment on
oblique films. These signs most frequently occur at the C6–C7 level. Anterior
osteophytes are considered the result of abnormal ligamentous stress rather than
part of the disc degeneration process. They occur most frequently below the C4
level, as do alterations of the covertebral joints.
DIFFERENTIAL DIAGNOSIS TIPS
Specific sensory and motor symptoms of acute disc herniation are shown in
Table 5.9. These features vary depending upon the direction of the disc bulge;
eg, upon the nerve root, IVF vessels, spinal cord, or combinations of involvement. In some acute and many chronic cases, numbness may manifest without pain. In acute disorders, the cervical signs may be confused with those of shoulder or elbow bursitis, epicondylitis, or subluxation, especially when no local cervical symptoms exist.
Table 5.9. Neurologic Signs in the Cervical Radiculopathies
Disc Nerve
Protrusion Root Level Features
C2 C3 Posterior neck numbness and pain radiating to the
mastoid and ear. The reflexes test normal.
C3 C4 Posterior neck numbness and pain radiating along
the levator scapulae muscle and sometimes to the
pectorals. The reflexes are normal.
C4 C5 Lateral neck, shoulder, and arm pain and paresthesia,
deltoid weakness and possible atrophy, hypesthesia
of C5 root distribution over middle deltoid area
(axillary nerve distribution).
The reflexes test normal.
C5 C6 Pain radiating down the lateral arm and forearm
into the thumb and index finger; hypesthesia of
the lateral forearm and thumb; decreased brachio-
radialis reflex; brachioradialis, biceps, and
supinator weakness.
C6 C7 Pain radiating down the middle forearm to the
middle and index fingers, hypesthesia of the middle
fingers, decreased triceps and radial reflexes,
triceps and grip weakness.
C7 C8 Possible pain radiating down the medial forearm and
hand to the little finger, ulnar hypesthesia,
intrinsic muscle weakness of the triceps and grip.
However, these symptoms are uncommon.
The reflexes are normal.
Lhermitte's Sign. With the patient seated, flexing the patient's neck and
hips simultaneously with the patient's knees in full extension may produce sharp
pain radiating down the spine and into the upper or lower extremities. When pain
is elicited, it is a positive sign that suggests irritation of the spinal dura
matter either by a protruded cervical disc, a tumor, a fracture, or multiple
sclerosis.
Vertebral Artery Compression. Associated subluxation and osteophyte development may produce vertebral artery compression, especially if a degree of arteriosclerosis is present. Symptoms of unsteadiness, dizziness, and fainting spells occur. This is especially true when the head is rotated to the opposite side.
Masses and Swellings
Carbuncles, lipomas, and neoplasms are the common masses found in the area
of the posterior neck.
Metastatic tumors are more common in adulthood than in youth. In men, metastasis is usually from the prostate gland or lung; in women, from the breast. In
metastatic lesions, pain is constant, day and night, and not relieved with rest.
The pain is increased by palpation, percussion, and movement. Cord tumors usually present pain with an insidious onset, but other early neurologic symptoms and
signs are not always present during the early stages.
Most cancerous tumors are associated with some degree of bone destruction, and a mass may or may not be palpable. Osseous tumors, benign or malignant, intramedullary or extramedullary, infrequently occur in youth. Neck pain is typical, and paralysis may or may not be present.
Neurovascular Compression Syndromes
BASIC INVESTIGATIVE APPROACH
The cervicothoracic junction area is a unique area of the spine. It is a common site of developmental anomalies; it is a major site of arterial, lymphatic, and neurologic traffic; and it presents the juncture of the highly mobile cervical spine with the very limited thoracic spine. The area of cervicothoracic transition is a complex of prevertebral and postvertebral fascia and ligaments subject to shortening. It offers a multitude of attaching and crossing muscles -- all of which are subject to spastic shortening and fibrotic changes that tether normal motion.
