++
Pain originating from disorders of the cervical spine is usually, although not always, experienced in the neck. The patient may experience headache, or pain around the ear, face, arm, shoulder, upper anterior or posterior chest.5
++
Possible symptoms include:
++
neck pain
neck stiffness
headache
migraine-like headache
facial pain
arm pain (referred or radicular)
myelopathy (sensory and motor changes in arms and legs)
ipsilateral sensory changes of scalp
ear pain (peri-auricular)
scapular pain
anterior chest pain
torticollis
dizziness/vertigo
visual dysfunction
++
FIGURE 24.1 in CHAPTER 24 indicates typical directions of referred pain from the cervical spine. Pain in the arm (brachialgia) is common and tends to cover the shoulder and upper arm as indicated.
++
Dysfunction of the 35 intervertebral joints that comprise the cervical spine complex is responsible for most cases of neck pain. The problem can occur at all ages and appears to be caused by disorder (including malalignment) of the many facet joints, which are pain-sensitive. Dysfunction of these joints, which may also be secondary to intervertebral disc disruption, initiates a reflex response of adjacent muscle spasm and myofascial tenderness.
++
Acute neck pain (ANP) is most commonly idiopathic or due to a whiplash accident. Serious causes are rare.6 Dysfunction can follow obvious trauma such as a blow to the head or a sharp jerk to the neck, but can be caused by repeated trivial trauma or activity such as painting a ceiling or gentle wrestling. People often wake up with severe neck pain and blame it on a ‘chill’ from a draught on the neck during the night. This is incorrect because it is usually caused by an unusual twist on the flexed neck for a long period during sleep.
++
Typical age range 12–50 years
Dull ache (may be sharp) in neck
May radiate to occiput, ear, face and temporal area (upper cervical)
May radiate to shoulder region, especially suprascapular area (lower cervical)
Rarely refers pain below the level of the shoulder
Pain aggravated by activity, improved with rest
Various degrees of stiffness
Neck tends to lock with specific movements, usually rotation
Localised unilateral tenderness over affected joints
Variable restriction of movement but may be normal
X-rays usually normal: plain X-rays are not indicated for the investigation of ANP in the absence of ‘red flags’ and a history of trauma6
++
The aim of treatment is to reduce pain, maintain function and minimise the risk of chronicity.
++
Provide appropriate reassurance, information and support.
Give advice to the patient about rules of living, including the following:
Do:
– Stay active and resume normal activities.
– Keep your neck upright in a vertical position for reading, typing and so on.
– Keep a good posture—keep the chin tucked in.
– Sleep on a low, firm pillow or a special conforming pillow.
– Sleep with your painful side on the pillow.
– Use heat and massage: massage your neck firmly three times a day using an analgesic ointment.
Don’t:
– Look up in a strained position for long periods.
– Twist your head often towards the painful side (e.g. when reversing a car).
– Lift or tug with your neck bent forwards.
– Work, read or study with your neck bent for long periods.
– Become too dependent on ‘collars’.
– Sleep on too many pillows.
Monitor the patient’s progress without overtreatment.
Analgesia:7
Prescribe an exercise program as early as possible; start with gentle exercises and maintain them at home. Suitable exercises are shown in FIGURE 62.5.
Refer to an appropriate therapist for cervical mobilisation for persisting pain. Mobilisation combined with exercises can be an effective treatment. Occasionally, manipulation may help with a stubborn ‘locked’ neck but should be left to an expert. If manipulation, which carries the rare but real risk of vertebral artery dissection and stroke, is to be performed, informed consent and an experienced therapist are required.8
++
++
Approximately 40% of patients recover fully from acute idiopathic ANP, about 30% continue to have mild symptoms, while 30% continue to have moderate or severe symptoms.6
++
Evidence of benefit (in summary)6
Staying active: resuming normal activities
Exercises
Combined cervical passive mobilisation/exercises
Pulsed electromagnetic therapy (up to 12 weeks)
+++
Chronic non-specific pain (lasting more than 3 months)7
++
Continue normal activities and exercises.
++
Additional treatment modalities to consider include:
++
a course of antidepressants
TENS, especially when drugs are not tolerated
hydrotherapy
acupuncture (may provide short-term relief)
corticosteroid facet injections (ideally under image intensification)
facet joint denervation with percutaneous radiofrequency (if nerve block provides relief)
multidisciplinary rehabilitation program
+++
Cervical spondylosis7
++
Cervical spondylosis following disc degeneration and apophyseal joint degeneration is far more common than lumbar spondylosis and mainly involves the C5–6 and C6–7 segments. The consequence is narrowing of the intervertebral foramen with the nerve roots of C6 and C7 being at risk of compression.
