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Mechanical causes of Cervical spine disorder

Outline:
1. Common lesion causing mechanical pain problem
2. Symptoms: pain (local or radiation); stiffness, neurological pain
3. Treatment:
- If present with pain only: conservative treatment
- If present with radiculopathy or myelopathy: surgical treatment
4. If surgical treatment: need to localize the site of pathology by:
clinical examination, XR, MRI, pain provocation test

Cervical spine disorder:


- Mechanical: degenerative 80% of cases
- Organic: infection, tumour, inflammation

Spine is designed for movement; injury is common

Mechanical Diseases
Commonest disease is neck strain, followed by cervical spondylosis
1. Cervical spondylosis IVD degeneration
2. Prolapsed iv disc
3. OA changes in facet joint Facet joint
4. Ossification diseases of ligament Posterior longitudinal ligament
(OPLL, OYL)  cervical stenosis Yellow ligament
5. Cervical stenosis
6. Cervical spondylolisthesis Uncommon
7. Neck strain Commonest
8. Cervical rib syndrome
9. C1, 2 subluxation trauma, degenerative, inflammatory, congenital (e.g. Down’s)

Prolapsed iv disc
- Why PID is less common in cervical area than in lumbar region?
 Less stress (cervical spine bare weight of head only)
 More nucleus propulsus in lumbar region
- A more distinct disease with protrusion of the nucleus
- Pain due to
 Mechanical Compression
 Cytokines release, inflammatory changes
OA of facet joint
- Key is the start in FACET JOINT; degeneration of articular cartilage
- Causes of pain
 Irritation causing Inflammatory changes (cartilage is soft, then surface flaking (condromalasia), gradual
breakdown, the debris formed is the source of irritation); synovitis
 Capsular contracture
 Uneven load-bearing
 Uncovered bone  friction
 Osteophyte: decreased ROM, pain only if compression on sth (SC, nerve root)

Cervical stenosis
- Causing myeolopathy
- Different from lumbar stenosis: lumbar stenosis is a different entity coz not only narrowing of the canal but also
neurogenic claudication: affecting the cauda equina

Ossification
- OPLL (Ossification of the posterior longitudinal ligament):
 Mainly in cervical region; even if present in lumbar region, usually asymtomatic due to larger spinal
canal; rarely in thoracic region
 Usually asymptomatic  clinically uncommon; BUT radiological very common
 Commoner in Asian coz narrower canal
 Ix: Pain XR is already useful, CT may more info; MRI not very useful
 Types: continous, segmental, mixed, circumscribed
- DISH (Diffuse idiopathic skeletal hyperostosis, aka Forestier disease):
 Treatment by laminoplasty (open up to increase the spinal canal space)
Cervical spondylosis
- Spondylosis = Degeneration of intervertebral disc (this may or may not cause symptoms)
- The secondary changes are the main cause of symptoms
 Narrowing of disc space  secondary osteophyte  press on dura, nerve root, spinal cord
 Affecting the alignment (due to degeneration of disc):
 Straightened or even kyphosis cervical spine
 Retrolisthesis (backward shift of vertebral body cf spondylolisthesis: assumed to be
anterolisthesis)  narrowing of spinal canal
 Pain + neurological sign esp. in extension of the neck
 Pressure built up not by the bones in same level
 PID (prolapsed IV disc) may be present only if there is a previous injury
- Symptoms
 Pain (local or radiated) + associated parathesia + pins and needles sensation
 Causes of pain
 Disc itself
 Fistula form nucleus
 Osteophyte to dura/ nerve root/ spinal cord
 Neurological: radiculopahty, myelopathy
 Stiffness
 Patient usually present with pain or neurological symptoms
- Investigation:
 XR:
 Narrowing disc space
 Osteophytes at Inferior or superior end-plate
 Alignment (decreased lordosis/straight/ kyphosis); retrolisthesis; spondylolisthesis
 MRI, indications
 Signs of spinal cord compression
 Plan for surgery: know the site, pathology
 Exclude other pathology e.g. infection, tumour
 Myelogram
 Not used because of invasive, allergy, not a direct view of lesion (only see it indirectly)
 Only use when:
 After op, there may be artifact from the inserts
 MRI are contraindicated
- Treatment
 Conservative: physiotherapy (traction, mobilization, heat [US, infrared]) +/- painkiller
 Surgical:
 Indications
 Neurological symptoms esp. myelopathy, radiculopathy
 Severe pain not responding to conservative tx and disturbing to daily living (usually the
cause is PID)
 Need to know the exact site/ level of the pathology; by
 P/E, XR, MRI, pain provocation test (concordant pain, relieve by injection)
 If neurological signs: MRI usually helpful and tell level
 If only pain with no neurological signs while XR and MRI can’t tell the exact site with
surgery planning: try provoke and abolish the pain
 Provoke: needle insertion
 Abolish: inject long-lasting LA
 But must ask the patient if the pain is like the one experienced usually (need to get the
exact type of pain concordant pain)
Cervical zygpophyseal joint pain pattern (Pain due to facet joint OA of cervical spine)
- Needle inserted to the facet join to reproduce the pain (this is the main aim)
- Make a PAIN DRAWING: from history, patient tell the location of pain which gives information to the possible
level, at least know whether it is upper or lower cervical, then correlate with XR findings; possible site can be
determined where provocation and abolishing test can be carried out
- Pain at C2-3 mainly behind mastoid process; C6-7 at scapular region
- Note the limitations
 Subject to patient and operator factors
 May help by: LA to skin, capsule
Myeolopathy hand signs

