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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
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
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
extremity paresthesias
weakness and decreased manual dexterity (dropping object, difficulty manipulating fine objects)
gait instability
urinary retention
not very useful in diagnosis due to high prevalence of urinary conditions in this patient population
Physical exam
motor
weakness
when patient holds fingers extended and adducted, the small finger spontaneously abducts due to
normally a patient can make a fist and release 20 times in 10 seconds. myelopathic patients may
struggle to do this
sensory
proprioception dysfunction
pinprick testing should be done to look for global decrease in sensation or dermatomal
changes
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
Hoffmann's sign
snapping patients distal phalanx of middle finger leads to spontaneous flexion of other
fingers
sustained clonus has poor sensitivity (~13%) but high specificity (~100%) for cervical
myelopathy
toe-to-heel walk
Romberg test
provocative tests
Lhermitte Sign
test is positive when extreme cervical flexion leads to electric shock-like sensations that radiate down the
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.