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The Cervical Spine

Functions: Upper C spine - orientation of sense organs, support the head and cervical viscera Mid C spine mobility Lower neck dissipation of forces, integration of the shoulder and thoracic mechanics Supports the visceral cranium, allowing the large amount of lymphatic tissue in this area to drain through it, pharynx, larynx, trachea and oesophagus. Supports the neurocranium (spinal cord) ROM Occ-C1: ext 20; Flex 10 C1-C2: rotation 90 (45 each way) C2-C7: gliding fle/ext 60 each direction and rot/sb 60 as well C5-C6: apex/leading to degeneration C7-T1: limited movement (acts to dampen) Typical: Small vertebral bodies londer from side to side than anteroposteriorly Concave sup surface of the vertebral bodies form uncinate processes Large and triangular vertebral foramen (brachial plexus) Short and bifid SPs C3-5 TPs have foramen for vertebral aa C1-6: foramina transversaria Facets: horizontal Atypical: C1/Atlas: Kidney shape body, lacking spinous process and body, consisting of two lateral bodies connected by ant and post arches. C2/Axis: Odontoid process projects superiorly from its body C7/vertebral prominens: long spinous process which is not bifid. Common csp ligaments: ALL: basilar part of occiput down over bodies thickly attached. Limits ext. Pain sensitive. PLL: Thicker over discs, double layered reinforcing the capsular ligaments. Controls tranverse gliding as well as flexion and extension. Pain sensitive Lig Flavum att lamina above to lamina below, elastic fibres, resists flexext, hypertrophy assoc with spondylarthrosis and IVD protrusion can cause spinal stenosis. No pain sensitive.

Cervical Vertebrae

Ligaments

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Interspinous ligaments connect between adjacent SPs Supraspinous ligaments connects tips of SPs merges with Lig Nuchae att from skull to foramen magnum to SP of C1-7 Intertransverse ligaments between TPs Ligamentum nuchae: Fibrous membrane limiting flexion. Occiput to C7. Probably no pain sensitive. Upper csp ligaments: Anterior A-O, A-A ligament-reinforced by the ALL Posterior A-O, A-A ligament-reinforced by the ligamentum nuchae Transverse ligament of the cruciate ligament. Has a fascial opening for the vertebral artery of C1. Alar ligament- reinforced by the ALL. From the odontoid process to the condyles of the occiput Apical ligament: tip of the odontoid peg to the ant margin of the foramen magnum. Blends with the cruciate ligament Tectorial membrane- reinforced by the PLL. Situated within the vertebral canal Apophyseal joints ALL, PLL and dura Nerve root and sheaths Outer fibres of IVD Uncovertebral joints (of Luschka) Myotendinous structures No disc between Occiput-C1-C2 Atlanto-occipital jt synovial condylar joints, permit primarily flex-ext Atlanto-axial joint: the dens acts as a pivot allows the atlas (and head) to rotate on the axis, transverse ligament holds dens against anterior arch C1 Shape of articular facets C2-3 restricts rotation - helps protect vertebral aa. Dampening function Mass of supporting ligaments and abundant synovium to lubricate movements RA or chronic infection can lead to softening/subluxation of dens and meningeal irritation Whiplash (flexion) injury will have pronounced affect upper C.spine as it is the location where these movements occur most readily Integrates with thorax, shoulder and cervical viscera Provides relative stability - transmission of neurovascular structures (subclavian aa and Ax aa, and vv, trunks of brachial plexus) Thoracic outlet tightly packed area compression can cause TOS Formed by loops joining anterior rami of C1-4 Muscular (deep) branches: e.g phrenic n (C3,4,5) to diaphragm, the ansa cervicalis (C1-C3) loop innervates the infrahyoid muscles (C1-C3), suboccipitals (C1) Cutaneous (superficial) branches: Lesser occipital n (C2), Greater occipital (C2-C3), Great auricular n (C2-C3), transverse cervical n (C2-C3), supraclavicular n (C3-C4): supply skin of neck, sup-lat thorax and post scalp Links with sympathetics via superior cervical ganglion, with hypoglossal n (C1) and accessory n (C2) Great auricular n (C2-C3) irritation: Arnold's neuralgia caused by subocc muscle spasm or traction in whiplash In neutral and flexion: cervical NR are pulled taut and occupy superior position in IV foramen,in extension dura folds, NR slacken and descend in foramen. Only if foramen narrowed will there be neurological impairment