ETIOLOGIC PICTURE
The etiologic theories of cervicobrachial syndromes are numerous; eg, compression of nerve trunks, trauma to nerve trunks, injuries to the sympathetic
and vasomotor nerves, trauma to the scalenus anterior muscle, embryologic
defects, postural or functional defects, narrowing of the upper thoracic cap as
a result of adjacent infections or anatomic defects, acute infection producing
myositis, intermittent trauma to the subclavian artery, or a cervical rib.
The 4th and 5th decades mark the highest incidence of trouble in this area,
probably because of regressive muscular changes. The incidence is more frequent
in females in the order of 3:1. This is probably due to weaker upper-extremity
development.
Trauma to the head, neck, or shoulder girdle is a common precipitating factor. In some cases, poor posture, anomalies, or muscle contractures may be
involved. Reduced tone in the muscles of the shoulder girdle, by itself, has
been shown to allow depression of the clavicle that narrows the thoracic outlet
and compresses the neurovascular bundle. In addition, subluxation syndromes (eg,
retrolisthesis) may initiate these and other disturbances of the shoulder girdle
and must be further evaluated.
Cervical pathology such as spinal canal or IVF encroachment by a buckling
ligamentum flavum, spinal stenosis, or spurs should be a consideration. During
degeneration, the dura and dentates become thickened, dura and arachnoid adhesions become prevalent, osteochondrophytes may develop from the borders of the canal or foramen -- all of which tend to restrict the cord and/or nerve root
during cervical motions. Osteochondrophytes near the foramen can readily
compress the vertebral artery and root together.
Differential diagnosis should exclude a cervical rib etiology from infectious neuritis, binding adhesions, arthritis of the shoulder joint, clavicle fracture callus, bifid clavicle, cervical arthritis, subacromial bursitis, 1st rib subluxation and posttraumatic deformities, spinal or shoulder girdle tumors,
Pancoast's tumor of the lung apex, and cardiac disease. Aneurysms of the subclavian artery are rarely involved.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
Symptoms usually do not occur until after the ribs have ossified. Two groups
of symptoms are seen, those of scalenus anticus syndrome and those due to cervical rib pressure. The symptoms of cervical rib and scalenus syndrome are similar, but the scalenus anticus muscle is the primary factor in the production of neurocirculatory compression whether a cervical rib is present or not.
When symptoms are present, they are usually from compression of the lower
cord of the brachial plexus and subclavian vessels such as numbness and pain in
the ulnar nerve distribution. See Table 5.5. Pain is worse at night because of
pressure from the recumbent position, and its intensity varies throughout the
day. Tiredness and weakness of the arm, finger cramps, numbness, tingling, coldness of the hand, areas of hyperesthesia, muscle degeneration in the hand, a
lump at the base of the neck, tremor, and discoloration of the fingers are
characteristic. Work and exercise accentuate symptoms, while rest and elevation
of the extremity relieve symptoms.
DIFFERENTIAL DIAGNOSIS TIPS
Several pertinent tests are described below. X-ray films should always be
taken before performing a cervical compression test, especially when the patient
has experienced trauma or shows physical signs of advanced degeneration. It is
important to rule out possible conditions that would be aggravated by any
testing procedure.
Adson's Test. With the patient seated, the examiner palpates the radial
pulse and advises the patient to bend the head obliquely backward to the opposite side being examined, take a deep breath, and tighten the neck and chest
muscles on the side tested. This maneuver decreases the interscalene space
(anterior and middle scalene muscles) and increases any existing compression of
the subclavian artery and lower components (C8 and T1) of the brachial plexus
against the 1st rib. Marked weakening of the pulse or increased paresthesiae
indicate a positive sign of pressure on the neurovascular bundle, particularly
of the subclavian artery as it passes between or through the scaleni musculature, thus indicating a probable cervical rib or scalenus anticus syndrome.
