NECK PAIN

DEFINITION:

• Discomfort or more intense forms of pain that are localized to the cervical region.

• This term generally refers to pain in the posterior or lateral regions of the neck.

The spine has three major components:

1. The spinal column (i.e., bones and discs).

2. Supporting structures (e.g., muscles and ligaments).

3. Neural elements (i.e., the spinal cord and nerve roots).

The spinal column:• It is composed of vertebrae that begin in the upper

torso and end at the base of the skull. Seven vertebrae make up the cervical spine.

• They are smaller in size when compared to other spinal vertebrae.

A typical vertebra consists of:• Large vertebral body in the front. • 2 strong bony areas (pedicles) connecting the vertebral body & the posterior arch. • A posterior arch of bony structures in the back (the spinous process, lamina & the

transverse process). • The vertebral bodies support 80% of all of the loads applied to the spine. • Its main purpose is to protect the spinal.

Intervertebral discs:The vertebrae are connected in the front of the spine by IVD. IVD make

up ¼ of the spinal column's length. Discs are not vascular & depend on the end plates to diffuse

nutrients. Discs help to support the spine & allow some vertebral motion (ext

& flex). Individual disc movement is very limited – however considerable motion is possible when several discs combine forces.

There are no discs between the Atlas (C1), Axis (C2), and Coccyx.

IVD are strong tissues, filled with gel. Composed of an annulus fibrosus & a nucleus pulposus.

The cartilaginous layers of the end plates anchor the discs in place.

The intervertebral discs are fibrocartilaginous cushions serving as the spine's shock absorbing system, which protect the vertebrae & other structures (i.e. nerves).

Supporting structures:

A complex system of ligaments, tendons, and muscles help to support and stabilize the cervical spine.

Ligaments:

Ligaments (which are comparable to thick rubber bands) work to prevent excessive movement that could result in serious injury (they provide stability to the spine).

Ligamentum Nuchae (fibrous membrane)

Atlas and Axis Ligament Systems

The Atlas (C1) & Axis (C2) are different from the other spinal vertebrae. The upper cervical ligament system is especially important in stabilizing the UCS from the skull to C2.

1. Occipitoatlantal Ligament Complex.(4)2. Occipitoaxial Ligament Complex.(4) 3. Altantoaxial Ligament Complex.(4) 4. Cruciate Ligament Complex.

Muscles:• They help to provide spinal balance and

stability, and enable movement. • There are different types of muscle:

forward flexors, lateral flexors, rotators, and extensors.

Types of Vertebral Muscles: General Location:

Forward flexors Anterior

Lateral flexors Lateral

Rotators Lateral

Extensors Posterior

Muscles of the Posterior Cervical and Upper Thoracic Spine

Semispinalis Capitus (head rotation/pulls backward)

Iliocostalis Cervicis (extends Cv)

Longissimus Cervicus (extends Cv)

Longissimus Capitus (head rotation/pulls backward)

Longissimus Thoracis (ext./lat. Flex. vert column, rib rotation)

Iliocostalis Thoracis (ext./lat. flexion vert column, rib rotation)

Semispinalis Thoracis (ext/rotates vert column)

Spinal Cord and Cervical Nerve Roots :

There are 8 pairs of cervical nerves. The PNS is the complex system of nerves that

branch off from the spinal nerve roots. The cervical nerves control many bodily

functions and sensory activities. C1: Head and neck C5: Wrist extensors

C2: Head and neck C6: Wrist extensors C3: Diaphragm C7: Triceps C4: Upper body muscles C8: Hands

(e.g. Deltoids, Biceps)

• The spinal cord is surrounded by spinal fluid (CSF) and by several layers of protective structures, including the dura mater, the strongest, outermost layer.

Vascular System of the Spine

Arteries Supplying Spinal Column:

Vertebral Basilar CarotidVeins Supplying Spinal

Column: Internal Jugular External Jugular Superior Vena Cava

How the Spinal Column Should Look? Posterior aspect

-> should be perfectly straight, with no lateral curves.

Sagittal view-> should be inward curves (lordosis) at the cervical & lumbar levels outward curve (kyphosis) at the thoracic level.

These curves allow the head to position over the pelvis in a sitting & standing position, while allowing for load bearing and shock absorption in the spine.

20 to 40˚

Facet Joints:(Zygapophyseal or Apophyseal Joints)

Are located at the back of the spine (posterior).

