1. Neck Pain

2. What is in… Cervical spondylosis Cervical spondylitis
Cervical spondylolisthesis/disk bulges

3. What is it?
Causes
Risk factors
Symptoms
Signs
Complications
Tests
Pharmacological/surgical management
Physiotherapy management

4. Cervical Spondylosis

5. A common cause of chronic neck pain
CS is a disorder in which there is abnormal wear on the cartilage and bones of the cervical vertebrae
A common cause of chronic neck pain
Cervical spondylosis is a disorder that happens with age. this happens due to degeneration of the bones of spine or the ribs. The spinal canal narrows down and causes the muscles or the nerves attaching to compress than normal size. and hence the mild pain starts and ends in severe dysfunction.
          Cervical spondylosis, also known as cervical arthritis, cervical osteoarthritis and neck arthritis, is a degenerative osteoarthritis condition that affects the cervical spine.
          The cervical vertebrae are the seven vertebrae between the skull and the chest that form the upper spine. Cervical spondylosis is often caused by earlier back injuries such as sports injuries and falls.
          A specific form of arthritis, which attacks vertebrae and connecting bony, and ligament structures, is known as spondylosis. Frequently it occurs in the cervical vertebrae. The spines of majority of people above the age of 50 have certain degree of osteo arthritic changes. But they seldom cause acute symptoms. Certain precipitating factors like trauma, incorrect posture of the body, pressure while sleeping and excessive intake of sour food usually precipitate these attacks.
          In ayurveda this condition is known as griva sandhigata vata. Pain in the back of neck, shoulder and arms, stiffness of the neck and even paraplegia occur due to this condition. The movement of the spine generally aggravates the pain of the neck. It is often associated with loss of memory and sleeplessness.

6. Causes CS is caused by chronic wear on the cervical spine
This includes the disks between the neck vertebrae and the joints between the bones of the cervical spine
There may be abnormal growths or "spurs" on the vertebrae

7. These changes can, over time, compress one or more of the nerve roots
These changes can, over time, compress one or more of the nerve roots. In advanced cases, the spinal cord becomes involved
Everyday wear and tear may start these changes
People who are very active at work or in sports may be more likely to have them

9. Risk factors
The major risk factor is aging {by age 60, most women and men (men>women) show signs of CS on x-ray}
Being overweight and not exercising
Having a job that requires heavy lifting or a lot of bending and twisting
Past neck injury (often several years before)

10. Past spine surgery
Ruptured or slipped disk
Severe arthritis
Small fractures to the spine from osteoporosis
Congenital deformity

11. Symptoms
Neck or shoulder pain, stiffness of the neck, and difficulty turning or bending the neck from side-to-side
Symptoms may get worse with turning, extending, or bending the neck
Pain that shoots down the arm, and numbness, weakness, or pains in the arm
Muscles spasm and popping sound near the neck
Point of diagnosis
Age: the most cases are over 40 years old, and men more than woman.
Pain in the neck, headache (back of head), shoulder, or radiating pain in the arm or fingers.
Numbness or tingling in the arm or fingers or thumb.
Dizziness.
Loss of balance.
Dry eyes, visual disturbances (eg, blurred vision, diplopia)
Tinnitus.
Disturbed concentration and memory
Hot flash (rarely).
X-ray, MRI, CT: will find particular problem.

12. Symptoms are caused by imposition on the spinal cord or the nerves as they exit the spine, or both
A stiff neck is most often one of the very first signs
Neck stiffness tends to grow progressively worse over time
Radiating pain (stabbing, burning, or dull ache) to the bottom of the skull and/or to the shoulder and down the arm
Can be accompanied by paresthesias and muscle weakness in the neck, shoulders, arms, and hands; numb, clumsy hands syndrome

13. Patterns of CS Radicular pattern Vertebral artery pattern
Myelopathy pattern
Sympathetic pattern
Combination pattern
1. Radicular pattern: neck pain, shoulder pain, arm pain, and shooting pain; neck stiff in the morning; tingling, numb in the arm or finger or thumb. 2. Vertebral artery pattern: Dizzy, tinnitus(ear ringing), nausea, diplopia. 3. Myelopathy pattern: Pain in the neck, arm or finger or thumb numbness, and upper limbs weakly, or lower limbs weak which can’t walk or limp, worse is the paralysis and incontinence. 4. sympathetic pattern: headache of occipital, dizzy, hotflase, sweat body, dry skin, dry eye, Visual disturbances (eg, blurred vision, diplopia).