Cervical Distraction Test. With the patient seated, the examiner stands to
the side of the patient and places one hand under the patient's chin and the
other hand under the base of the occiput. Slowly and gradually the patient's
head is lifted to remove weight from the cervical spine. This maneuver elongates
the cervical IVFs, decreases the pressure on the joint capsules around the facet
joints, and stretches the paravertebral musculature. If the maneuver decreases
pain and relieves other symptoms, it is a probable indication of narrowing of
one or more IVFs, cervical facet syndrome, or spastic paravertebral muscles.
Eden's Test. With the patient seated, the examiner palpates the radial pulse
and instructs the patient to pull the shoulders backward, throw the chest out in
a “military posture,” and hold a deep inspiration as the pulse is examined. The
test is positive if weakening or loss of the pulse occurs, indicating pressure
on the neurovascular bundle as it passes between the clavicle and the 1st rib
-- thus indicating a costoclavicular syndrome.
Passive Cervical Compression Tests. Two tests are involved. First, with the
patient seated, the examiner stands behind the patient. The patient's head is
laterally flexed and rotated slightly toward the side being examined. Interlocked fingers are placed on the patient's scalp and gently pressed caudally. If
an IVF is physiologically narrowed, this maneuver will further insult the foramen by compressing the disc and narrowing the foramen, producing pain and
reduplication of other symptoms. In the second test, the patient's neck is extended by the examiner who then places interlocked fingers on the patient's
scalp and gently presses caudally. If an IVF is physiologically narrowed, this
maneuver mechanically compromises the foraminal diameters bilaterally, producing
pain and reduplication of other symptoms.
Shoulder Depression Test. With the patient seated, the examiner stands behind the subject. The patient's head is laterally flexed away from the side
being examined. The doctor stabilizes the patient's shoulder with one hand and
applies pressure alongside the patient's head with the palm of the other hand;
stretching the dural root sleeves and nerve roots or aggravating radicular pain
if the nerve roots adhere to the foramina. Extravasations, edema, encroachments,
and conversion of fibrinogen into fibrin may result in interfascicular, foraminal, and articular adhesions and inflammations that will restrict fascicular glide and the ingress and egress of the foraminal contents. Thus, pain and reduplication of other symptoms during the test suggest adhesions between the nerve's dura sleeve and other structures around the IVF.
Spurling's Test. This is a variation of the passive cervical compression
test. The patient's head is turned to the maximum toward one side and then
laterally flexed to the maximum. A fist is placed on the patient's scalp, and a
moderate blow is delivered to it by the other fist. The patient's position produces reduced IVF spaces, and the blow causes a herniated disc to bulge further into the IVF space or an irritated nerve root to be aggravated, thus increasing the symptoms.
Wright's Test. With the patient seated, the radial pulse is palpated from
the posterior in the downward position and as the arm is passively moved through
an 180° arc. If the pulse diminishes or disappears in this arc or if neurologic
symptoms develop, it may indicate pressure on the axillary artery and vein under
the pectoralis minor tendon and coracoid process or compression in the retroclavicular space between the clavicle and 1st rib -- thus indicating a hyperabduction syndrome.
Nuchal Rigidity
Nuchal rigidity refers to a spasmotic contraction of the posterior muscles
of the cervical spine. Also see Stiff Neck and Torticollis.
ETIOLOGIC PICTURE
The most common cause of nuchal rigidity, by far, is meningitis. However,
the sign is not pathognomonic. A number of inflammatory conditions may be
involved. For example: Carbuncle Epidural abscess Osteomyelitis
Cellulitis Encephalitis Retropharyngeal abscess
Cervical pyogenic Meningitis Rheumatoid spondylitis
infection Myositis/fibrositis Sprain
Several other conditions must also be eliminated. For example: Fracture Pyramidal tract disease Subluxation (acute)
Mediastinal emphysema Spinal cord tumor Tuberculosis
Metastasis Spondylosis
Parkinsonism Subarachnoid hemorrhage
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
See Table 5.10.
