Medicine

1. NECK PAIN

2. DEFINITION:
• Discomfort or more intense forms of pain that
are localized to the cervical region.
• This term generally refers to pain in the
posterior or lateral regions of the neck.

3. The spine has three major
components:
1. The spinal column
(i.e., bones and discs).
2. Supporting structures
(e.g., muscles and ligaments).
3. Neural elements
(i.e., the spinal cord and nerve
roots).

4. The spinal column:
• It is composed of vertebrae that begin in the upper
torso and end at the base of the skull. Seven
vertebrae make up the cervical spine.
• They are smaller in size when compared to other
spinal vertebrae.

5. A typical vertebra consists of:
•Large vertebral body in the front.
•2 strong bony areas (pedicles) connecting the vertebral body &
the posterior arch.
•A posterior arch of bony structures in the back (the spinous process, lamina & the
transverse process).
•The vertebral bodies support 80% of all of the loads applied to the spine.
•Its main purpose is to protect the spinal.

6. Intervertebral discs:
The vertebrae are connected in the front of the spine by IVD. IVD
make up ¼ of the spinal column's length.
 Discs are not vascular & depend on the end plates to diffuse
nutrients.
 Discs help to support the spine & allow some vertebral motion
(ext & flex). Individual disc movement is very limited – however
considerable motion is possible when several discs combine
forces.
 There are no discs between the Atlas (C1), Axis (C2), and
Coccyx.

7.  IVD are strong tissues, filled with gel. Composed of an
annulus fibrosus & a nucleus pulposus.
 The cartilaginous layers of the end plates anchor the
discs in place.
 The intervertebral discs are fibrocartilaginous cushions
serving as the spine's shock absorbing system, which
protect the vertebrae & other structures (i.e. nerves).

8. Supporting structures:
A complex system of ligaments, tendons, and muscles
help to support and stabilize the cervical spine.

9. Ligaments:
Ligaments (which are
comparable to thick
rubber bands) work
to prevent excessive
movement that
could result in
serious injury
(they provide
stability to the
spine).

10. Ligamentum Nuchae
(fibrous membrane)

11. Atlas and Axis Ligament Systems
The Atlas (C1) & Axis (C2) are different from the
other spinal vertebrae. The upper cervical
ligament system is especially important in
stabilizing the UCS from the skull to C2.
1. Occipitoatlantal Ligament Complex.(4)
2. Occipitoaxial Ligament Complex.(4)
3. Altantoaxial Ligament Complex.(4)
4. Cruciate Ligament Complex.

12. Muscles:
• They help to provide spinal balance and
stability, and enable movement.
• There are different types of muscle:
forward flexors, lateral flexors, rotators,
and extensors.
Types of Vertebral Muscles: General Location:
Forward flexors Anterior
Lateral flexors Lateral
Rotators Lateral
Extensors Posterior

13. Muscles of the Posterior Cervical and
Upper Thoracic Spine
Semispinalis Capitus
(head rotation/pulls backward)
Iliocostalis Cervicis
(extends Cv)
Longissimus Cervicus
(extends Cv)
Longissimus Capitus
(head rotation/pulls backward)
Longissimus Thoracis
(ext./lat. Flex. vert column, rib rotation)
Iliocostalis Thoracis
(ext./lat. flexion vert column, rib rotation)
Semispinalis Thoracis
(ext/rotates vert column)

14. Spinal Cord and Cervical Nerve Roots :
There are 8 pairs of cervical nerves.
The PNS is the complex system of nerves that
branch off from the spinal nerve roots.
The cervical nerves control many bodily
functions and sensory activities.
C1: Head and neck C5: Wrist extensors
C2: Head and neck C6: Wrist extensors
C3: Diaphragm C7: Triceps
C4: Upper body muscles C8: Hands
(e.g. Deltoids, Biceps)

15. • The spinal cord is surrounded
by spinal fluid (CSF) and by
several layers of protective
structures, including the dura
mater, the strongest,
outermost layer.