Each vertebra has 2 sets of facet joints. One pair faces upward (superior

articular facet) & one downward (inferior articular facet).

There is one joint on each side (rt & lt). They are synovial hinge–like joints

(surrounded by a capsule of connective tissue, produces a fluid to nourish & lubricate the joint & there surfaces are coated with cartilage allowing joints to move or glide smoothly [articulate] against each other).

They allow flexion (bend forward), extension (bend backward) and twisting motion.

Certain types of movement are restricted.

The spine is made more stable due to the interlocking nature to adjacent vertebrae.

ROM of the neck: The neck has a significant amount of motion (e.g., rotate

side to side, bend forward and backward).Flexion & extension mainly at occipito-atlantoid j.

may extends throughout cervical spine.Lateral flexion throughout cervical spine.Rotation mainly at atlanto-axial j.

may extends throughout cervical spine.

EXTENSION:55 degree.ROTATION:

30 degree rotation

LATERAL FLEXION:40 degree.

FLEXION: Able to touch chest with chin.

Neck Pain

Neck pain may result from abnormalities in the soft tissues—the muscles, ligaments, and nerves—as well as in bones and joints of the spine.

The most common causes of neck pain are soft-tissue abnormalities due to injury or prolonged wear and tear.

In rare instances, infection or tumors may cause neck pain.

In some people, neck problems may be the source of pain in the upper back, shoulders, or arms.

Cause:Intrinsic causes:

Deformities: Infantile torticilis.

Infections of bone:TB of cervical spine.Pyogenic infection of cervical

spine. Tumours:

Benign & malignant tumours in relation to cervical spine & nerve roots.

Psychogenic.

Arthritis of spinal joints: RA. AS. OA of cervical spine( cervical

spondylosis). Mechanical derangement:

Prolapsed cervical disc. Cervical spondylolithesis. Whiplash injury. Cervical spine fracture. Neck muscle strain. Neck sprain.

Extrensic causes:• Referred pain:

• Ear. • Throat. • Brachial plexus.• Angina (pain extends to

neck). • Aortic aneurysm.• Meningismus.

Cervical Disc Disease:• Most common site C5-6 & C6-7.• Cause:

– Trauma is a predisposing factor. • Pathology:

– Disc bulge: generalized symmetric extension of the disc margin. – Disc protrusion: herniation of nuclear material through a defect in annulus. – Extrusion: herniation of nuclear material

resulting in an anterior extradural massattached to the nucleus of origin(pedicle).

– Disc sequestration: separation of material from the disc.

Protrusion

Extrusion Sequestration

• Clinical features:– Radicular pain with decreased cervical range of motion

(ROM).– Discogenic pain without nerve root involvement:

decreased cervical ROM, normal neurologic examination & possible pain exacerbation with axial compression.

– Myofascial tender or trigger points commonly are palpable.

– Tenderness with posteroanterior mobilization may suggest disc pathology.

Investigations:PXR -> narrowing of disc space.MRI -> modality of choice. Electrodiagnostic studies .

TREATMENT:1. Physical Therapy2. Surgical Intervention3. MEDICATION

○ NSAIDs are 1st line of R for most cervical conditions.○ Muscle relaxants to potentiate the NSAID analgesic effect &

not necessarily to control muscle spasm.○ Oral corticosteroids treat inflammatory cervical radiculopathy.

Sagittal MRI demonstrating cervical

intervertebral disc protrusions at C3-C4 and

C7-T1.

Cervical Spondylosis: Chronic degeneration of the cervical spine that affects the vertebral

bodies, IVD (disk herniation and spur formation), facet joints, longitudinal ligaments, ligamentum flavum & spinal canal contents(nerve roots and/or spinal cord).

Pathology: IVD lose hydration & elasticity with age -> cracks and fissures. Ligaments lose their elastic properties -> develop traction spurs. Disk collapses (biomechanical incompetence) -> annulus bulge outward. Disk space narrows, annulus bulges & facets override -> increases motion at that spinal segment & hastens the damage to the disk.-> cross-sectional area of the canal is narrowed.Acute disk herniation may complicate chronic spondylotic changes.

Clinical features:40-60 years of age.

Examination:Spurling sign - Radicular pain exacerbated by extension and

lateral bending of the neck toward the side of the lesion. Lhermitte sign - This generalized electrical shock sensation

with neck extension. Cervical pain with decreased ROM in the cervical spine.Radiculopathy .Distal weakness. Increased reflexes in the lower extremities & upper

extremities below the level of the lesion. Extensor planter reflex & Hoffman sign in severe myelopathy.

