Anatomy

The cervical spine is made up of seven vertebrae (C1-C7). A typical vertebra has a body and neural arch. The neural arch is made up of two pedicles and two vertebrae; the laminae meet at the spinous process posteriorly. A transverse process projects out laterally on each side of the pedicle and lamina (Fig. 31-1). The articular processes on the superior and inferior parts of each vertebra at the junction of the pedicle and lamina meet at the facet joints. The first two vertebrae have distinct features. The atlas, C1, articulates with the occipital bone and has no spinous process or body. The axis, C2, has an odontoid process that articulates with C1 (Fig. 31-2); much of the rotational function of the neck occurs at this joint. C7 has a long spinous process, resulting in a palpable prominence below the skin in the lower neck.

Figure 31-1 Typical cervical vertebra. S, Spinous process; L, lamina; A, articular facet; P, pedicle; T, transverse process; B, body.

(Redrawn from Mercier L. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 27.)

Figure 31-2 1, Axis. 2, Atlas and transverse ligament (T). 3, Articulation of the atlas and axis.

(Redrawn from Mercier L. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 27.)

Several ligaments stabilize the neck. The anterior and posterior ligaments support the entire vertebral column (Fig. 31-3). The spinous process of each vertebra is attached by the nuchal ligament to the neck and the interspinous ligaments. Intervertebral disks separate each vertebra. Their function is to distribute the pressure over a wider area of the vertebra and allow mobility. Each disk consists of a gelatinous central nucleus and outer fibrous annulus fibrosus. Eight pairs of nerves originate from the cervical spine. The first seven nerve roots exit the spinal canal above the corresponding vertebra, and the eighth nerve root exits from below C7 (Fig. 31-4).

Figure 31-3 Ligaments of the cervical spine. A, Anterior longitudinal ligament; P, posterior longitudinal ligament; N, nuchal ligament; I, interspinous ligament.

(Redrawn from Mercier L. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 27.)

Figure 31-4 Spinal cord and nerve roots in relation to the vertebrae.

(Redrawn from Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 242.)

History

The relevant history includes age of the patient, location of any pain, acute or gradual onset, radiation and duration of pain, and any related associated symptoms that indicate whether the pain is of cervical origin or referred from another condition. An older patient is more often affected by arthritis and a younger person by musculoskeletal pain. Rest or nighttime pain may be a symptom of a tumor or infection. Other symptoms include neck stiffness, headache, and symptoms of radiculopathy such as tingling, numbness, and loss of strength in the upper extremities. Where the pain is caused by nerve entrapment, the pain may radiate along the distribution of the involved nerve. Events leading up to the presentation may also give clues to the problem.

Physical Examination

The neck examination includes inspection for any neck lesions, masses, or scars as well as posture and normal cervical lordosis, characterized by a slight anterior curvature (Fig. 31-5). The neck is palpated for points of tenderness. The range of movement is assessed by observing forward flexion with chin tilted down toward the chest and backward extension with the head tilted backward so that the eyes are looking toward the ceiling (Fig. 31-6). Lateral flexion to the right and left is the lateral bending of the neck, pointing the ear toward the shoulder on the same side. Lateral rotation to the right and left is the chin turned toward each shoulder while the head is kept upright (Table 31-1).

Figure 31-5 Vertebral spine. Note that thoracic spine has relatively fixed kyphosis and lumbar spine relatively flexible lordosis.

(Redrawn from Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 241.)

Figure 31-6 Range of motion. A, Flexion. B, Lateral flexion. C, Rotation.

(Redrawn from Carr AJ, Harnden A. Orthopedics in Primary Care. Newton, Mass, Butterworth-Heinemann, 1997, p 56.)

Table 31-1 Normal Range of Movement: Neck (Cervical Spine)

Examination should also include examination of the extremities. Inspection of the upper limbs may reveal muscle wasting or fasciculations. A detailed examination of the nervous system includes assessment of the power and tone of the muscles, reflexes, and sensory system, using sharp and light touch. Mapping the sensory loss by dermatomes and demonstrating asymmetry of deep tendon reflexes may show the cervical level with nerve compression. A complete general examination, including the head, neck, lower extremities, and gait, allows for evaluation of other potential causes and effects of neck problems. Specific tests to evaluate the cervical spine also include the axial compression test, which may increase symptoms of radicular pain. The distraction test may relieve radicular symptoms. Spurling’s test may produce pain on the same side as nerve root encroachment.