16. Vascular System of the Spine
Arteries Supplying Spinal
Column:
 Vertebral
 Basilar
 Carotid
Veins Supplying Spinal
Column:
 Internal Jugular
 External Jugular
 Superior Vena Cava

17. How the Spinal Column Should Look?
 Posterior aspect
-> should be perfectly
straight, with no lateral
curves.
 Sagittal view
-> should be inward curves
(lordosis) at the cervical &
lumbar levels  outward
curve (kyphosis) at the
thoracic level.
 These curves allow the head
to position over the pelvis in
a sitting & standing
position, while allowing for
load bearing and shock
absorption in the spine.
20 to 40˚

18. Facet Joints:(Zygapophyseal or Apophyseal Joints)
 Are located at the back of the
spine (posterior).
 Each vertebra has 2 sets of facet
joints.
 One pair faces upward (superior
articular facet) & one downward
(inferior articular facet).
 There is one joint on each side (rt &
lt).
 They are synovial hinge–like
joints (surrounded by a capsule
of connective tissue, produces a
fluid to nourish & lubricate the
joint & there surfaces are coated
with cartilage allowing joints to
move or glide smoothly
[articulate] against each other).

19.  They allow flexion (bend
forward), extension
(bend backward) and
twisting motion.
 Certain types of
movement are restricted.
 The spine is made more
stable due to the
interlocking nature to
adjacent vertebrae.

20. ROM of the neck:
 The neck has a significant amount of motion (e.g., rotate
side to side, bend forward and backward).
 Flexion & extension  mainly at occipito-atlantoid j.
may extends throughout cervical spine.
 Lateral flexion  throughout cervical spine.
 Rotation  mainly at atlanto-axial j.
may extends throughout cervical spine.
EXTENSION:
55 degree.
ROTATION:
30 degree rotation
LATERAL
FLEXION:
40 degree.
FLEXION:
Able to touch
chest with chin.

21. Neck Pain
 Neck pain may result from abnormalities in the soft
tissues—the muscles, ligaments, and nerves—as well
as in bones and joints of the spine.
 The most common causes of neck pain are soft-tissue
abnormalities due to injury or prolonged wear and
tear.
 In rare instances, infection or tumors may cause neck
pain.
 In some people, neck problems may be the source of
pain in the upper back, shoulders, or arms.

22. Cause:
Intrinsic causes:
 Deformities:
 Infantile torticilis.
 Infections of bone:
 TB of cervical spine.
 Pyogenic infection of cervical
spine.
 Tumours:
 Benign & malignant tumours
in relation to cervical spine &
nerve roots.
 Psychogenic.
 Arthritis of spinal joints:
 RA.
 AS.
 OA of cervical spine( cervical
spondylosis).
 Mechanical derangement:
 Prolapsed cervical disc.
 Cervical spondylolithesis.
 Whiplash injury.
 Cervical spine fracture.
 Neck muscle strain.
 Neck sprain.

23. Extrensic causes:
• Referred pain:
• Ear.
• Throat.
• Brachial plexus.
• Angina (pain extends to
neck).
• Aortic aneurysm.
• Meningismus.

24. Cervical Disc Disease:
• Most common site C5-6 & C6-7.
• Cause:
– Trauma is a predisposing factor.
• Pathology:
– Disc bulge: generalized symmetric extension of the disc margin.
– Disc protrusion: herniation of nuclear material through a defect in annulus.
– Extrusion: herniation of nuclear material
resulting in an anterior extradural mass
attached to the nucleus of origin(pedicle).
– Disc sequestration:
separation of material from the disc.
Protrusion
Extrusion Sequestration

25. • Clinical features:
– Radicular pain with decreased cervical range of motion
(ROM).
– Discogenic pain without nerve root involvement:
decreased cervical ROM, normal neurologic examination &
possible pain exacerbation with axial compression.
– Myofascial tender or trigger points commonly are
palpable.
– Tenderness with posteroanterior mobilization may suggest
disc pathology.