++
Cervical spondylosis is generally a chronic problem but it may be asymptomatic. In some patients the pain may lessen with age, while stiffness increases.
++
Dull, aching suboccipital neck pain (see FIG. 62.6)
Stiffness
Worse in morning on arising and lifting head
Improves with gentle activity and warmth (e.g. warm showers)
Deteriorates with heavy activity (e.g. working under car, painting ceiling)
Usually unilateral pain—may be bilateral
Pain may be referred to head, arms and scapulae
May wake patient at night with paraesthesia in arms
C6 nerve root most commonly involved
Acute attacks on chronic background
Aggravated by flexion (reading) and extension
Associated vertigo or unsteadiness
Restricted tender movements, especially rotation/lateral flexion
Joints tender to palpation
X-ray changes invariable
++
++
Provide appropriate reassurance, information and support.
Refer for physiotherapy, including warm hydrotherapy.
Use regular mild analgesics (e.g. paracetamol).
Use NSAIDs: a trial for 2 weeks and then review.
Prescribe gentle mobilising exercises as early as possible.
Give passive mobilising techniques.
Outline general rules to live by, including advice regarding sleeping and pillows, and day-to-day activities.
++
++
Torticollis (acute wry neck) means a lateral deformity of the neck. This is usually a transient self-limiting acutely painful disorder with associated muscle spasm of variable intensity.
++
Age of patient between 12 and 30 years
Patient usually awakes with the problem
Pain usually confined to neck but may radiate
Deformity of lateral flexion and slight flexion/rotation
Deformity usually away from the painful side
Loss of extension
Mid-cervical spine (C2–3, C3–4, C4–5)
Any segment between C2 and C7 can cause torticollis
Usually no neurological symptoms or signs
++
The exact cause of this condition is uncertain, but both an acute disc lesion and apophyseal joint lesion are implicated, with the latter the more likely cause. Acute torticollis is usually a transient and self-limiting condition that can recover within 48 hours. Sometimes it can last for about a week. Encourage heat massage and early mobility. Avoid cervical collars. Management by mobilisation and muscle energy therapy is very effective.
+++
Muscle energy therapy
++
This amazingly effective therapy relies on the basic physiological principle that the contracting and stretching of muscles leads to automatic relaxation of agonist and antagonist muscles.9,10 Lateral flexion or rotation or a combination of movements can be used, but treatment in rotation is preferred. The direction of contraction can be away from the painful side (preferred) or towards the painful side, whichever is most comfortable for the patient.
++
Explain the method to the patient, with reassurance that it is not painful.
Rotate the patient’s head passively and gently towards the painful side to the limit of pain (the motion barrier).
Place your hand against the head on the side opposite the painful one. The other (free) hand can be used to steady the painful level—usually C3–4.
Request the patient to push the head (in rotation) as firmly as possible against the resistance of your hand. The patient should therefore be producing a strong isometric contraction of the neck in rotation away from the painful side (see FIG. 62.7A). Your counterforce (towards the painful side) should be firm and moderate (never forceful) and should not ‘break’ through the patient’s resistance.
After 5–10 seconds (average 7 seconds) ask the patient to relax; then passively stretch the neck gently towards the patient’s painful side (see FIG. 62.7B).
The patient will now be able to turn the head a little further towards the painful side.
This sequence is repeated at the new improved motion barrier. Repeat three to five times until the full range of movement returns.
Ask the patient to return the following day for treatment, although the neck may be almost normal.
++
++
The patient can be taught self-treatment at home using this method.
+++
Acceleration hyperextension (whiplash) injury
++
Patients with the whiplash syndrome, preferably referred to as an acceleration hyperextension injury, typically present with varying degrees of pain-related loss of mobility of the cervical spine, headache and emotional disturbance in the form of anxiety and depression. The problem can vary from mild temporary disability to a severe and protracted course.
++
The injury occurs as a consequence of hyperextension of the neck followed by recoil hyperflexion, typically following a rear-end collision between motor vehicles. There is a reversal of the sequence of these movements in a head-on collision. In addition to hyperextension, there is prolongation or anterior stretching plus longitudinal extension of the neck.8 It can also occur with other vehicle accidents and in contact sports such as football.