Diagnostic Tests

Diagnostic tests include radiographs of the cervical spine. Computed tomography (CT) may assess the bone further, and magnetic resonance imaging (MRI) is useful to assess the soft tissue, especially with associated neurologic symptoms.

Torticollis

Key Points

Congenital torticollis is caused by the contraction of the sternomastoid muscle. The cause is unclear but may be associated with birth trauma or an abnormal fetal uterine position causing local muscle ischemia. Children with hip dysplasia and breech delivery have a higher incidence of torticollis. Also, delayed development of the face on the affected side may result in facial asymmetry and changes in the cervical vertebrae. On examination, a small lump may be palpable in the muscle, known as a sternomastoid tumor.

In mild cases, treatment is initiated early and includes gentle stretching exercises several times daily. Supervised physical therapy may be considered. Surgery may be considered in special circumstances with patients who do not respond to conservative treatment. The procedure includes surgical release of the sternomastoid muscle, followed by corrective exercises.

Acquired torticollis usually does not involve contraction of the sternomastoid on the same side of the neck. The torticollis has a particular cause, such as upper respiratory tract infections, cervical lymphadenitis, trauma minor neck injury, unilateral subluxation of the vertebrae, or fractures, as well as unusual causes such as spinal tumor or retropharyngeal abscess. Torticollis may also be seen in relation to ocular disturbance, such as strabismus, known as ocular torticollis.

History includes duration and onset of symptoms, whether sudden or gradual, associated symptoms (e.g., fever, sore throat), and history of injury. Clinical examination, in addition to the clinical appearance of torticollis, requires careful general examination of the head and neck, looking for a cause. Diagnosis may be apparent from the history and physical examination. Radiographs of the cervical spine may be obtained, if indicated, to rule out a vertebral cause.

Management includes referral for emergency evaluation and treatment of traumatic injury and retropharyngeal abscess. Pain is relieved and the underlying cause treated. Persistent pain requires further evaluation.

Whiplash

Whiplash is a hyperextension injury. The injury is caused by abnormal stretching of the muscles and soft tissue structures. There may be an associated disk herniation and tracheal and esophageal injury, resulting in hoarseness and dysphagia. Clinical features are pain in the lower neck and shoulders radiating to the occipital area, which may cause headaches. The neck pain may continue for weeks to months. The patient may have tenderness on palpation of the neck, perhaps some limitation in range of movement, and usually a normal neurologic examination. Radiographs are usually normal. Treatment is conservative with rest, a cervical collar, cold compresses, and pain relief, followed by simple range of motion (ROM) exercises. If symptoms improve, structured physical therapy may be considered.

Cervical Strains and Sprains

Cervical strains and sprains are characterized by pain in the neck because of irritation and spasm of muscles at the back of the neck. Common related factors are poor posture (e.g., while working or studying), carrying heavy bags on one shoulder, emotional or physical stress, and trauma. The patient has a history of pain in the lower neck and upper back; stiffness in the neck, back, and shoulders; and perhaps a new work environment, working in a certain posture (e.g., at computer), and trauma. Clinical findings include tenderness posterior to neck, with or without ROM limitation. Diagnosis may be apparent from the history and physical examination. Uncomplicated pain is managed by conservative treatment and correction of causative factors, such as changes in associated environmental factors (e.g., adjustment of height of desk or chair, avoiding straps on shoulders). Stress reduction is beneficial to aid reduction of muscle tension. Warmth applied to the neck is helpful, as are ROM exercises, pain relief, and referral to physical therapy. Persistent symptoms, history of trauma, or neurologic signs in the extremities require further evaluation with radiography.

