Function

The neck is highly mobile. It is highly susceptible to injury because the weight of the head creates large forces in high energy accidents.

Presentation

• Cervical spondylosis (arthritis) presents with stiffness and painful spasm in the neck muscles. However, there can also be numbness and pain running down the arm. If the cause is shown to be nerve roots trapped by osteophytes, and the symptoms are disabling, surgery may need to be considered.

Whenever you see a patient with a problem in the upper limb, examine the neck as this may give you a key to the origin of the problem.

• Rheumatoid arthritis. In rheumatoid arthritis, the facet joints may be eroded away to such an extent that the neck becomes unstable. When a patient is being intubated, the spinal cord may be damaged by excessive extension. It is therefore important to always inform an anaesthetist of a patient with rheumatoid arthritis so that they can ensure that suitable precautions are taken.

Function

The thoracic spine is a support for the neck and upper limbs. It moves very little apart from allowing the ribs to move and the lungs to expand during inspiration.

Presentation

• Crush fractures can occur in osteoporotic patients after a fall. Myeloma and secondaries can produce lytic lesions, which may also collapse.
  
• Shingles. Herpes zoster (shingles) may cause severe pain in the dermatome of an intercostal nerve.
  
• Ankylosing spondylitis may produce severe stiffness of the spine, which restricts vital capacity and may also cause a progressive flexion deformity (see Chapter 25).
  
• Scoliosis is commonly a growth abnormality of the spine, which develops during adolescence in children of tall parents, who are growing fast. It leads to rotation and then curvature of the spine, which produces a characteristic hunchback. It is much more noticeable as soon as the patient bends forward to touch their toes. If the curvature looks as if it is going to become severe, surgery may be needed to straighten and fuse the spine, so limiting the deformity.

Causes of backache

• Simple mechanical low back pain. Low back pain or lumbago is a vicious circle of muscle spasm creating pain, which in turn creates more muscle spasm. Most backache will get better whatever you do, but alternative medicine is useful because it seems to be good at breaking this pain cycle.
  
• Sciatica. If pain only radiates as far as the knee, then it is usually assumed that this is referred pain (the origin is in the back). If, however, the pain goes right down into the foot, then it is likely that this is nerve root irritation, possibly caused by a prolapsed intervertebral disc. The differential diagnosis however is of tumour, and infection, although both are much rarer.
  
• Sinister backache. Backache that keeps patients awake at night may be due to an infection (discitis) or a tumour (myeloma or a secondary). It is usually associated with a low grade fever, and the patient feels generally unwell.
  
• Prolapsed intervertebral disc. If the contents of the disc, the nucleus pulposus, prolapse through a rupture in the annulus (the tough ring enclosing the pulposus), then there may be pressure and rubbing of the nerve roots and an inflammatory reaction may be set up. This causes sciatica. In over 90% of cases the inflammation dies down in time. Therefore, the condition should be allowed to take its natural course if possible. The patient will need pain relief – any measure that might help with the muscle spasm such as osteopathy, acupuncture, aromatherapy etc. can be used.