Investigations:PXR ->

facet joints, the foramen, intervertebral disk spaces, and osteophyte formation.

Myelography + CT -> to assess spinal and foraminal stenosis. [INVASIVE]

CT with or without intrathecal dye -> to estimate the diameter of the canal, small lateral osteophytes & calcific opacities in the middle of the vertebral body.

MRI -> modality of choice. Electrodiagnostic studies .

TREATMENT:1. Physical Therapy.2. Surgical Intervention.3. Injection: Cervical, zygapophyseal, intra-

articular steroid injection4. MEDICATION:

○ NSAIDs are 1st line of R for most cervical conditions.

○ Muscle relaxants to control muscle spasm.○ Oral corticosteroids treat inflammatory

cervical radiculopathy.

Cervical Sprain and Strain: One cause of cervical strain is termed

cervical acceleration-deceleration injury (whiplash injury).

Causes:Motor vehicle accidents, lifting or pulling heavy

objects, awkward sleeping positions, unusual upper-extremity work & prolonged static positions.

Repetitive or abnormal postures may contribute to cervical sprains and strains.

Pathology:Cervical strain is produced by an overload injury to the

muscle-tendon unit because of excessive forces on the cervical spine.

->Elongation & tearing of muscles or ligaments. ->Secondary edema, hemorrhage, and inflammation may occur.

Clinical features: C/O:

Neck pain & headache.Difficulty sleeping, disturbed concentration & memory due to

pain. Neurologic symptoms: weakness or heaviness in the arms,

numbness & paresthesia. Examination:

stiffness of the neck with decreased active & passive ROM.spasm tightness, muscle hardness.

Treatment:1. Physical therapy.2. Traction, manipulation or acupuncture.3. Injection (chronic, persistent neck pain). Types

of injection include epidural, selective nerve root, or facet block injections.

4. Percutaneous radiofrequency neurotomy of medial branch nerve to facet joint is effective for chronic neck pain due to cervical zygapophysial joint pain.

5. MEDICATION:○ NSAIDs are 1st line of R for most cervical conditions.○ Muscle relaxants to control muscle spasm.○ Oral corticosteroids.

Full recovery within weeks

Cervical sublaxation & dislocation:• Spontaneous or 2ry to injury.• Types:

1. Cong. failure of fusion of odontoid body with axis vertebra.

2. Inflammatory softening of trans lig of atlas.3. Instability dt previous injury or RA.

Displacement of atlas with

densDisplacement of atlas

on axis

Sublaxation of v over 1

below

Clinical features: Discomfort stiffness

& muscle spasm. Radiology:

Displacment. Treatment:

According to cause:Traction or plaster collar or operative fusion.

Tumours in relation to Cx spine: Site:

1. In the spinal Column.2. In the meninges or rarely spinal cord.3. In the fibrous components of PN (neurofibroma).4. In adjacent soft tissue.

Type: Malignant > benign. Usually metastatic.

Examples: Meningioma -> uncommon to compress the cord. Neurofibroma in IV foramen -> cord compression.

Clinical features: Of compression on CORD, interference with BRACHIAL PLEXUS or local

destruction & collapse.

Ankylosing spondylitis: It creeps up the spine from below. Cause:

Unknown. Pathology:

Begins with SIJ usually extends upwards to involve lumber, thoracic & cervical spine, in severe cases hip or shoulder involvement.

Articular cart., synovium & lig. Show ch. Infl changes & then ossification. Clinical features:

Men, 16-25 yrs. Aching pain in low back with increasing stiffness then extends upwards

to neck. Treatment:

Patient education. Exercise. Support cervical spine by plastic collar.

Rheumatoid Artheritis: It is chronic infl of joints associated with mild

constitutional symptoms. Usually affected in rheumatoid polyartheritis, especially in sero –ve disease.

Cause:Unknown. Maybe autoimmune or infection.

Importance:IVD destruction leads to gradual forward sublaxation.Risk of atlanto-axial sublaxation dt softening in transverse lig

of atlas. Radiological:

1-Errosions of IV joints. 2-Sublaxation. Treatment:

Support cervical spine by plastic collar or in some cases local IV fusion.

Diagnosis:1. Simultaneous

involvment of other joints.