Cervical Radiculopathy

Radiculopathy occurs when nerve root compression at the neck or spine results in pain, tingling, and numbness, with or without loss of function in the area supplied by the affected nerve. Common causes of cervical radiculopathy are neural foramen narrowing, usually caused by cervical arthritis in older adults, and cervical disk lesion caused by disk degeneration or herniation. Disk degeneration results in loss of disk space, with closer approximation of the vertebrae on either side of the involved disk space and subsequent impingement on the neural foramen (Fig. 31-7). The decrease in size of the neural foramen results in nerve root compression. The C5-C6 and C6-C7 disk spaces are more often affected. Disk herniation also occurs more often in these disks (Fig. 31-8). Some of the gelatinous pulp protrudes through the annulus fibrosus at the weakest point, usually where the posterolateral longitudinal ligament crosses the disk. In a smaller disk herniation, mild local pain may be caused by pressure on the posterior ligament. A larger disk herniation may impinge on the nerve and may be posterolateral or central herniation with resultant radicular symptoms.

Figure 31-7 Osteoarthritis of cervical spine. A, Initial degeneration and narrowing of intervertebral disk, with formation of osteophytes anteriorly. B, Later, posterior or facet joints are affected; articular cartilage is worn away, and marginal osteophytes may encroach on the intervertebral foramen.

(Redrawn from Adam JC, Hamblen DL. Outline of Orthopedics, 13th ed. New York, Churchill Livingstone, 2001, p 159; and Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed. Philadelphia, Saunders, 1999, p 266.)

Figure 31-8 Prolapsed cervical disk. A, Posterolateral prolapse, with compression of the issuing nerve. B, Much less common central prolapse, with impingement on the spinal cord.

(Redrawn from Adam JC, Hamblen DL. Outline of Orthopedics, 13th ed. New York, Churchill Livingstone, 2001, p 163.)

The patient has a history of pain radiating to the shoulder or down the upper extremity, which may be aggravated by coughing, sneezing, or straining; paresthesias of the fingers; and less often, weakness in the extremity. There may be a history of prior trauma. Cervical radiculopathy on examination may reveal tenderness on the neck, limitation in certain movements of the neck, focal neurologic findings such as sensory loss in the dermatome pattern corresponding to the distribution of the affected nerve root, and asymmetric tendon reflexes in the upper extremities (Fig. 31-9). General examination should include the lower extremities and gait. Axial compression testing may reproduce the pain.

Figure 31-9 Volar and dorsal dermatome patterns of the forearm and hand. Pain and paresthesias may radiate into these areas when the affected nerve root is compressed. Note that extremity symptoms as a result of disk disease are almost always unilateral.

(Redrawn from Mercier R. Practical Orthopedics, 5th ed. St Louis, Mosby, 2000, p 29.)

Diagnostic tests include radiographs of the cervical spine, which may appear normal or may show loss of normal cervical lordosis, narrowing of the disk space, and bone spurs with foramen encroachment. If the patient has neurologic symptoms, MRI identifies soft tissue structures and may show displacement of the disk. CT may also be performed.

Treatment relieves pressure on the affected nerve and is mainly conservative, including rest, pain relief, stress reduction, and short-term muscle relaxants. Patients with persistent symptoms may need structured physical therapy and referral for specialist evaluation. Neurologic signs and symptoms and loss of strength are also indications for referral to neurosurgery. A few patients require surgical intervention.

Anatomy

The back is supported by 12 thoracic vertebrae (T1-T12) and five lumbar vertebrae (L1-L5). The lumbar vertebrae are larger and thicker than the cervical and thoracic vertebrae because they carry the most amount of body weight and are subject to the largest forces and stresses along the spine (see Fig. 31-5). The alignment of thoracolumbar vertebrae with their disk and ligament is similar to the cervical spine. The joints between the vertebrae, ligaments, and muscles of the back stabilize the vertebral column.

The major longitudinal ligaments connecting the vertebrae are the anterior and posterior ligaments (connect vertebral bodies), ligamentum flavum (between adjacent laminae), and supraspinous and interspinous ligaments (connect spinous processes). The anterior and posterior longitudinal ligaments and supraspinous ligament run along the entire length of the vertebral column and support the spine. The interspinous ligament and ligamentum flavum provide additional posterior stability to the spine (Fig. 31-10).

Figure 31-10 Supporting ligaments of the spine.

(Redrawn from Brinker MR, Miller MD. Fundamentals of Orthopedics. Philadelphia, Saunders, 1999, p 242.)

Related posts:

The Family Physician Herbs and Other Dietary Supplements Sports Medicine Difficult Patients: Personality Disorders and Somatoform Complaints Rheumatology and Musculoskeletal Problems Gastroenterology

Stay updated, free articles. Join our Telegram channel

Join