Cervical Spine Anatomy and Pain

• Musculoskeletal physical therapy covers medical-surgical conditions of the spine.

Cervical Spine (Neck)

• Includes neck pain, neuroanatomy, blood supply, and nerves of the cervical spine.
• Also patterns of pain in the zygapophyseal joints.

Lumbar Spine (Lower Back)

• Includes anatomy, biomechanics, pain generators, history, physical exam, and conditions of the lumbar spine.
• Also LBP in different populations.

Types of neck pain

• Cervical axial pain: Pain in inferior occiput to superior intercapsular region, middle or paramidline.
• Cervical radicular pain: Involves shoulder girdle and/or distal areas (e.g., upper limb), limb pain is greater than axial pain.

Cervical Zygapophyseal Joints (Facet Joint)

• Allow motion in the cervical spine, connecting each vertebral segment.
• Innervated by medial branches from the cervical dorsal rami.

Cervical Segment Motion

• AO joint (C0-C1): 10 degrees flexion, 25 degrees extension; innervated by C1 ventral ramus.
• AA joint (C1-C2): 45-degree B rotation; innervated by the C2 ventral ramus lat.
• C2-C3: Lateral flexion., coupled c ipsilateral rotation.
• C3-C4 & C4-C5: Greatest lateral bending.
• C4-C5 & C6-C7/C5-C6: Greatest amount of flexion.
• C3-C7: Joints of Luschka are located between rheumatoid uncinate process.
• Osteoarthritic changes can narrow IV foramina and cause nerve impingement.

IV Foramina

• Widest at C2-C3, decrease caudally.

IV Disc

• Thicker anteriorly which explains cervical lordosis.

Blood Supply of the Cervical Spine

• Anterior spinal artery supplies blood to the cervical spinal cord.
• Upper cervical spinal cord is supplied by the anterior spinal artery from the vertebral arteries.
• Midcervical spinal cord supplied by 2 - 3 anterior radiculomedullary arteries.
• Lower cervical and upper thoracic spinal cord supplied by the anterior radiculomedullary artery from the deep cervical artery.
• Radiculo/medullary arteries supply blood to the spinal cord.
• Penetration can induce cord infection.
• Radiculopial artery is a pial network and posterior/spinal arteries.

Nerves of the Cervical Spine

• Dorsal and ventral nerve roots contain the spinal cord.
• Dorsal root ganglion: Primary sensory afferent fibers.
• Ventral root ganglion: Primary motor efferent fibers.

Innervation of IV Disc

• Anteriorly supplied by afferent branches of the sympathetic trunk.
• Posteriorly-posterolateral disk supplied by the sinuvertebral nerve.

Pain Generators of the Cervical Spine

• Includes the IV disc, zygapophyseal joint, posterior longitudinal ligament.
• Can produce somatic referral of pain into the upper limb.
  • Somatic pain originated from skin, muscle, and bones;
  • Pain produced w/o irritation of the neural tissue.
  • Mesodermal structure stimulated to another mesodermal tissue of the same origin.
• Convergence: Afferent fibers from cervical spine and distal upper limb converge on 2nd order neurons dorsally.
• Root ganglion within spinal cord, it leads spine that pain is from limbs instead of the cervical area

Patterns of Pain in the Zygapophyseal Joint

• C1-C2 & C2-C3: Rostral to occiput.
• C3 - C4: Occiput.
• C3 - C4 & C4 - C5: Posterior neck.
• C5-C6: Supraspinous fossa of scapula.
• C6-C7: Caudal scapula.

Common Clinical Disorders: Cervical Strain & Sprain

• Musculotendinous overload injury commonly caused by motor vehicle accidents (MVA).

• History: Trauma, MVA, Sports.

• Sharp/dull headaches localize to shoulder girdle.

• Aggravated by passive/active motion.

• Decreased ROM caused by muscle guarding and splinting, most commonly involved areas are the trapezius and SCM.

• Diagnostic testing not included unless neurologic or motor abnormalities.

• X-ray is initially done if diagnostic testing is included or required. - NSAID & Paracetamol -Muscle relaxants for 5 - 7 days, but not always -Tizanidine or TCAs antidepressants -Massage -> sedatives, reduction of adhesions, muscle relaxation, -Superficial and deep heat -> analgesia, muscle relaxation -ES -TENS -Soft cervical collar -> restrict to the first 72 hours post injury -Gradual return to activities by 2-4 weeks

Cervical Radiculopathy & Radicular Pain

• Pathologic process involving neurophysiological dysfunction of the nerve root with a hyper excitable state.
• Dull ache or sharp, lancing pain
• Cervical radiculopathy: Reflex and strength deficits mark hypofunctional nerve root.
• Axial cervical pain followed by the explosive onset of UE pain. -Patients may present -Paresthesia: Sensory disturbance. -Depressed muscles and stretch reflex

Nerve Root and Location of Pain

-C5, C6, C7 :Medial scapular edge -C5 or C6: Superior trapezius, precordium, deltoid and lateral arm -C6 or C7: Anterolateral forearm -C7 or C8: Posterior forearm -C7, C8 or T1: Posteromedial arm -C6-8 or T1: UE digits

• In order of decreasing frequency: C7>C6>C8>C5

Important Considerations

• Differentiate between conditions due to differing management.
• Peak incidents occur at ages 50-54 years old.