Table 5.10. Nuchal Rigidity and Associated Symptoms
Syndrome: Nuchal Rigidity + Primary Suspect Disorder(s)
Focal neurologic signs Cerebral hemorrhage Osteomyelitis
Cerebral abscess Spondylosis
Encephalitis Subluxation (acute)
Meningitis
Pyrexia Cervical pyogenic in- Osteomyelitis
fection Retropharyngeal abscess
Meningitis Subarachnoid hemorrhage
Retinal hemorrhage and Collagen disease Subarachnoid hemorrhage
pyrexia Stroke
Tremor and diffuse spasm Parkinsonism
BASIC LABORATORY WORKUP CONSIDERATIONS Blood smear and culture Psychometric tests Tuberculin test
CBC and differential Sedimentation rate Urinalysis
Chest x-ray Serum ceruloplasmin level Urine culture
EEG Serum copper level VD serology
Hair analysis Skull x-ray
Nose and throat culture Spinal roentgenography
Pain
An underlying neurologic insult is considered to be the most frequent cause
of posterior neck pain; however, the focus of irritation may be either local or
remote. In addition to biomechanical and traumatic causes, neoplasms, cerebrospinal inflammations, and arthritic conditions must always be considered.
Disturbances of nerve function associated with subluxation syndromes manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve or nerve root disorders, or of a reflex nature.
ETIOLOGIC PICTURE
See Table 5.11.
Table 5.11. Typical Causes of Posterior Neck Pain
Neurologic
Traumatic Inflammatory Psychologic Vascular
Compression Abscess Brachial neuritis Angina pectoris
Contusion Dental infection Cervical subluxa- Dissecting aortic
Dislocation Fibrositis tion syndrome aneurysm
Fracture Lymphadenitis Multifidi trigger Subarachnoid
Hematoma Meningitis point hemorrhage
IVD syndrome Myalgia Postural subluxa- Temporal arteritis
Rheumatoid arth- tion complex
ritis Psychoneurosis
Riedel's struma Scalenus anticus
Trichinosis syndrome
Tuberculosis Sternocleidomas-
toid trigger point
TMJ dysfunction
Trapezius trigger
point
Degenerative
Neoplastic Deficiency Congenital
Carcinoma Cervical spondylosis Branchial cyst
Cyst Osteoarthritis Cervical rib
Hodgkin's disease Pott's disease Congenital diverticulum
Metastasis Platybasia
Pancoast tumor Other anomalies
Spinal cord tumor
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
See Table 5.12.
Table 5.12. Posterior Neck Pain and Associated Symptoms
Syndrome:
Posterior Neck Pain + Primary Suspect Disorders
Mass Bony congenital anomaly Lipoma
Carbuncle Lymphadenitis
Cyst Metastatic carcinoma
Hematoma Tuberculosis
Nuchal rigidity Atlantoid fracture Subarachnoid hemorrhage
Dens fracture Subluxation (acute)
Meningitis Torticollis
Radiation absent Angina pectoris Remote subluxation reflex
Ankylosing spondylitis Retropharyngeal abscess
Cervical spondylosis Subluxation (mild)
Fibrositis Sternocleidomastoideus
Meningitis trigger point
Multifidi trigger point Torticollis (variable)
Pyogenic infection Trapezius trigger point
Radiation to one or both Angina pectoris Pancoast's tumor
upper extremities Cervical IVD syndrome Scalenus anticus syndrome
Cervical rib Spinal cord tumor
Cervical spondylosis Subluxation complex
Cervicobrachial syndrome Trauma (eg, whiplash) CBC and differential Serum alkaline phospha- Spinal roentgenography
Chest x-ray tase Throat culture
EMG Serum calcium Tuberculin test
Sedimentation rate Serum phosphorus Urinalysis
Serum acid phosphatase Skull x-ray VD serology
Postural Syndromes
Cervical Curve Reversal
As compared with the primary thoracic kyphosis which is a structural curve,
the cervical and lumbar anterior curves are functional arcs produced by their
wedge-shaped IVDs. They normally flatten in the non-weightbearing supine position
and quickly adapt to changes involving the direction of force.
