HISTORY

It is important to ascertain the relationship of the present symptoms to any previous neck disorder. Has there been any previous injury to the neck? Or a sudden jerk of the head that might have jarred the cervical spine? Is there a history of ‘stiff neck’ – a common feature in the early stages of prolapsed cervical disc?

If pain in the upper limb is an associated symptom, it is important to determine its exact distribution. Pain caused by pressure upon a nerve root in the cervical region follows a clearly defined course which depends upon the particular nerve root involved, and it is usually severe. It commonly extends down the upper arm into the forearm and hand, radiating to one or more of the fingers. It is often accompanied by paraesthesiae, described as ‘pins and needles’ or ‘numbness’. In contrast, pain referred down the limb from a lesion of the shoulder or humerus is more diffuse and ill defined, and it seldom extends below the elbow.

EXPOSURE

The patient must be stripped to the waist. Preferably he should stand, or he may sit upon a stool.

STEPS IN CLINICAL EXAMINATION

A suggested routine for clinical examination of the neck is summarised in Table 12.1.

Table 12.1 Routine clinical examination in suspected disorders of the neck

DEFORMITY

The cervical spine normally has a slight anterior curvature (lordosis). Straightening of this curve, or an angulation in the reverse direction (kyphosis), is sometimes significant and may suggest an underlying abnormality. Any lateral or rotational deformity (torticollis) must also be noted.

MOVEMENTS

The movements to be examined are flexion, extension, lateral flexion to right and left, and rotation to right and left (Fig. 12.1). Flexion–extension movements occur mainly at the occipito-atlantoid joint but to some extent throughout the cervical spine. Lateral flexion takes place throughout the cervical spine. Rotation occurs largely at the atlanto-axial joint, with a small range of movement at the other joints. It is important to find out whether movement causes pain and, if so, whether the pain is felt locally in the neck or whether it is referred down the upper limbs. It should be noted also whether movement is accompanied by audible or palpable crepitation.

Fig. 12.1 Normal movements of the cervical spine in A flexion and extension, B lateral flexion and C rotation.

NEUROLOGICAL EXAMINATION OF UPPER LIMBS

This is an essential step in the investigation of the neck because cervical lesions so often interfere with the brachial plexus.

Muscular system. The muscles of the shoulder girdle, arm, forearm, and hand must be examined for wasting or fasciculation, a comparison being made on the two sides. The tone and power of each muscle group are then tested in turn and a comparison is made with the opposite limb. It is worth remembering the major root innervation for each muscle group when testing; C5 to deltoid, C6 biceps and wrist extensors, C7 triceps and wrist flexors, C8 finger flexors, and T1 to intrinsic muscles of hand.

Sensory system. Examine the patient’s sensibility to touch and pin prick. In appropriate cases test also the sensibility to deep stimuli, joint position, vibration, and heat and cold. The nerve roots supplying the sensory dermatomes in the upper limb are shown in Fig. 12.2. In the assessment of sensory loss it should be remembered that the middle or long finger, representing the central axis of the limb, is innervated mainly from the seventh cervical nerve. The radial half of the hand is innervated by the proximal roots of the brachial plexus (C5, C6) whereas the ulnar half is innervated from the more distal roots (C8, T1).

Fig. 12.2 Dermatomes of the upper limb. A knowledge of these in testing sensory impairment will assist in determining the level of root involvement in cervical spine disease.

Sweating. Feel whether the digits are moist or dry. Sweating is dependent upon intact sudomotor nerve fibres.

Reflexes. Compare on the two sides the biceps jerk (mainly C6), the triceps jerk (mainly C7), and the brachioradialis jerk (mainly C6).

From the findings elicited it should be possible to determine whether there is a neurological disturbance and, if so, whether it is of upper or lower motor neurone type, and the identity of the roots, trunks, or branches involved.

VASCULAR EXAMINATION OF THE UPPER LIMB

The subclavian artery is sometimes interfered with by a lesion of the neck. The efficiency of the circulatory system in each upper limb must therefore be determined. Judge and compare on the two sides the colour and warmth of the forearm, hand and fingers. Test and compare the radial pulses, first with the limb at rest, then with the shoulder depressed and the head rotated towards the side examined.