Pain sensitive structures

Upper C spine

Lower C spine

Cervical plexus

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Blood Vessels

Neck Muscles

Carotid sheath

Common carotid a. bifurcates at C3-4 int/ext carotid, at the level of the thyroid. Branches of ext carotid supply neck, Int carotid has no branches in neck: ascending pharyngeal artery, occipital artery, post auricular artery, sup thyroid artery, lingual artery, facial artery. Vertebral aa (branch: subclavian aa) pass through transverse foramen C16, at the level of each IVF small branches to the nerve root anastomose Int Jug v drains brain, ant face, deep mm of the neck, cervical viscera Ext jug v and anterior jug v drain superficial structures of neck Superficial and lateral mm: platysma, trapezius, scm Suprahyoid: mylohyoid, geniohyoid, stylohyoid, digastric Infrahyoid: sternohyoid, omohyoid, sternothyroid, thyrohyoid Anterior vertebral mm: longus colli, longus capitis, rectus capitis anterior, rectus capitis lateralis Lateral vertebral mm: splenius capitis, levator scapulae, posterior, middle, anterior scalenes Occipital mm: rectus capitis posterior major & minor, oblique capitis inferior & superior The carotid sheath is an anatomical term for the fibrous connective tissue that surrounds the vascular compartment of the neck. It is part of the deep cervical fascia of the neck. the common carotid artery as well as the internal carotid artery internal jugular vein CN X the deep cervical lymph nodes

Pre-tracheal sheat Lymphatic

Spreads up mediastinal infections to the brain Superficial: lie along the EJV

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supply Deep: lie along the IJV

Vindicater Vascular Inflammatory Neoplasm Degenerative Infection Congenital Autoimmune Trauma Endocrine Rheumatologic Neurological Other
Spondylarthrosis Spondylosis IVD injury Postural injuries

Angina, Myocardial infarction, Subarachnoid haemorrhage, TOS, VB ischaemia Apophysitis, facet lock, cervicogenic HA Primary Metastastic lesions (Leukaemia, Hodgkins disease), Bone tumours, Cervical cord tumours, Lung cancer: Pancoasts tumour, Oesophageal cancer, Thyroid cancer Spondylosis, Spondyloarthroses, O/A, Osteoporosis, Ossification of PLL Vertebral Osteomyelitis, Meningitis, Lyme disease, Retropharyngeal abscess, TB, Poliomyelitis, MS Cervical Rib, Kippel-Feil, Torticollis, Springels shoulder Ankylosing Spondylitis Vertebra #, Whiplash injury, IVD prolapse Rheumatoid arthritis NRI, Cervical myelopathy Oesophagitis Degenerative Most commonly C6-T1 Most common C4-C6 Less common in C.sp Ligamentous overstrain: creep and other changes causing mm ischaemia. Desk work: flexion injury A-O jt and mid-cervical complexes Extension injuries: decorators and professions where arms are used above head. Def: Condition associated with spondylosis which leads to cord compression Incidence: in either sex, between 30 to 70 years old Cause: The most common cause is degenerative changes within the cervical spine, which leads to narrowing (cervical spine stenosis:ligamentum flavum, osteophytic growth) and ultimately pressure on the cord. Other causes including a central cervical disc prolapse, tumours or infection. Patients may have a predisposition if they are born with a narrow canal or have a deformity secondary to previous neck injury. Usually affects C5/C6, C6/C7 D.D: Multiple sclerosis Pathophysiology: The combination of direct pressure on the spinal cord and ischemia (reduction of the blood supply) of the spinal cord leads to the spinal cord damage Signs: -Cervical root syndrome:often affected C6, C7 and C5. -Compressive cervical myelopathy:Inversion of the reflexes (C5,C6 are absent and C7 is brisk) mild to moderate spastic paraparesis. In most cases there are no sensory symptoms and bladder function is unimpaired. The signs are often confined to the motor system: all reflexes are brisk and both