14. Pathology – radicular pattern
Posterolateral protrusion of the cervical disc
Hyperplacia, hypertrophy of the facet joint
Stimulate or compress nerve roots as they emerge from the cord to pass peripherally through the intravertebral foramen

16. Clinical manifestation
Symptoms
Neck pain: radiating to the ipsilateral upper extremity
Paresthesia
Muscle weakness in appropriate distribution
Pain and paresthesia may be intensified by neck movement, especially by extension or lateral flexion to the side of the herniation
May be improved by traction on the neck

17. Signs Stiffness of the neck Tenderness, spasm of paraspinous muscles
Limitation of active and passive motion of the neck and affected upper extremity

18. Osteophyte formation and narrowing of intervertebral foramen; CT scan
Radiographic studies

19. Pathology – myelopathy pattern
Midline herniation of nucleus pulposus
Osteophyte of posterior rims of vertebral body
Hyperplasia of the ligamentum flavum
Calcification of the posterior longitudinal ligament
These all lead to compression of the spinal cord

20. Clinical manifestation
Symptoms
Weakness
Loss of balance
Cannot handle small objects
Neck pain not obvious
Numbness
Dysfunction of upper motor neuron is gradually present from the lower part of the body to the upper
Spastic paraplegia or quadriplegia
Loss of control of the bladder or bowels

21. Signs - CSM Marked motor and relatively few sensory changes
Hypertonicity
Hyperreflexia
Patellar clonus (+)
Ankle clonus (+)
Pyramidal tract sign
Hoffmann’s sign
Babinski’s sign
Obstacle of fine motion of the fingers, such as buttons or writing
A Hoffmann (or Tinel's sign) is a tingling sensation triggered by a mechanical stimulus in the distal part of an injured nerve. This sensation radiates peripherally, from the point where it is triggered to the cutaneous distribution of the nerve. The tingling response can be compared with that produced by a weak electric current, as in transcutaneous electrical nerve stimulation (TENS). This unpleasant sensation is not a severe pain and does not persist.

22. Calcification of the posterior longitudinal ligament

23. MRI

24. Pathology – vertebral artery pattern
Hyperplasia, stenosis of cervical vertebral transverse foramen, hypertrophy of articular process, unstable cervical vertebra
Directly stimulate, compress vertebral artery

25. Clinical manifestation
Symptoms
Vertigo is main, induced by rotating neck
Migraine
Sudden blackout/diplopia, recovered in a short time
Cataplexy caused by sudden spasm of artery due to stimulation, come to normal at once after falling to the ground
Sign
Positive neck rotation test

26. Differential diagnoses
Adhesive capsulitis
Brown-Sequard syndrome
Carpal tunnel syndrome
Central cord syndrome
Cervical disc disease
Cervical myofascial pain
Chronic pain syndrome

27. Diabetic neuropathy
Multiple sclerosis
Myofascial pain
Neoplastic brachial plexopathy
Osteoporosis and spinal cord injury
Radiation-induced brachial plexopathy
Rheumatoid arthritis
Traumatic brachial plexopathy

28. Signs – summary
An examination may show that patient has trouble moving head toward shoulder and rotating head
Ask patient to bend head forward and to the sides while putting slight downward pressure on the top of the head - increased pain or numbness during this test is usually a sign that there is pressure on a nerve in patient’s spine
Weakness or loss of feeling can be signs of damage to certain nerve roots or to the spinal cord (reflexes are often reduced)

29. Special tests Cervical range of motion Upper limb tension test
The patient is seated and cervical rotation is measured with a standard goniometer
Considered positive if the patients ipsilateral cervical rotation is less than 60°
Upper limb tension test
Considered positive if:
1) Symptoms are reproduced
2) Side-to-side differences in elbow extension are greater than 10°
3) If contralateral lateral flexion of the cervical spine increases symptoms or ipsilateral lateral flexion decreases symptoms
Normal cervical ranges of motion
Flexion – 50 degrees or more
Extension – 60 degrees or more
Lateral flexion – 45 degrees or more
Rotation – 80 degrees or more

30. Upper limb tension test
Scapular depression
Shoulder abduction
Forearm supination with wrist/fingers extension
Shoulder lateral rotation
Elbow extension
Contralateral cervical side bending
Ipsilateral cervical side bending

31. Neck distraction/axial manual traction test
Axial loading
Spurling maneuver
Lateral flexion and extension of the neck, and then axial pressure on the spine
Neck distraction/axial manual traction test
One hand under the patient’s chin and the other hand around the occiput, then slowly lift the patient’s head as axial traction force is gradually applied up to 30 pounds
Positive if the pain is relieved when the head is distracted
Shoulder abduction
Place the hand of the affected extremity on the head
A positive response is alleviation of patient symptoms

32. Cervical distraction
Spurling’s compression
Shoulder abduction

33. Sensitivity & Specificity Of Tests - (according To Viikari-Juntura et al)
Position
Sensitivity
Specificity
Spurling Compression
Seated
40-60%
92-100%
Shoulder Abduction
43-50%
80-100%
Neck Distraction
Supine (10-15kg)
40-43%
100%

