Management of Cervical Spine Disorders PDF

MANAGEMENT OF CERVICAL SPINE DISORDERS Introduction Anatomy Degenerative Joint Disease/Cervical Spondylosis Cervical Disk Dysfunction  By Assoc. Prof. Mohamed Behiry Head of Department of physical therapy for Orthopaedic and its surgery....

MANAGEMENT OF CERVICAL SPINE DISORDERS Introduction Anatomy Degenerative Joint Disease/Cervical Spondylosis Cervical Disk Dysfunction  By Assoc. Prof. Mohamed Behiry Head of Department of physical therapy for Orthopaedic and its surgery. Delta University for science and technology Introduction The etiology of injury to the cervical spine are numerous. They can be myogenic, mechanical, neurogenic, or psychosomatic in origin and can be further divided into acute and chronic states. Acute injuries may be due to trauma, poor working or sleeping position. Chronic pathology usually is due to poor posture, poor muscle tone, or illness. One reason the cervical spine is vulnerable to injury is its high degree of mobility with a heavy weight, the head, perched on top of it.  Anatomy The cervical spine is comprised of seven vertebrae: C1, C2, C3, C4, C5, C6, and C7. These vertebrae begin at the base of the skull and extend down to the thoracic spine. The cervical vertebra nearest the skull, C1, is the smallest, and then the vertebrae get bigger as they go down to C7. The lower vertebrae need to be bigger to support the extra loads from above. Typical Vertebrae: C3, C4, C5, and C6 Cervical vertebrae C3 through C6 are known as typical vertebrae because they share the same basic characteristics with most of the vertebrae throughout the spine. Typical vertebrae have: Vertebral body , Vertebral arch , Facet joints. Unique Vertebra: C7, also called the vertebra prominens, connects with the top of T1 to form the cervicothoracic junction. Top Vertebrae: C1 and C2 at the Top of the Neck C1 Vertebra (the atlas) and C2 Vertebra (the axis) are considered atypical vertebrae and have some distinguishing features compared to the rest of the cervical spine. Vertebral arch & spinal canal On the back of each vertebra are bony projections that form the vertebral arch. The arch is made of two supporting pedicles and two laminae. The hollow spinal canal contains the spinal cord, fat, ligaments, and blood vessels. Under each pedicle, a pair of spinal nerves exits the spinal cord and pass through the intervertebral foramen to branch out to your body. Spinal Cord and Spinal Nerve Roots The spinal cord starts at the base of the brain, runs throughout the cervical and thoracic spine, and typically ends at the lower part of the thoracic spine. The spinal cord does not run through the lumbar spine (lower back). After the spinal cord stops in the lower thoracic spine, the nerve roots from the lumbar and sacral levels come off the bottom of the cord like a "horse's tail" (named the cauda equina) and exit the spine. The spinal cord can be divided into segments according to the nerve roots that branch off of it. Nerves along the cord consists of: 8 cervical nerves 12 thoracic nerves 5 lumbar nerves 5 sacral nerves 1 coccygeal nerve Spinal nerves Thirty-one pairs of spinal nerves branch off the spinal cord. Each spinal nerve has two roots. The ventral (front) root carries motor impulses from the brain and the dorsal (back) root carries sensory impulses to the brain. The ventral and dorsal roots fuse together to form a spinal nerve, which travels alongside the cord, until it reaches its exit hole - the intervertebral foramen , then it branches; each branch has both motor and sensory fibers. Relationship of cervical nerve root to intervertebral discs The nerve root is named according to the LOWER spinal segment that the nerve root runs between. For example, the nerve at the C5- C6 level is called the C6 nerve root. It is named this way because as it exits the spine the nerve root passes OVER the C6 pedicle. Intervertebral Disc Ligaments The ligaments are strong fibrous bands that hold the vertebrae together, stabilize the spine, and protect the discs. The three major ligaments of the spine are the ligamentum flavum, anterior longitudinal ligament (ALL), and posterior longitudinal ligament (PLL). The ALL and PLL are continuous bands that run from the top to the bottom of the spinal column along the vertebral bodies. They prevent excessive movement of the vertebral bones. The ligamentum flavum attaches between the lamina of each vertebra. Joints of Luschka also known as uncovertebral joints, are found between vertebral segments from C3 down to C7. These joints are comprised of two uncinate processes—one rising up from the top of each side of the vertebral body. The cervical facet joints diarthrodial joints formed by the articulation of the superior articular process (SAP) of the caudal vertebrae with the corresponding inferior articular process (IAP) of the cephalad vertebrae. Each facet joint is surrounded by a fibrous capsule Degenerative Joint Disease/Cervical Spondylosis Degenerative joint disease is a chronic and commonly progressive degeneration of the cervical articular facet joints and/or the intervertebral disk. The cause is unknown but may be accelerated by trauma, overuse, or genetic predisposition. It is associated with heavy lifting and driving. It preferentially affects the C5–C7 vertebrae and affects the intervertebral disk and the facet joints Pathomechanics The degenerative process, which in part involves the development of hypertrophic spurs along the margins of the disk, the joints of Luschka, and along the articular facet joints. If the spurring continues, it eventually compresses the contents of the spinal canal. If it exceeds on the spinal canal, it is called central (or spinal) stenosis ,while If it exceeds on the intervertebral foramina (narrowing) , it is called lateral stenosis. Evaluation I. History A. Site of pain. Patients will primarily complain of axial neck pain exacerbated with extension and/ or rotation, and possible radiation of pain into the occiput, shoulder, scapula, and proximal upper arm. B. Nature of pain. The stiff lower cervical joints may be a source of pain, which is often described as a burning pain across the base of the neck C. Onset of pain. A gradual onset of pain. Pain is worse in the morning and is improved with moderate activity.  