2. Raised ESR.3. RF +ve.

TB of cervical spine• Less common than in thoracic spine &

lumbar region.• Pathology:

Clinical features:Child, & young adults.Pain in neck and occiput, aggravated by motion.+ 1 of following: diff of swallowing, abcess, sinus, neurological

sympt. from cord dysfunction (UL before LL)On examination:

○ Cervical muscle spasm. Prominent 1 or more spinal process.○ Local tenderness on deep palpation over spinal process. Limited painful

neck ROM.

Investigations:ESR -> raised. Mantoux test: +ve. Tb bacilli in pus.Radiological: 1-Dec disc space. 2-Bone destruction.

3-Abscess shadow. Treatment:

Principle R: Antibacterial therapy.Local R: support Cv spine (plaster of Paris or plastic collar.Operative R: drain abscess, decompress spinal cord, stabilize spine .

Diagnosis:1. History(contact or septic focus).2. Muscle spasm with limited ROM.3. Radiological findings.

Pyogenic infection(Pyogenic cervical spondylosis): Uncommon in cervical vertebrae or IVD. Cause:

staph., strept., pneumococci & less commonly salmonella or brucella. Pathology:

As TB. Clinical features:

Acute or subacute with fever.As TB but more rapid course .

Investigations:ESR -> raised. PNL-> raisedRadiological: 1-Dec disc space. 2-Bone destruction.

3-Abscess shadow. 4-osteoperosis. Treatment:

Principle R: Proper a antibaiotic therapy.Local R: support Cv spine (plaster of Paris or plastic collar.Operative R: spontaneous fusion usually makes it unnecessary.

Infantile torticilis Tilting & rotation of head by contarctures of sternomastoid

muscle of 1 side. Causes:

?? Interference in blood supply of sternomastoid muscle, dt injury during birth.

Pathology:Muscle fibers replaced by fibrous tissue.

Clinical features:Child, 6m-3yrs, head held to 1 side.On examination:

○ Contracted sternomastoid muscle (cord like).○ In long standing cases: Retarded facial development on same side (facial

asymmetry).

Treatment:In sternomastoid pseudo-tumour stage: Stretching of muscle.In established stage: Surgical division with postoperative exercise.

Diagnosis:1. History.2. Cord like.3. Facial asymmetry.

THANK YOU.

Examination of the neck:

ROM Fix the head with one hand while you examine neck Inspection

Note the normal concavity of cervical spine Identify Transverse process of C7 Observe Trapezius and Sternomastoid muscles

Palpation Feel each spinous process looking for focal areas of tenderness Joint

○ Feel for crepitus during passive motion Para spinal muscles

Range of motion Active

○ Touch chin for flexion ○ Throw head back for extension ○ Touch each shoulder with ears for lateral flexion ○ Touch each shoulder with chin for lateral rotation

Passive ○ Feel for crepitus during passive motion

Normal: 30 degree rotation, able to touch chest with chin, 55 degree extension and 40 degree

lateral bend. No resistance during the range of motion.

CERVICAL MUSCLES FUNCTION NERVE

Sternocleidomastoid Extends & rotates head, flexes vertebral column C2, C3

Scalenus Flexes & rotates neck Lower cervical

Spinalis Cervicis Extends & rotates head Middle/lower cervical

Spinalis Capitus Extends & rotates head Middle/lower cervical

Semispinalis Cervicis Extends & rotates vertebral column Middle/lower cervical

Semispinalis Capitus Rotates head & pulls backward C1 – C5

Splenius Cervicis Extends vertebral column Middle/lower cervical

Longus Colli Cervicis Flexes cervical vertebrae C2 – C7

Longus Capitus Flexes head C1 – C3

Rectus Capitus Anterior Flexes head C2, C3

Rectus Capitus Lateralis Bends head laterally C2, C3

Iliocostalis Cervicis Extends cervical vertebrae Middle/lower cervical

Longissimus Cervicis Extends cervical vertebrae Middle/lower cervical

Longissimus Capitus Rotates head & pulls backward Middle/lower cervical

Rectus Capitus Posterior Major Extends & rotates head Suboccipital

Rectus Capitus Posterior Minor Extends head Suboccipital

Obliquus Capitus Inferior Rotates atlas Suboccipital

Obliquus Capitus Superior Extends & bends head laterally Suboccipital

Muscles of the Spinal Column

• However, because it is less protected than the rest of the spine, the neck can be vulnerable to injury and disorders that produce pain and restrict motion.