Progressive cervical myelopathy

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plantar responses are extensor. The weakness of the legs is of pyramidal type but is confined to the legs. Weakness of the arms is a late and relative minor problem. Positive Lhermittes sign (tingling in all four limbs with neck flexion) Symptoms: Cant hurry for a bus, starts to trip or fall Tets: MRI scan, X-Ray Ttt: Descompression by ant dissectomy (more successful: excision of the disc and ant osteophyts ), post laminectomy, no evidence for the use of cervical collar Spondylotic bar Def: Cervical spondylosis is a common degenerative condition of the cervical spine. It is most likely caused by age-related changes in the intervertebral discs Associated with:spondyloarthopathy, hypertrophy of the ligamentum flavum, and ossification of the posterior longitudinal ligament, osteophytes. Most common C5/C6. Symptoms: Neck and shoulder pain,suboccipital pain, neck stiffness, HA (usually start at the occiput and travel to the forehead), radicular pain (dermatomal linear shap pain, pins and needles, weakness, numbness), myelopathy. Lhermittes sign: barber chair sign, shooting pain in all limbs following neck flexion. Ttt: nonsteroidal anti-inflammatory drugs (NSAIDs), physical modalities, and lifestyle modifications. Surgery is advocated for cervical radiculopathy in patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. Surgical indications for cervical spondylotic myelopathy remain somewhat controversial, but most clinicians recommend operative therapy over conservative therapy for moderate-tosevere myelopathy. Inflammatory Apophysitis Neck held in flexion/ S/B (wry neck), no trauma recalled, problem recurrent due to underlying vulnerability. The facet joint is painful and swollen. Subsides in 3-7 days. Local pain as well as referring to areas of the head, shoulders and scapula Facet Lock Def: Clinical presentation of movement dysfunction related to facet dysfunction probably involving the capsule and intrinsic muscles. Symptoms: Rising in the morning with acutely painful unilateral joint lesion. Neck held flexed and side bent. Neck pain and shoulder pain Agg: arm mvmts, neck mvmts Cause: bruxism, fist clenching (boxing) or powerfully twisting the neck, physiological response to csp muscle becoming cold causing spasm (sleep with open window), meniscoid structure. Cervicogenic HA Def: as well as causing local pain in the neck, problems arising in structures in the neck can be responsible for pain in the head. Neck contains many pain sensitive tissues and the HA is likely to be referred from one or more muscular, neurogenic, osseous, articular or vascular structures in the neck. Incidence: Women over 40 Rheumatologic RA AA joint common site due to abundant synovium. Softening and subluxation of dens causes meningeal irritation. Contraindication: HVT Traumatic Whiplash Def: Hyper flexion or hyper extension injuries. Important to establish direction of impact. Rear end collision: muscles off guard and ligs vulnerable. In ext injury: OA affected primarily due to momentum of the head. The occipital condyles move ant/sup and may even lock causing spasm of

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sub-occipitals. Stress on alar and cruciate ligaments.The odontoid peg may be # in response of this stress or the cruciate ligament torn. Strain of the ALL. Injury of the apex of the csp: C4-C5 Secondary injury (due to recoil): Protective muscle spasm of erector spinae, trapezius. Tearing of tectorial membrane, ligamentum nuchae, PLL, transverse part of the cruciate ligament. Spinal cord involvement. Long term problems: hypermobility of the upper csp, apex moves superiorly, flexion group develops at AO jt C1-C2 will be affected if any rotation is involved. Mild whiplash with rotation poorer prognosis: instability from damage to alar ligaments. Condition of central pain processing where symptoms persist after tissue healing. Autonomic disturbance may occur. LBP may develop 5 yrs later due to changed spinal mechanics. Vascular

WAD: whiplash associated disorder Thoracic Outlet (TOS)

Vertebrobasilar Insufficiency or Ischaemia (VBI)

Definition: is a syndrome involving compression at the superior thoracic outlet resulting from excess pressure placed on a neurovascular bundle and giving to the patient upper limb symptoms Structures involved: subclavian and axillary vascular supply and the trunks of the brachial plexus. Sites of compression: Supra-clavicular lesion - inter-scalene compression of n-vas bundle Costo-clavicular lesion - between clavicle, first rib and subclavius muscle Infra-clavicular lesion - under pect minor, carotid and costo-carotid membrane Causes: poor posture, scaleni hypertrophy (breathing problems) cervical ribs, clavicle fracture (callus formation), apical tumour, scoliotic alteration of thorax, tractional trauma- sleeping with arm in abduction/work related. Symptoms: neuro, vascular or mixed Lower brachial plexus compression over first rib affects C8-T1 tingling, numbness, pain in medial forearm, hand Vascular symptoms: pain more constant & diffuse, cold, cyanosed fingers, pulses normally present Adsons test, intermittent claudication test Temporary occlusion of vertebral aa causing relative ischaemia to base of brain. Mainly affecting brainstem, cerebellum, post part of the cerebrum (occipital) and thalamus Brain stem>reticular formation>conciousness Commonly assoc with cervical spondylosis: precipitated by hyper-ext and rotation of neck, symptoms develop as vertebral artery momentarily blocked, resolve as compression is released. RTA, ligamentous laxity, suboccipital hypertension Risk factor: diabetes, hypertension, atherosclesoris S+S: Vertigo, nystagmus, diplopia, drop attacks (reticular formation) Subdural: Bridging veins in parietal region. Slow onset. Confusion. Elderly shrink of the veins, alcohol, anticoagulation therapy. Maybe HA Subarhacnoid: aneurysm of the circle of Willis (malformation, congenital: Berrys aneurysm). Sudden, young, exertion, meningism post fossa; hit with a brick / worst headache Extradural: Trauma related. Middle meningeal artery above temporal midzygoma. Usually young male, traumatic, rapid evolution, talk and die, headache common

Haemorrhages

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Intracerebral: for instance Capsular CVA (Cerebro Vascular Attack) HA Migraines: Prodromal Aura Migraines Cause: hormonal changes, hypoglycaemia Pathophysiology: vc/vd and serotonin levels Signs and symptoms