34. Other special tests Tension arm test Percussion head test Jackson test
Compression shoulder test

35. 1 2 3 4

36. Vertebrobasilar circulation assessment
Vascular Insufficiency may be aggravated by positional change in the cervical spine
Assessment of the vertebrobasilar circulation must be done if cervical adjustment or manipulation is to be performed
Positional change in the cervical spine compresses the vertebral artery at the atlantoaxial junction on the side opposite of rotation

37. Testing Barre-Lieou sign Maigne’s test Dekleyn’s test Hautant’s test
Underburg’s test
Hallpike’s maneuver

38. Complications Chronic neck pain
Progressive loss of muscle function or feeling
Poor balance
Permanent disability (occasionally)
Use of a neck brace to immobilize the neck
Inability to retain feces
Urinary incontinence

39. Diagnostic tests - Imaging
Neck x-ray (lateral)
Bony outgrowths at the margin of the joints
Reduced space between the vertebrae of neck
Narrowed opening between the bones
CT scan
MRI of the neck (when there is severe pain, weakness, numbness)
Loss of normal curvature of neck
Vertebral bone canal diameter is decreased
Spinal canal is narrowed
Neck X-ray. An X-ray may show abnormalities, such as bone spurs, that indicate cervical spondylosis. It is ordered primarily as a screening test to look for rare, serious causes for neck pain and stiffness — such as tumors, infections or fractures.
Computerized tomography (CT scan). This test takes X-rays from many different directions and then combines them into a cross-sectional view of the structures in your neck. It can provide much finer details than a plain X-ray, particularly of the bones.
Magnetic resonance imaging (MRI). MRI uses a magnetic field and radio waves and can produce detailed, cross-sectional images of both bone and soft tissues. This can help pinpoint areas where nerves may be getting pinched.
Myelogram. This test involves generating images using X-rays or CT scans after dye is injected into the spinal canal. The dye makes areas of your spine more visible.

40. Cervical x-ray

44. The vertebral artery, which is the first branch of the subclavian artery, provides one of the major blood supplies to the brain.
The vertebral artery originates at the subclavian, and reaches the cranial cavity by passing through the transverse foramina of cervical vertebrae 6 through 1.
Cervical MRI

45. Nerve function tests - Diagnostic tests
Electromyelogram (EMG)
Nerve conduction velocity test
Electromyogram (EMG). This test measures the electrical activity in your nerves as they transmit messages to your muscles when the muscles are contracting and when they're at rest. The purpose of an EMG is to assess the health of your muscles and the nerves that control them.
Nerve conduction study. For this test, electrodes are attached to your skin above the nerve to be studied. A small shock is passed through the nerve to measure the strength and speed of nerve signals.

46. Pharmacological/surgical management
Treatment is aimed at relieving pain and preventing permanent spinal cord and nerve root injury
Treatments include:
Anti-inflammatory medication (NSAIDs)
Cortisone injections
Narcotics or opioids (if pain is very severe)
Cognitive behavioral therapy (talk therapy) may be helpful if the pain is having a serious impact on life (helps better understand pain and teaches how to manage it)
Surgery to remove bone and disc tissue to relieve the pressure on the nerves or spinal cord (foraminotomy, laminectomy, spinal fusion)
Mild cases - no treatment is required

47. Foraminotomy
Laminectomy
Spinal fusion

48. Physiotherapy management
Cervical traction
Postural education
Exercises
Stretching
Strengthening
Manual therapy
Cold packs and heat therapy

68. Tips to a healthier neck
Always stretch before exercise or other strenuous physical activity
At home or work, make sure the work surface is at a comfortable height
Don’t lean when standing or sitting. When standing keep the weight balanced on the feet.
Sit in a chair with good lumbar support and proper position and height for the task. Keep the shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. If one must sit for a long period of time, rest the feet on a low stool.

69. Wear comfortable, low heeled shoes.
Avoid weight lifting in poor postures.
Sleep on the side to reduce ay curve in the spine. Always sleep on a firm surface.
Maintain proper nutrition and diet to reduce and prevent excessive weight. A diet with sufficient daily intake of calcium, phosphorus, and vitamin D helps to promote proper bone growth.
If one smokes, quit smoking. Smoking reduces blood flow to the spine and causes the spinal discs to degenerate.
Avoid excessive stress. Stress will also contribute to the pain intensity.

70. References Google images
A.D.A.M. Medical Encyclopedia (04 June, 2011). Cervical spondylosis. PubMed Health. Available at: Accessed on: 31 August, 2012.
Shrotriya, Rajesh (Not Available). Cervical spondylosis. Dr. Rajesh A Shrotriya's Blog. Available at: Accessed on: 31 August, 2012.
Cervical spondylosis/degenerative neck disease (Not Available). MedIndia. Available at: Accessed on: 31 August, 2012.
Cervical spondylosis (12 July, 2012). Mayo Clinic. Available at: Accessed on: 31 August, 2012.