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Disease
Anatomy
Overview
Spine
5 regions
Function: axial
support for the
body and balance
Protect spinal
cord
Flexible motion
Also known as
vertebral column
Cervical Vertebrae
7 cervical
vertebrae
Identified as C1C7
First 2 are called
atlas and axis
because they
perform different
functions
Atlas has no body and allows you to nod yes
Axis acts as the pivot for the rotation
Thoracic
Larger than
cervical
vertebrae
Articulate to
ribs
T1-T12
1-Vertebral Body 2-Spinous Process 3-Transverse Facet
4-Pedicle 5-Foramen 6-Lamina 7-Superior Facet
Intervertebral Discs
Pads of flexible
fibrocartilage
which separate
individual
vertebrae
Cushion
vertebrae,
absorb shocks,
allow for spine
flexibility
Intervertebral Discs
It is composed of :
1- Annulus fibrosus: fibrous
,tough, outer layer
2- Nucleus pulposus:
gelatinous part, with 80%
water, which decrease with
aging.
Ligaments
Vertebra are also stabilized by the
following ligaments:
1- Anterior longitudinal ligament
2- Posterior longitudinal ligament
3- Ligamentum flavum; between
laminea, the strongest one.
4- Interspinous ligament; between
inner surface of spinous process.
5- Supraspinous ligament;
between tips of the spinous
process.
6- Intertransverse ligament;
between transverse processes
Facet Joints
Each vertebra has two sets of
facet joints. One pair faces
upward (superior articular facet)
and one downward (inferior
articular facet).
There is one joint on each side
(right and left).
Facet joints are hingelike and link
vertebrae together.
They are synovial joints.
This means each joint is surrounded
by a capsule of connective tissue
and produces a fluid to nourish and
lubricate the joint.
Cervical degenerative
disease
Cervical spine disorders predominantly cause
neck pain and/or arm symptoms.
Cervical disc prolapse and cervical spondylosis
are the two common cervical spine disorders.
Degenerative changes in the vertebral column
are the basic underlying pathological processes
in both these conditions.
the critical clinical feature depends on whether
there is nerve root entrapment causing arm pain
and/or focal signs of neural compression in the
upper limb.
Clinical presentation:
The characteristic presenting features of a patient with an
acute cervical disc herniation consist of neck and arm pain
and the neurological manifestations of cervical nerve root
compression.
The pain begins in the cervical region then radiates to the
periscapular region and shoulder down to the arm
(brachial neuralgia )
The neck pain commonly regresses while the radiating arm
pain becomes more severe. deep, boring or aching
pain
sensory disturbance, particularly numbness or tingling in
the distribution of the dermatome affected.
Examination features:
Cervical spine movements will be restricted and the head is
often held rigidly to one side
Usually moderately flexed, and tilted towards the side of the
pain in some patients but occasionally away from it in
others. Lateral tilt relaxes the roots on the side of the
concavity but diminishes the intervertebral foraminae, and
flexion slightly separates the posterior part of the
intervertebral space and lessens the tension in the prolapse.
If the disc herniation is long standing there may be wasting
in the appropriate muscle group, particularly the triceps in a
C7 root lesion.
The patient is then examined for weakness in each of the muscle groups
Radiological investigations:
High-quality MRI is now the investigation of choice and
has almost completely replaced both myelography and
CT
The cervical myelogram using water-based non-ionic
iodine contrast material was a most useful investigation
for determining the presence and site of the disc
herniation
CT scanning by itself is frequently not helpful, but if
performed following intrathecal iodine contrast it will
demonstrate a disc herniation, and smaller volumes of
intrathecal contrast are necessary than with
myelography
Differential diagnosis:
cervical nerve root compression by a spinal
tumour (e.g. meningioma, neurofibroma)
thoracic outlet syndrome
Pancoasts tumour infiltrating the roots of the
brachial plexus
peripheral nerve entrapments, such as carpal
tunnel
syndrome, median nerve entrapment in the cubital
fossa
Management:
conservative treatment:
This should include bed rest, a cervical collar, simple analgesic
medication, non-steroidal anti-inflammatory medication and muscle
relaxants.