Pathophysiology

• MC: Cervical IV disk herniation & Spondylitic changes.

Exacerbating Factors

• Increase subarachnoid pressure: Coughing, Sneezing, and Valsalva maneuver
• Cervical stenosis can occur if unaddressed properly.

Physical Exam

• Inspection: Ask patient to tilt head toward herniated disk.
• Check for atrophy. MMTs more specific than sensory deficits/reflex loss.
• Sensation check (light touch, pinprick, and vibration).
• Special clinical tests as described above

Treatment Considerations

• Avoid deep heating (utz) because the increased metabolic response leads to inflammation, aggravating the nerve root injury
• TENS, can limits painful ROM
• Cervical orthoses : soft cervical coolers -> kinesthetic reminders, narrow-band segment anteriorly, worn for 1-2 weeks
• Cervical Traction 25lbs of force for 25 minutes at an 24degree angel

Medication Considerations

• NSAIDs - first line

• Muscle relaxants for 5-7 days to aid in sleep

• TCAS - amitriptyline/notriptyline 10-25 mg ODHS

• Antiepileptics ;Gabapentin 300-900 mg/day max 3600 mg/day or Pregablin, tiagabine, zonisamide, oxcarbazepine

• Opiates for pain.

• Stabilization and functional restoration include biomechanical correction, physical conditioning, and strength training.

• Start with pain-free ROM, increase ROM by addressing any restriction, restore proper cervical biomechanics : strengthening

• Diagnostic selective nerve root block (SNRB) ,Cortiocsteriods

• Therapeutic selective nerve root injection (SNRI)

• Percutaneous discectomy/disc compressiion

• Nucleoplasty: uses coblation energy to vaporize nuclear tissue into gaseous elementary molecules

• Surgery: intractibale pain, severe myotomal deficits (progressive or stable), mylopathy

• Difference beetween conservative and surgery equals in 1 Year

Cervical Joint Pain

• MC symptomatic level: C2-3 → C5-6 → C6-7.
• Usually, only 1 joint is symptomatic, rarely 2.
• Common source of chronic posttraumatic neck pain.
• Patients with whiplash injury usually have C2-3 zygapophyseal joint pain when they complains of posterior headaches.
• Lower cervical usually involves C5-C6 with traumatic incidents.

History

• Ask for neck position at time of impact/accident.
• Traumatic C2-C3 joint pain unilateral occipital headaches.
• Can present unilateral paramidline neck pain w/wo periscapular symptoms; more painful headaches.
• Patient can pinpoint localized spot of maximal pain

Analysis

• Assess neurologic function and cervical ROM Tenderness posterolaterally over joint
• Focal suboccipital pain or is exacerbated with 45 degrees of cervical flexion and axial rotation suggests a painful C1-2 joint

Imaging

• CT scans better delineate joint fracture, treatment medications like NSAIDs, opitaes
• Physical Modalities like are Cryotherapy preferred over that superficial heat for 20mins 3-4x a day, soft tiss mobilzaiton and massage, and soft cervical collars up to 72 hrs after injury Restorative phase stabilization functional and Restoration (ROM soft tissue length, strengthening)

Treatment of Cervical Joint Pain

• Transition begins with reducing pain acute acute
• Interventional spaine diagnostic and therapeutic injections.
• Percutaneous Radiofrequency.
• Objectives:
• resolution of pain

Disruption in Neruroanatomy

• Internal disruption involves, derangement of internal architecture or external modification

Presentation Analysis Post-Histroy

• Present with

• Posterior occipital

• suboccipital, upper, interscapular

• Trapezial

• Vertigo, Tinitus, ocular dysfunction, facia

• History trauma, all are sudden/graduated and or Explosive pain is nondescript

Exam

• Exacerbated by prolong sitting
• Reliving supine
• Imagery such as Xrays MRI provocation
• Treatments
• NSAIDS
• TCAS
• Opioids

Special Population Tx

• Cervical colors but only 72 hours then discontinue spinal stabilization strengthening .
• Surgery

Cervical myelopaothy

• Most Common the cord lession after
• History of radiculopathy or no
• Symptoms: insidious
• axial pain or numbness paresthesia
• Treat: cervicals/orthotics or surgery

Cervicogenic headache

• Can occur the cervical and or or no
• deep ache deep stabbing

Vertebrae

• Cervical lumbar vereterbrae 5
• Vertebr body increases down
• lower area are wedges

Ligamets- Spinal

• Spinal and Vertebrae

Lumbar Pain

• Largest pain are disabling, pain and psycho.
• Supportive care

Musclrs Origins

• Origins on the lumbar spine are and Postiror
• nerve
• Pain and Spinal

Degeneration of Muscle

• Annulus
• Stiffmobile

Physio exam

• Spinal pelvic examination
• Check knees / hips

Waddell signs are persented

• inapproriate tests
• Stress pressure

Scolossis

• Can be class
• Thoracic
• Lunmbar

Spinal and cancer

• Spinal Thoracic
• History bed

Infection- Spinal

• Verbalis
• Low fever

LBP

• McKenzie test
• Flexion is good