BASIC INVESTIGATIVE APPROACH
A flattened cervical spine in the erect posture resembles a normal spine
during flexion. The nucleus of the disc serves as a fulcrum during flexion and
return extension. When the spine is subjected to bending loads during flexion,
half of the disc on the convex side suffers tension, widens, and contracts,
while the other half of the disc on the concave side suffers compression, thins,
and bulges. Concurrently, the nucleus bulges on the side of tension and contracts on the side of compression, which increases tension on the adjacent anulus. This creates a self-stabilizing counteracting flexion force to the motion unit that aids a return to the resting position.
A pathologic straightening of the normal anterior curve of the cervical
spine, as viewed in a lateral weight-bearing x-ray film, results in mechanical
alteration of normal physiologic and structural integrity. The normal vertical
A-P line of gravity, as viewed laterally, falls approximately through the odontoid and touches the anterior border of T2. As the cervical spine tends to flatten in the erect position, the gravity line passes closer to the center of the cervical discs.
ETIOLOGIC PICTURE
Although the cervical curve is the first secondary curve to develop in the
infant, its maintenance in the erect posture is essentially determined by the
integrity of the lumbar curve. A flattened cervical spine that is not compensatory to a flattened lumbar spine may be the result of a local disorder such as a
subluxation syndrome caused by posterior shifting of one or more disc nuclei,
hypertonicity of anterior musculature, or anterior ligamentous shortening as the
result of local overstress, inflammation, occupational posture, or congenital
anomaly.
The clinical picture is often the result of trauma-producing whiplash injury, herniated disc, subluxation, dislocation, fracture, or ligamentous injury. Torticollis, arthritis, malignancy, tuberculosis, osteomyelitis, and other
pathologies may also be involved. The condition occurs more frequently after the
age of 40, and the sexes appear equally affected.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
Cervical flattening is usually the result of paraspinal spasm secondary to
an underlying injury, irritation, or inflammatory process. The acute clinical
picture is one of torticollis. Other manifestations include headaches (occipital, occipital-frontal, supraorbital), vertigo, tenderness elicited on lateral C4–C6 nerve roots, neuritis involving branches of the brachial plexus
due to nerve-root pressure, hyperesthesia of one or more fingers, and loss or
lessening of the biceps reflex on the same or contralateral side. Infrequently,
the triceps reflex may be involved. One or more symptoms are often aggravated by
an abnormal position of the head such as during reading in bed, an awkward
sleeping position, or long-distance driving.
ROENTGENOGRAPHIC CONSIDERATIONS
The typical radiographic findings include loss of the normal lordotic curve
by the straightened cervical spine (78% cases), anterior and posterior subluxation on flexion and extension views, narrowing of IVD spaces at C4–C6 in 46% cases, discopathy at the affected vertebral level as the injury progresses, and osteoarthritic changes that are often accompanied by foraminal spurring.
Cervical Scoliosis
Cervical scoliosis is often mechanically predisposed by flattening rather
than exaggeration of the cervical lordosis. This is quite common during youth.
The posterior joints become relatively lax during flattening of the cervical
spine, and this encourages retropositioning and posterior subluxations that are
frequently the first step toward cervical scoliosis.
BASIC INVESTIGATIVE APPROACH
When viewed from the posterior, the vertical line of gravity passes through
the occipital protuberance and the vertebrae's spinous processes. In cervical
scoliosis, the midcervical spinous processes, especially, tend to deviate
laterally from this line.
In typical rotary cervical scoliosis, the spinous processes tend to rotate
toward the convex side of the lateral curve, the vertebral bodies rotate toward
the concave side, and the discs and articular facets become subjected to abnormal stretching forces as they open on the side of convexity and to compressive forces on the side of concavity. This type of cervical scoliosis is usually the compensatory effect of a lower scoliosis to the other side and a common cause of recurring episodes of nontraumatic torticollis.