Cluster HA: Red flags: 1 HA, associated with trauma, vomiting, worse, consciousness, special sense changes, balance, dizziness Def: Transient disruption in blood supply resulting in a lack of oxygen (ischaemia) to the brain. It usually lasts 8 minutes (<24h). Pathophysiology: Virchows triad: endothelial injury/Circulatory stasis/ Hypercoagulable state Signs and symptoms: F.A.S.T., which stands for Face-paralysis/pain affecting face (VII-V) Arms-contralateral hemiplegia/hemiparesis Speech-slurred (X-IX) Time Anhydrosis (Sympathetic) Vomiting/vertigo/nistagmus (cerebellum/VIII) Arterial pain Coordination/ataxia (cerebellum) Drop attacks (reticular formation) Cause: Atherosclerotic plaque in the carotid artery or vertebra basilar artery, embolus, atrial fibrillation P.F: Atrial fibrillation, hypertension, diabetes, hypercholesterolemia, migraine, haemorrhage Risk factors: Family history, over 55, male, menopause, HBP, diabetes mellitus, tobacco, Africans, africo-caribeans, south asian Tests in clinic: BP, carotid burst Medical tests: BP, ECG, ultrasound of the carotid artery Complication: Cerebro vascular attack Ttt: warfarin, heparin, aspirin CVA: Cerebro Vascular Attack
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TIA

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Congenital Kippel-Feil Def: congenital fusion of any 2 of the 7 cervical vertebrae Cause: presence of a congenital defect in the formation or segmentation of the cervical spine Signs and symptoms: shortness of the neck, very low hairline and the ability of the neck to move is limited Associated abnormalities may include: Springels shoulder scoliosis spina bifida anomalies of the kidneys and the ribs, cleft palate (hole in the roof of the mouth), respiratory problems, heart malformations. short stature congenital elevation of the scapula known as Sprengel's Deformity

Infantile (congenital muscular) Torticollis (wryneck)

Def: is a rare congenital skeletal abnormality where a person has one shoulder blade that sits higher on the back than the other. Cause: The deformity is due to a failure in early foetal development where the shoulder fails to descend properly from the neck to its final position Associated with: The deformity is commonly associated with other conditions, most notably Klippel-Feil syndrome, congenital scoliosis including cervical scoliosis, fused ribs, the presence of an omovertebral bone and spina bifida. The left shoulder is the most commonly affected shoulder but the condition can be bilateral Prevalence: About 75% of all observed cases are girls Signs: The scapula is small and rotated so that its inferior edge points toward the spine. There is a high correlation between Sprengel's deformity and the Klippel-Feil syndrome. Sometimes a bony connection is present between the elevated scapula and one of the cervical vertebrae, usually C5 or C6. This connection is known as the omovertebral bone Def: Unilateral contracture of the SCM muscle for an unknown reason leads to the contorted posture Cause: Position of head in uterus or a difficult delivery might result in a compartment syndrome and eventual fibrosis and contracture of the SCM. Symptoms: Parents may notice swelling in the SCM when the infant is 3-6 weeks which disappears but the resulting head tilt is what causes concern (tilted in lateral bending toward the affected muscle and rotated toward the opposite side) Signs: shortening or excessive contraction of the sternocleidomastoid muscle, Sometimes a mass, such as a sternocleidomastoid tumor, is noted in the affected muscle at the age of two to four weeks. Gradually it disappears, usually by the age of eight months, but the muscle is left fibrotic, face is flattened on the involved side Ttt: stretching exercises, position exercises, massage, surgery Others

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Oesophagitis Def: This causes incompetence of the oesophago gastric sphincter mechanism which allows reflux of gastric acid into the oesophagus with consequent damage to the delicate oesophageal mucosa. Reflux may occur without hiatus hernia.(physiological lesion) Hiatus hernia: If a part of the stomach herniates through the diaphragm into the thorax, the patient is said to have a hiatus hernia. (anatomical lesion) Symptoms: Acid regurgitation and heartburn (retrosternal burning pain) made worse by stooping, chest pain, pain T7-T8, band of pain around the thorax, difficulties swallowing, vomiting, bitter taste, abdominal pain (30 minutes), bloating, burping (fermentation of food), upper abdominal pain, throat pain. Pathophysiology: decrease mucousa>inflammation>scarring>narrowing of the lumen>difficulties swollowing Management: losing weight, stooping posture, stopping smoking, raising the head from the bed, avoiding large meals, tight clothes, spicy foods, alcohol, acidic foods, fatty foods Antacids, proton pump inhibitors Complications: oesophageal ulceration and Barrels oesophagus. It can lead to oesophageal adenocarcinoma. Bleeding PF: Pregnancy, obesity, tight clothes, coffee, smoking, gallstones (bile doesnt neutralize the gastric acide), scleroderma Test: Endoscopy