Clinical note : Neurological symptoms, such as numbness, tingling, or weakness in the upper limbs should be absent with facet arthropathy. II. Physical Examination Observation The patient will generally have a forward-head posture. Often stiffness of the cervicothoracic region causes the development of a kyphotic (hump) deformity. Palpation The area over the cervical facet joints (just lateral to the midline) may be tender to palpation ROM There will be capsular restriction of the lower cervical spine (limited active rotation and lateral flexion as well as extension) Imaging findings X-rays may confirm the diagnosis ,The typical changes seen on X-ray include: Osteoarthrotic changes (joint space narrowing, sclerosis and osteophytosis) III. Management Conservative treatment is almost always successful in uncomplicated osteoarthritis of the neck. ROM exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), and modalities such as heat and cold and cervical pillows are the mainstays of treatment. Therapeutic Modalities They are primarily used to treat the overlying myofascial component of the patient’s pain rather than the primary underlying facet dysfunction. Cryotherapy is thought to be beneficial with deep heat in the form of ultrasound has a growing amount of literature supporting its use in treating myofascial pain. Manual Therapy Manual techniques include joint soft tissue mobilization, neural tissue mobilization, mobilization with movement, myofascial release, muscle energy and strain/counter strain techniques. In the early phase of treatment, mobilization to the unaffected cervical and thoracic hypomobile segments may be effective at relieving tension and pain in the affected levels of arthropathy. Joint and soft tissue mobilization techniques can be performed with more vigor to accelerate the recovery in the subacute and chronic phases. Supine mobilization technique to restore Mobilization with movement to improve extension and left side bending rotation. cervical extension. Therapeutic Exercise Therapeutic exercises for cervical arthropathy as well as most all problems arising from the cervical spine involve a combination of stretching and strengthening of the cervical spine, upper thoracic, shoulder, and scapular muscles as well as core strengthening exercises. The common muscles that need to be strengthened include the deep craniocervical flexor muscles, deep lower cervical extensors, cervical rotators, middle and lower trapezii, latissimus dorsi, and core stabilizers. Strength training may begin with isometric strengthening in positions that do not overload the weak muscle groups. These are then followed by active and resistive strengthening of the affected weak muscles. Stretching of the cervical and shoulder girdle Stretching of the cervical and shoulder girdle muscles (here, the sternocleidomastoid). muscles (here, the upper trapezius). Cervical submaximal isometrics in four planes. A: Flexion. B: Extension. C: Rotation. D: Side bending. Postural Training patients with increased thoracic kyphosis had an increased incidence of neck pain compared to those with decreased kyphosis. Postural changes are commonly due to a change in muscular activation of the upper trapezii, levator scapulae, lower trapezii, latissimus dorsi, and cervical extensors, therefore, a rehabilitation program must address appropriate facilitation and inhibition of these muscle groups. Postural control is essential to maintain the functionality of the muscles and the stability of the craniocervical system. A, Retraction. B, Protraction. Training of the scapular stabilizing muscles. A, Scapular winging. B, Scapula engaged.  Cervical Disk Dysfunction The cervical intervertebral discs allows to support axial loads while providing adequate range of motion (ROM) in multiple planes. It is estimated that 20% of chronic neck pain may be due to cervical intervertebral disc disruption. As in lumbar intervertebral discs, cervical discs are comprised of an outer annulus fibrosus and an inner nucleus pulposus. Repetitive microtrauma or an excessive single load occurrence may cause an annular fissure or herniated pulposus. Disk herniation can happen suddenly or insidiously.  