++
Whiplash causes injury to soft tissue structures, including muscle, nerve roots, the cervical sympathetic chain, ligaments, apophyseal joints and their synovial capsules and intervertebral discs. Damage to the apophyseal joints appears to be severe, with possible microfractures (not detectable on plain X-ray) and long-term dysfunction.
++
Pain and stiffness of the neck are the most common symptoms. The pain is usually experienced in the neck and upper shoulders but may radiate to the suboccipital region, the interscapular region and down the arms. The stiffness felt initially in the anterior neck muscles shifts to the posterior neck.
++
Headache is a common and disabling symptom that may persist for many months. It is typically occipital but can be referred to the temporal region and the eyes.
++
Nerve root pain can be caused by a traction injury of the cervical nerve roots or by inflammatory changes or direct pressure subsequent to herniation of a disc.
++
Paraesthesia of the ulnar border of the hand, nausea and dizziness are all relatively common symptoms.
++
Delayed symptoms are common. A patient may feel no pain until 24 (sometimes up to 96) hours later; most experience symptoms within 6 hours. Complications of whiplash are summarised in TABLE 62.4.
++
++
The Canadian guidelines (1995) for whiplash are:
++
Grade I—neck pain, stiffness or tenderness
Grade II—neck symptoms + musculoskeletal signs (e.g. decreased range of motion, point tenderness)
Grade III—neck symptoms + neurological signs
Grade IV—neck symptoms + fracture or dislocation
+++
Management principles
++
The objective of treatment is to obtain a full range of free movement of the neck without pain by attending to both the physical and the psychological components of the problem. Other objectives include an early return to work and discouragement of unnecessary and excessive reliance on cervical collars and legal action.
++
Establish an appropriate empathy and instil patient confidence with a positive, professional approach. Discourage multiple therapists.
Provide appropriate reassurance and patient education.
Encourage normalisation of activities as soon as possible.
Compare the problem with a sprained ankle, which is a similar injury.
Inform that an emotional reaction of anger, frustration and temporary depression is common (lasts about 2 weeks). Offer psychotherapy, e.g. CBT for evidence of post-traumatic stress.
X-ray is required for ‘red flags’.
Prescribe rest only for grades II and III (max. 4 days).
Use a cervical collar (limit to 2 days) for grades II and III. Provide collar and refer for grade IV.
Use analgesics (e.g. paracetamol)—avoid narcotics.
Use a trial of NSAIDs for 14 days (poor evidence).
Use tranquillisers, mild—up to 2 weeks.
Refer for physiotherapy.
Provide neck exercises (as early as possible).
Use heat and massage—‘spray and stretch’—or ice.
Give passive mobilisation (not manipulation).9
++
Recovery can take any time from 1–2 weeks up to about 3 months. A valuable reference is Update Quebec Task Force Guidelines for the Management of Whiplash—Associated Disorder at <www.nhmrc.gov.au/guidelines/>.
+++
Cervical disc disruption
++
Disruption of a cervical disc can result in several different syndromes.
++
Referred pain over a widespread area due to pressure on adjacent dura mater.
Note: A disc disruption is capable of referring pain over such a diffuse area (see FIG. 62.8) that the patient is sometimes diagnosed as functional (e.g. hysterical).
Nerve root or radicular pain (radiculopathy). The pain follows the dermatomal distribution of the nerve root in the arm.
Spinal cord compression (myelopathy).
++
++
Apart from protrusion from an intervertebral disc, nerve root pressure or irritation causing arm pain can be caused by osteophytes associated with cervical spondylosis. Uncommon causes include various tumours involving the vertebral segment, the meninges and nerves or their sheaths. The pain follows neurological patterns down the arm, being easier to localise with lower cervical roots, especially C6, C7 and C8.
++
The cervical roots exit above their respective vertebral bodies. For example, the C6 root exits between C5 and C6 so that a prolapse of C5–6 intervertebral disc or spondylosis of the C5–6 junction affects primarily the C6 root (see FIG. 62.4).
One disc—one nerve root is the rule.
Spondylosis and tumours tend to cause bilateral pain (i.e. more than one nerve root).