EXTRINSIC CAUSES OF NECK SYMPTOMS

Occasionally neck symptoms have their origin outside the neck itself. Thus pain may be referred to the neck from the ears or throat. These sites should be examined routinely for evidence of disease.

Symptoms in the upper limb that might suggest the possibility of a neck disorder involving the brachial plexus may in fact have their origin in the shoulder or elbow, or at any point along the peripheral distribution of the nerve trunks.

DIAGNOSTIC IMAGING

Radiographic examination. Routine radiographs of the cervical spine include an antero-posterior and a lateral projection. Additional projections are often required when it is desired to show a particular structure more clearly. For a study of the dens (odontoid process) of the axis a special antero-posterior projection is made through the open mouth. Occasionally oblique projections are required for a proper investigation of the intervertebral foramina and the facet joints, and is also valuable in revealing the size and shape of a cervical rib.

Other techniques of imaging. Magnetic resonance imaging (MRI) is used increasingly to demonstrate the relationship between the bony and neurological structures in the cervical spine. Computerised tomography (CT scanning) and radioisotope scanning may sometimes be required to demonstrate pathological changes in the bony structures.

INFANTILE TORTICOLLIS (‘Congenital’ torticollis; muscular torticollis)

In infantile torticollis (wry neck) the head is tilted and rotated by contracture of the sternomastoid muscle of one side. Strictly this is not a true congenital deformity because it arises after birth. With improvements in obstetrical practice it is now seen much less often than it was in the past.

Cause. This is uncertain. Probably there is interference with the blood supply of the sternomastoid muscle, caused by injury during birth.

Pathology. In the established condition, part of the affected muscle is replaced by contracted fibrous tissue. In some cases contracture is known to have been preceded, in early infancy, by a tumour-like thickening of the muscle (‘sternomastoid tumour’), the histology being that of muscle infarction and replacement by fibrous tissue.

Clinical features. The child, often between 6 months and 3 years old when brought for consultation, is noticed to hold the head on one side. On examination, the contracted sternomastoid muscle is felt as a tight cord. The ear on the affected side is approximated to the corresponding shoulder. In long-established cases there is retarded development of the face on the affected side, with consequent asymmetry (Fig. 12.3).

Fig. 12.3 Infantile torticollis. Note the tense cord-like left sternomastoid muscle and the facial asymmetry.

Diagnosis. The condition has to be distinguished from other forms of wry neck, including structural deformities of the cervical spine, ocular torticollis, muscle spasm from a local inflammatory lesion such as infected glands, and psychogenic (hysterical) torticollis. The important diagnostic features are the history, the cord-like contracted sternomastoid muscle, and the facial asymmetry. Imaging of the spine with plain radiographs is important to exclude any underlying vertebral abnormalities or subluxations.

Treatment. If the condition is seen at the stage of ‘sternomastoid tumour’, repeated stretching of the muscle under the supervision of a physiotherapist is effective. In established cases the contracted muscle should be divided at its lower attachment. After operation corrective exercises should be encouraged.

CONGENITAL SHORT NECK (Klippel–Feil syndrome)

This is an uncommon non-familial congenital malformation of the cervical spine characterised clinically by short neck and limitation of head movements. The cause is unknown.

The degree of abnormality varies widely. The bony deformity consists in fusion of two or more of the cervical vertebrae. Clinically, the neck appears short or absent, and the hair-line is low. The neck may also be webbed to the shoulder. Movements of the head are restricted. Radiographs show the underlying bony abnormality, but operation is seldom indicated.

CONGENITAL HIGH SCAPULA (Sprengel’s shoulder¹)

Congenital high scapula is an uncommon congenital deformity characterised by an abnormally high position and relative fixity of the scapula. The cause is unknown. The anomaly represents a failure of the scapula – originally a cervical appendage – to descend during development to its normal thoracic position. The scapular muscles are ill developed and may be represented only by tough fibrous bands.