When radial annular tears; the nucleus pulposus may protrude into the spinal canal to compress the spinal cord or spinal nerves. Herniation can cause radiculopathy either by local compression or, more commonly, by focal chemical irritation to the nerve root. disk herniation is less common in the cervical spine than in the lumbar spine. It primarily involves the 30- to 55-year age range and cervical levels of C5–C6, C6–C7, and C4–C5. Evaluation I. History A. Site of pain. the patient may develop axial pain, referral zone pain, radicular pain, radiculopathy, or even myelopathy if the spinal cord is compressed. B. Nature of pain. The pain is usually unilateral and may be felt anywhere in the cervical or scapular area. C. Onset of pain. The pain usually starts in the cervical area and then diminishes and quickly extends in to the scapula, shoulder, upper arm, and then possibly the forearm and hand. II. Physical Examination Observation Inspect for atrophy of neck, periscapular, and upper limb muscles and for postural deficits including forward head posture. Palpation Palpate for muscle spasm or trigger points to evaluate for muscular imbalances. Sensory examination Alterations in sensation should include dermatomes C5-T1. Myotome testing. Delayed muscle weakness during myotome testing. Reflexes may be diminished in radiculopathy and can be tested at the biceps (C5), brachioradialis (C6), triceps (C7), pronator teres (C6-7), and deep finger flexors (C8). peripheral nerve examination (e.g., median vs. radial vs. ulnar) can help distinguish radiculopathy from brachial plexopathy or peripheral neuropathy. Imaging findings MRI is the imaging modality of choice for radiculopathy of nontraumatic onset; in the case of trauma, x-rays or CT scan may be warranted to quickly assess for bony pathology  Electrodiagnostic studies, which include nerve conduction studies (NCS) and electromyography (EMG) is also a useful tool for distinguishing among several suspected pathologies (e.g., radiculopathy vs. plexopathy, concurrent peripheral nerve injury) Special tests Special tests can also be performed to attempt to confirm cervical radiculopathy. 1- Foraminal compression test (Spurling’s test) Reproduces pain with the neck extended and then rotated toward the affected side with axial compression.  The distraction test Shoulder abduction test (Bakody’s sign).  Vertebral artery (cervical quadrant) test. Vertebral artery (cervical quadrant) test. The examiner passively moves the patient’s head and neck into extension and side flexion (1) and then rotation (2), holding for 30 seconds.  III. Management. Therapeutic Modalities The first step in managing cervical radiculopathy is pain control. Relative, but not complete, rest can help reduce motions and positions that provoke pain. Cervical orthoses, such as a soft cervical collar, have been shown to decrease neck pain by increasing proprioception and limiting movement. Modalities such as ice or heat can be prescribed for use in therapy or at home to assist with pain control. Ultrasound as a deep heating modality Transcutaneous electrical nerve stimulation (TENS)  Cervical traction has been used for decades to relieve neural tension (places the patient supine, with the neck flexed to 24° and intermittent traction with 30 lbs of force over 20 minutes; this has been shown to maximize radiologic separation at the C5-C6 and C6-C7 levels Physical Therapy Techniques. These pictures illustrate the equipment and appropriate set up for cervical traction, soft cervical collar. Manual Therapy Manual therapy, when based upon the principles of McKenzie Mechanical Diagnosis and Treatment MDT, is believed to be a more effective means of achieving symptomatic relief than other therapeutic approaches. Manual techniques include joint soft tissue mobilization, myofascial release Neural tissue mobilization to mobilize the peripheral nerves focusing on identifying and freeing up any areas where the nerves may become compressed and irritated within various parts of the body Muscle energy and strain/counter strain techniques , SCS was effective in reducing pain in the upper trapezius of symptomatic subjects.  muscle energy technique An example of Strain and Counterstrain technique Therapeutic Exercise The hallmark of therapy for cervical radiculopathy to be the McKenzie Mechanical Diagnosis and Treatment (MDT) method, which is based upon the concept of centralization. Avoidance of positions and movements that cause peripheralization throughout the day is also very important. A posture of sustained flexion significantly increased peripheral pain and root compression (as measured by H-reflex amplitude). Yet, repeated retractions significantly decreased both the pain and nerve root compression. Overactive muscles are stretched and underactive muscles are strengthened to achieve muscular balance.  Cervicothoracic stabilization helps to correct cervical lordosis, normalize segmental loading, open the neural foramen and the thoracic outlet, and restore muscle balance. Exercises progress from supine to seated to standing, isometric to concentric, and static to dynamic/functional. Isometric exercises of neck flexion, extension, lateral bending, and rotation are performed first. Allowing ergonomic corrections to the workplace, evaluation of daily activities, and training in correct postures is vital to treatment and prevention of future exacerbations. Cervicothoracic Stabilization Exercises : sitting cervical retraction (a), prone scapular retraction (b), prone butterflies (c), supine abduction pull out (d), and standing row with resistance band (e). References David J. Magee, Pathology and Intervention in Musculoskeletal Rehabilitation 2nd ed. 2016 Management of Common Musculoskeletal Disorders 4th Edition,2006 Rehabilitation techniques for sports medicine and athletic training 5th ed. 2011 David J. Magee , Orthopedic Physical Assessments Atlas And Video:Selected Special Testes and Movements 5th ed. 2011 James Wyss, Therapeutic programs for musculoskeletal disorders , 2013