The following are indications for further investigation and surgery.
1 Pain:
(a) continuing severe arm pain for more than 10 days without benefit
from conservative therapy
(b) chronic or relapsing arm pain.
2 Significant weakness in the upper limb that does not resolve
with conservative therapy.
3 Evidence of a central disc prolapse causing cord compression
this should be investigated urgently.
Surgery :
1) Cervical foraminotomy with excision of
the disc prolapse.
Advantages :
the nerve is directly decompressed both
by removal of the disc herniation and by
enlargement of the foramen
Disadvantages :recurrent disk herniation
Cervical spondylosis
Cervical spondylosis is a degenerative arthritic
process involving the cervical spine and affecting
the intervertebral disc and the facet joints.
Radiological findings of cervical spondylosis are
present in 75% of people over 50 years of age
who have no significant symptoms referable to
the cervical spine.
Pathological changes
1) Reduced water
content and
fragmentation of the
nuclear portion of the
cervical discs are
natural ageing
processes
2)Degeneration of the
disk result in greater
stress on the articular
cartilages of the
vertebral end-plates
Presenting features
1)Neck pain
2)Radiating arm pain
3)cervical myelopathy
Neck pain
This is the most common clinical manifestation of
cervical spondylosis and its onset may be
precipitated by minor trauma.
The pain usually settles over a period of a few
days or weeks but frequently recurs and is
associated with increasing stiffness of the neck.
Cervical myelopathy
o Cervical myelopathy results from cervical cord
compression due to a narrow cervical vertebral canal.
o Causes of narrowing canal :
congenital narrowing
cervical spondylosis involving hypertrophy of the facet
joints and osteophyte formation
hypertrophy of the ligamenta flava
bulging (or prolapse) of a cervical disc
o The myelopathy results from:
direct pressure on the spinal cord
ischaemia of the cord due to compression and
obstruction of small vessels within the cord
Clinical features:
1) Neck pain.
2) Muscular weakness:
The patient initially notices clumsiness involving the hands and
fingers, particularly in fine skilled movements According to the
level and extent of the cord lesion the signs in the upper limbs
will be predominantly of a lower or upper motor neurone type
and there will be a spastic paraparesis of the lower limbs.
3) Sensory symptoms:
diffuse numbness and paraesthesiae in the hands and fingers.
Radiologic findings
Management
Neck pain due to cervical spondylosis
The pain usually resolves with simple
conservative measures, including the use of nonsteroidal anti-inflammatory medication and
simple analgesics.
During an acute episode the patient may be more
comfortable in a soft cervical collar.
As the pain subsides the patient should be
encouraged to perform simple mobilizing
exercises which may be best undertaken with
the supervision of a physiotherapist.
Arm pain
The symptoms frequently settle with the management
described above. The following are indications for
surgery :
Severe pain that does not settle with conservative
treatment over 23 weeks.
Chronic or recurrent pain.
Progressive weakness in the arm which causes
functional disability.
The most frequently involved nerve root producing
significant functional weakness is the C7 root
Surgery:
1) Cervical foramenotomy : with
decompression of the nerve root,
excision of the osteophytes and
enlargement of the neural foramen, is
an effective surgical technique.
2)anterior cervical discectomy :
with excision of the osteophyte
extending into the neural foramen.
Causes
The progressive wear and tear that is noted with
degenerative disc disease increases the risk of
injury via trauma.
Contributing factors to disc injury include the
following:
Age
Trauma
Smoking
Obesity
Sedentary lifestyle
Poor physical fitness
Follow Up
Prevention
Exercises; including cardiovascular training
and abdominal/lumbar muscle training, are
the primary preventive measure for thoracic
disc disease.
Prognosis
Thoracic disc disease is essentially self-limiting
and rarely requires surgical intervention. Most
cases resolve within the first 4-6 weeks
following onset.