ETIOLOGIC PICTURE
When a cervical disc is loaded unilaterally, the disc initially becomes
wedge-shaped and the normally parallel vertebral plateaus form an angle. This
vertically stretches the anular fibers that are opposite the weight-bearing
side, but this action is quickly counteracted by forces transmitted laterally
from the resilient nucleus to help the disc return to its normal shape. This
self-stabilization factor is the product of a healthy nucleus and anulus working
as a mechanical couple.
In cervical scoliosis, there are also disc reactions to rotary forces that
must be considered. As the apposing layers of anular fibers run alternately
oblique in opposite directions, the oblique disc fibers angled toward the direction of twist become stretched when a vertebra rotates, and the oblique fibers running against the direction of rotation tend to relax. The greatest tension from stretch is seen centrally where the fibers are nearly horizontal. This increases nuclear pressure by compression in proportion to the amount of rotation. If severe, the nucleus can be dislodged from its central position.
Cervical scoliotic rotation is also associated with a lateral tilt that
increases the distance between the lateral margins of the vertebral bodies on
the convex side of the curve. This stretches the lateral anulus, which produces
a contraction of that part of the disc and a compensatory bulging of its contralateral (thinned) aspect. If the anular filaments become stretched, weakened,
and the disc loses some of its stiffness property, the nucleus may shift from
its central position so that the vertebral segment is unable to return to its
normal position. A firmly locked rotational subluxation can result.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
When continuous compression is applied to any active and mobile joint, cartilaginous erosion followed by arthritis can be expected. When continuous
stretching is applied to any active and mobile synovial joint, capsulitis can be
anticipated.
If scoliotic rotation takes place evenly among the cervical segments and the
cervical nuclei hold their relatively central position in the discs, the situation is usually asymptomatic even though erosion and arthritis can be demonstrated on roentgenographs. However, if a nucleus fails to hold its central position
and shifts laterally away from the point of maximum compression, the superimposed vertebra is encouraged to produce a fixed clinical subluxation.
Shaken Infant Syndrome
The term shaken infant syndrome is relatively new to health-science literature. Parents who would never strike an infant sometimes have a tendency to shake the child roughly during a moment of irritation or frustration in an attempt to “shake some sense into him.”
It is obvious that infants and young children have disproportionate heavy
heads that rest on underdeveloped cervical structures. Severe shaking can result
in brain damage, cerebral hemorrhage, mental retardation, brain stem ruptures,
spinal cord injury, occipital or cervical subluxation or dislocation and their
varied consequences, eye damage, and even death.
Spondylosis
Cervical spondylosis is a chronic condition in which there is progressive
degeneration of the IVDs leading to secondary changes in the surrounding vertebral structures, including the posterior apophyseal joints. It can be the result
of direct trauma (eg, disc injury), occupational stress, aging degeneration, or
found in association with and adjacent to congenitally defective vertebrae.
BASIC INVESTIGATIVE APPROACH
Three not infrequent diseases of the cervical spine with biomechanic implications are spondylosis, rheumatic spondylitis, and ankylosing spondylitis. In each of these conditions, severe subluxation is a cardinal manifestation.
Spondylosis may produce compression of either the nerve root or spinal cord.
During the degenerative process, intradisc pressure decreases, the anulus protrudes, and the end-plates approximate due to reduction of disc thickness. As
the disc protrudes, it loosens the attachment of the posterior longitudinal
ligament. This allows the anulus to extrude into the cavity formed between
the posterior vertebral body and the ligament, and this portion of the anulus,
in time, becomes fibrous and then calcifies. Because of this process, posterior
osteophytes prevail in the cervical and lumbar regions, while anterior spurs are
more common to the dorsal spine.
The incidence is high in the second half of life with increasing severity in
advancing years; 60% at 45 years, 85% at 65 years. The degenerative process,
which may or may not progress, appears greatest in those segments below the
maximum point of the lordosis because of the loading forces in the upright posture. Signs are most often seen at the C5 level, and next in frequency at the C6 level.