Cervical myeolopathy present with UML and LML


- UML: loss of higher control, muscle (spasticity, hyperrelexia, loss of coordination, clonus, barbinski sign)
- LML: fasciculation, muscle wasting, weakness

Myeolopathy hand signs


- Earlier and more significant than the signs in LL:
 ??? Hand receive nerve supply from C8-T1; lesion is usually at C4/C5
 Loss of motor neurons for the control of hand movement (fine movement); compression of spinal cord
will lead to ischaemia of the nerve
- Main mechanism of disease
 Lack of synergy of movement (can’t stabilize other joints, can’t coordinate contraction and relaxation of
agonist & antagonist muscles)

1. 10-second test
- Notes to perform:
 Full extension of all joints (both hands reaching out)
 Patient must fully open and close the fingers
- Causes
 To perform the motion, wrist joint has to be stabilized; in patient with myelopathy, patient cannot
coordinate the motion; he will extend wrist on flexion of finger and flex wrist on finger extension
 Failure of synergy between wrist and fingers
 Exaggerated wrist flexion on finger extension
 Exaggerated wrist extension on finger flexion
 Grip and release: 10 sec test <20
2. Finger escape sign
- Weak closure, can’t hold the finger, drop of finger at MCP joints
- Mechanism is unknown
3. Hoffman’s sign
- Mechanism: A form of hyperreflexia
- Note: the shoulder and elbow should be relaxed (provided with a good support—support the hand just
proximal to the DIP joint of middle finger)
- Stretch muscle tendon—the flexor in the hand (the flexors are usually as a group if one of the flexor
tendon is stretched, other fingers will have the reflex)
- Look at the thumb is the best coz it has a different plane with other fingers; this eliminates the effect of
rebound
4. L’Hermitt’s sign: a very rare sign (shock feeling radiating down LL)
Cervical spine disorders

Symptoms

 neck pain and stiffness

 axial neck pain (often times absent)

 occipital headache common

 extremity paresthesias

 diffuse nondermatomal numbness and tingling

 weakness and clumsiness

 weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)

 gait instability

 patient feels "unstable" on feet

 weakness walking up and down stairs

 gait changes are most important clinical predictor

 urinary retention

 rare and only appear late in disease progression

 not very useful in diagnosis due to high prevalence of urinary conditions in this patient population

Physical exam

motor

 weakness

 usually difficult to detect on physical exam

 lower extremity weakness is a more concerning finding

 finger escape sign

 when patient holds fingers extended and adducted, the small finger spontaneously abducts due to

weakness of intrinsic muscle

 grip and release test

 normally a patient can make a fist and release 20 times in 10 seconds. myelopathic patients may

struggle to do this

 sensory

 proprioception dysfunction

 due to dorsal column involvement

 occurs in advanced disease

 associated with a poor prognosis

 decreased pain sensation

 pinprick testing should be done to look for global decrease in sensation or dermatomal

changes

 due to involvement of ventral spinothalamic tract

 vibratory changes are usually only found in severe case of long-standing myelopathy
 upper motor neuron signs (spasticity)

 hyperreflexia

 may be absent when there is concomitant peripheral nerve disease (cervical or lumbar

nerve root compression, spinal stenosis, diabetes)

 inverted radial reflex

 tapping distal brachioradialis tendon produces ipsilateral finger flexion

 Hoffmann's sign

 snapping patients distal phalanx of middle finger leads to spontaneous flexion of other

fingers

 sustained clonus post

 three beats defined as sustained clonus

 sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical

myelopathy

 Babinski test post

 considered positive with extension of great toe

 gait and balance

 toe-to-heel walk

 patient has difficulty performing

 Romberg test

 patient stands with arms held forward and eyes closed

 loss of balance consistent with posterior column dysfunction

 provocative tests

 Lhermitte Sign

 test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the

spine and into the extremities

Faculty: Prof. J.C.Y. Leong


Objective: To be able to examine patients with mechanical/degenerative cervical spine disorders and plan
for treatment.

A 55-year-old accountant complains of intermittent neck pain, and pins and needles down the left upper
arm and forearm, as well as the thumb and index finger. The pain is worse at the end of a working day,
and gets better after a good night’s sleep.
A 67-year-old man has a 6-month history of progressive difficulty in walking. In the last 3 months he has
also experienced some clumsiness whilst using chopsticks or buttoning of his shirts. He has intermittent
neck pain but is not severe.

A 30-year-old man has been moving house in the last 3 weeks. 10 days ago he experienced severe neck
pain, and radiation down his right upper limb. 5 days ago he noticed weakness in abducting his right
shoulder. The neck pain is so severe he finds it difficult to find a comfortable posture.

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