Clinically, the scapula on one or both sides is abnormally high. Its attachments seem almost rigid and it does not rotate freely during abduction of the arm. The range of shoulder abduction is consequently impaired, but the functional disability is slight.

Treatment. The condition is often best left alone, but some cases are suitable for operation. The upper part of the scapula (above its spine) is excised after division of the contracted levator scapulae muscle and of tight fascial bands. The blade of the scapula is then divided vertically throughout its length near the vertebral border. This allows the main (lateral) part of the scapula to be displaced downwards relative to the medial strip, and the two parts are re-united with sutures through drill holes.

CERVICAL SUBLUXATION AND DISLOCATION (Spontaneous subluxation of the cervical spine; cervical spondylolisthesis)

Most displacements of the cervical spine are caused by injury, but in some circumstances there may be spontaneous displacement, usually forwards, of a cervical vertebra upon the one next below it.

Causes and pathology. There are three types, caused by:

Congenital or acquired non-fusion of dens. Occasionally the dens fails to fuse with the body of the axis by bone, being attached only by fibrous tissue (os odontoideum). Under the constant stress of superimposed weight the fibrous bond slowly stretches, allowing the dens, and with it the atlas and skull, to slide gradually forwards upon the axis (Fig. 12.4A). A similar condition may exist after fracture of the dens, but this would be preceded by a history of trauma. Instability may also be present in patients with Down’s syndrome and radiological screening may be indicated in patients with this condition.

Fig. 12.4 Three types of cervical spondylolisthesis or spontaneous subluxation. A Displacement of atlas with the dens permitted by congenital or post-traumatic non-fusion of the dens with the axis. B Displacement of atlas on axis, from softening of the transverse ligament of the atlas. C Subluxation of a cervical vertebra upon the one next below it from instability of the intervertebral joint after previous injury. Instability may also be caused by rheumatoid arthritis.

Inflammatory softening of the transverse ligament of the atlas. In this type the underlying cause is an inflammatory lesion in the upper part of the neck, such as rheumatoid arthritis or a severe local infection of the throat or glands. There is rarefaction of the atlas, with softening of the transverse ligament. In consequence the atlas is able to slide forwards upon the axis (Fig. 12.4B).

Instability from previous injury or from arthritis. A traumatic fracture- dislocation or subluxation at any level in the cervical spine may cause permanent instability, with a liability to slow redisplacement months or years after the initial injury (Fig. 12.4C).

In all types the upper segment is displaced forwards in relation to the lower. The spinal canal becomes progressively more flexed and narrowed, and there is always a grave risk of compression of the spinal cord.

Clinical features. In the inflammatory type there is complaint of ‘stiff neck’. The head is held rigidly, the cervical muscles being in spasm. In subluxation from congenital or post-traumatic instability there are discomfort and stiffness in the neck, and flexion deformity is apparent. Radiographs will show the displacement, its level and its type (Fig. 12.5).

Fig. 12.5 Lateral radiograph of upper cervical spine in rheumatoid arthritis showing atlanto-axial subluxation. The anterior arch of the atlas has displaced anteriorly because of destruction by the rheumatoid inflammatory process of the transverse ligaments that normally hold it against the odontoid process of the axis. As a result the odontoid peg (arrow) will compress the anterior aspect of the spinal cord and medulla with severe neurological complications.

Complications. In all types the complication to be feared is compression of the spinal cord. The first symptoms appear in the upper limbs and consist of root pain, paraesthesiae, motor weakness, or sensory impairment. Eventually, increasing cord compression may lead to spastic paralysis below the level of the lesion, and to bladder and bowel dysfunction.

Treatment. This depends upon the underlying cause and upon whether or not neurological disturbance is present.

Inflammatory type. The displacement is reduced by head traction, which is continued for two weeks. Thereafter the neck is immobilised in extension in a plaster jacket for 2 months. Atlanto-axial fusion may be required.

Congenital or post-traumatic instability

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Clinical methods of history taking and examination Other investigation techniques Imaging for orthopaedics The upper arm and elbow The thigh and knee The forearm, wrist, and hand

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