ETIOLOGIC PICTURE
Pre-existing spinal stenosis, a thickened ligamentum flavum, a protruding
disc, and spur formation may complicate the picture of cervical spondylosis.
The weight of the head in faulty posture (eg, exaggerated dorsal kyphosis and
cervical lordosis) along with activity stress may contribute to chronic degenerative spondylosis that is often superimposed upon asymptomatic anomalies. A
vicious cycle is often seen in which subluxation contributes to degenerative
processes and these processes contribute to subluxation fixation.
Jeffreys points out that there appears to be a correlation of cervical spondylosis to carpal tunnel syndrome, lateral humeral epicondylitis, cervical
stenosis, and low back and/or lower extremity osteoarthritis. There is almost no
correlation between the degree of pain in the neck and the degree of arthritic
changes noted in x-ray films.
PERTINENT ASSOCIATED COMPLAINTS AND FINDINGS
The onset is usually rapid and insidious but may be subjectively and objectively asymptomatic. The classic picture, however, is one of a middle-aged
person with greatly restricted cervical motion, marked muscle spasm, positive
cervical compression signs, insidious neck and arm pain and paresthesia aggravated by sneezing or coughing, acute radiculopathy from disc herniation, and usually some muscle weakness and fasciculations.
Whiting lists the manifestations that develop in spondylosis to also include
neck crepitus, subjective or objective; local neck tenderness; headaches; neck
pain radiating to the scapulae, trapezius, upper extremities, occiput, or anterior thorax; extremity muscle weakness; paresthesia of the upper and/or lower
extremities; dizziness and fainting; impaired vibration sense at the ankle;
hyperactive patellar and Achilles reflexes; and positive Babinski responses.
ROENTGENOGRAPHIC CONSIDERATIONS
Due to the constant weight of the head, postural strains, occupational insults, degrees of congenital anomalies, and posttraumatic or postinfection
effects with or without an associated disc involvement, the development of chronic degenerative spondylosis offers some distinct progressive characteristics:
(2) A-P fixation and restricted mobility;
(3) thinning of the atlanto-occipital and atlantoaxial articular plates, resulting in motion restriction;
(4) middle and lower cervical disc wearing and thinning that narrow the IVFs;
(5) disc weakness encouraging nuclear shifting and herniation contributing to nerve encroachment;
(6) osseous lipping and spurs with extensions into the IVFs; and
(7) infiltration and ossification of paravertebral ligaments adding to inflexibility and pain upon movement.
DIFFERENTIAL DIAGNOSIS TIPS
Nelson believes that head weight and postural strains are overemphasized.
“It has often been established clinically that unless overt trauma can be shown,
most neck problems are the result of reflex vasospasm where the reflex originates in the viscera below the diaphragm. Everyone would be affected if weight of the head and postural strains were common causes.”
Regardless of the merit of this controversial concept, it is important to
avoid the pitfall of assuming that all the patient's symptoms involving the neck
and upper extremities are caused by a cervical spondylosis when it is found
radiographically. Cervical spondylosis is common, and symptoms may thus be associated with unrelated neurologic disorders that may coexist with the spondylosis, making the diagnosis more difficult.
Stiff Neck
A stiff neck may be exhibited that does not represent a central nervous
system involvement (eg, meningitis, subarachnoid hemorrhage) or a spastic contracture. See Nuchal Rigidity and Torticollis.
Diffuse neck stiffness is a common manifestation in subluxation syndromes,
children with febrile diseases and tonsillar herniation, chronically ill
patients, and elderly patients with fibrositis and/or spondylosis. The following
additional etiologies should also be excluded: Amoebic invasion Froin's syndrome Multiple sclerosis
Arteritis Fungus infection Mumps
Brain abscess Lead poisoning Sarcoidosis
Brain carcinomatosis Leukemia Subarachnoid hemorrhage
Brain tumor Lymphoma Syphilis
Brucellosis Meningism Tuberculosis
Cerebral thrombosis Meningitis Ventricular hemorrhage