++
A sharp aching pain in the neck, radiating down one or both arms
Onset of pain may be abrupt, often precipitated by a sudden neck movement on awakening
Paraesthesia in the forearm and hand (in particular)—in 90% with proven disc prolapse9
Stiffness of neck with limitation of movement
Nocturnal pain, waking patient during night
Pain localised to upper trapezius and possible muscle spasm
++
Plain X-ray (AP, lateral extension and flexion, oblique views to visualise foramina); not required before 6–8 weeks unless red flags present; not useful for diagnosis or for surgery
Plain CT scan
CT scan and myelogram—excellent visualisation of structures but invasive
MRI—excellent but expensive, sometimes difficult to distinguish soft disc from osteophytes
Electromyography—may help delineate lesions requiring surgery
++
Many patients respond to conservative treatment, especially from a disc prolapse. It is basically a self-limiting disorder—about 10% remain severely disabled:10
++
bed rest
soft cervical collar
analgesics (according to severity—see CHAPTER 38)
consider a course of corticosteroids for severe neck radicular pain, e.g. prednisone 30 mg (o) daily for 5–10 days then taper off to 3 weeks (limited evidence)8
tranquillisers, especially at night
traction (with care)
careful mobilisation (manipulation is contraindicated)
+++
CERVICAL SPONDYLITIC MYELOPATHY
++
Sometimes the presence of large or multiple osteophytes or in the presence of a narrowed spinal canal symptoms of spinal cord involvement may develop.11,12 The common cause is a hard mass of material projecting from the posterior aspect of the vertebral body to indent the spinal cord and possibly the nerve roots at the exit foramina. This resultant spinal cord compression may result in several different clinical presentations, notably myelopathy in particular, but also central cord and anterior cord syndrome. A full neurological assessment is necessary.
++
Older patients, typically men >50 years
Insidious onset—symptoms over 1–2 years
Numbness and tingling in fingers
Leg stiffness
Gait disturbance
Numb, clumsy hands, especially with a high cervical lesion
Signs of UMN: spastic weakness, increased tone and hyper-reflexia (arms > legs) ± clonus
Neurological deficit, which predicts the level with reasonable accuracy
Bowel and bladder function usually spared
++
Note: LMN signs occur at the level of the lesion, and UMN signs and sensory changes occur below this level.
++
Cervical spondylosis
Atlantoaxial subluxation: rheumatoid arthritis, Down syndrome
Primary spinal cord tumours (e.g. meningiomas)
Metastasis to cervical spine → epidural spinal cord compression
++
+++
Central cord syndrome12
++
This rather bizarre condition occurs classically in a patient with a degenerative cervical spine following a hyperextension injury that causes osteophytes to compress the cord anteriorly and posteriorly simultaneously.
++
The maximum damage occurs in the central part of the cord, leading to sensory and motor changes in the upper limbs with relative sparing of the lower limbs due to the arrangements of the long tracts in the cord.
++
Fortunately, the prognosis is good, with most patients achieving a good neurological recovery.
+++
Anterior cord syndrome
++
Anterior cord syndrome occurs with hyperflexion injuries that produce ‘teardrop’ fractures of the vertebral bodies or extrusion of disc material. The syndrome can also be produced by comminuted vertebral body fractures.
++
It is characterised by complete motor loss and the loss of pain and temperature discrimination below the level of the injury, but deep touch, position, two-point discrimination and vibration sensation remain intact.
++
Because it is probably associated with obstruction of the anterior spinal artery, early surgical intervention to relieve pressure on the front of the cord may enhance recovery. Otherwise the prognosis for recovery is poor.
++
One of the more sinister problems with trisomy 21 syndrome is hypoplasia of the odontoid process, leading to C1–2 subluxation and dislocation. If unrecognised in the early stages, sudden death can occur in these children. If suspected, flexion–extension lateral views of the cervical spine will highlight the developing instability and the need for early specialist opinion.
+++
Rheumatoid arthritis7,15
++
Involvement of the cervical spine is usually a late manifestation of rheumatoid arthritis (RA). It is important to be aware of the potentially lethal problem of C1–2 instability due to erosion of the major odontoid ligaments in the rheumatoid patient. These patients are especially vulnerable to disasters when under general anaesthesia and when involved in motor vehicle accidents. Early cervical fusion can prevent tragedies, especially with inappropriate procedures such as cervical manipulation. It is imperative to perform imaging of the cervical spine of all patients with severe RA before major surgery to search for C1–2 instability. Lateral plain X-rays in flexion and extension may reveal increased distance in the atlanto–dens interval. This can be assessed further with MRI or CT scanning in a specialist clinic.
+++
Treatment of spondylitic myelopathy
++
Conservative (may help up to 50%):2
++
++
Surgery is indicated when the myelopathy interferes with daily activities. One procedure is the Cloward method, which is anterior decompression with discectomy and fusion. The aim of surgery is to halt deterioration.