27.  Investigations:
 PXR -> narrowing of disc space.
 MRI -> modality of choice.
 Electrodiagnostic studies .
TREATMENT:
1. Physical Therapy
2. Surgical Intervention
3. MEDICATION
○ NSAIDs are 1st line of R for most cervical conditions.
○ Muscle relaxants to potentiate the NSAID analgesic
effect & not necessarily to control muscle spasm.
○ Oral corticosteroids treat inflammatory cervical
radiculopathy.
Sagittal MRI
demonstrating cervical
intervertebral disc
protrusions at C3-C4 and
C7-T1.

28. Cervical Spondylosis:
 Chronic degeneration of the cervical spine that affects the
vertebral bodies, IVD (disk herniation and spur formation), facet
joints, longitudinal ligaments, ligamentum flavum & spinal canal
contents(nerve roots and/or spinal cord).
 Pathology:
 IVD lose hydration & elasticity with age -> cracks and fissures.
 Ligaments lose their elastic properties -> develop traction spurs.
 Disk collapses (biomechanical incompetence) -> annulus bulge
outward.
 Disk space narrows, annulus bulges & facets override
-> increases motion at that spinal segment & hastens the damage to the
disk.
-> cross-sectional area of the canal is narrowed.
 Acute disk herniation may complicate chronic spondylotic changes.

30.  Clinical features:
 40-60 years of age.
 Examination:
 Spurling sign - Radicular pain exacerbated by extension and
lateral bending of the neck toward the side of the lesion.
 Lhermitte sign - This generalized electrical shock sensation
with neck extension.
 Cervical pain with decreased ROM in the cervical spine.
 Radiculopathy .
 Distal weakness.
 Increased reflexes in the lower extremities & upper
extremities below the level of the lesion.
 Extensor planter reflex & Hoffman sign in severe
myelopathy.

31.  Investigations:
 PXR ->
facet joints, the foramen,
intervertebral disk spaces, and
osteophyte formation.
 Myelography + CT ->
to assess spinal and foraminal
stenosis. [INVASIVE]
 CT with or without intrathecal
dye ->
to estimate the diameter of the
canal, small lateral osteophytes
& calcific opacities in the middle
of the vertebral body.
 MRI -> modality of choice.
 Electrodiagnostic studies .

32.  TREATMENT:
1. Physical Therapy.
2. Surgical Intervention.
3. Injection: Cervical, zygapophyseal, intra-
articular steroid injection
4. MEDICATION:
○ NSAIDs are 1st line of R for most cervical
conditions.
○ Muscle relaxants to control muscle spasm.
○ Oral corticosteroids treat inflammatory
cervical radiculopathy.

33. Cervical Sprain and Strain:
One cause of cervical strain is termed
cervical acceleration-deceleration injury
(whiplash injury).
Causes:
 Motor vehicle accidents, lifting or pulling heavy
objects, awkward sleeping positions, unusual
upper-extremity work & prolonged static
positions.
 Repetitive or abnormal postures may contribute
to cervical sprains and strains.

34.  Pathology:
 Cervical strain is produced by an overload injury to the muscle-
tendon unit because of excessive forces on the cervical spine.
->Elongation & tearing of muscles or ligaments.
->Secondary edema, hemorrhage, and inflammation may occur.
 Clinical features:
 C/O:
 Neck pain & headache.
 Difficulty sleeping, disturbed concentration & memory due to
pain.
 Neurologic symptoms: weakness or heaviness in the
arms, numbness & paresthesia.
 Examination:
 stiffness of the neck with decreased active & passive ROM.
 spasm tightness, muscle hardness.

35.  Treatment:
1. Physical therapy.
2. Traction, manipulation or acupuncture.
3. Injection (chronic, persistent neck pain). Types
of injection include epidural, selective nerve
root, or facet block injections.
4. Percutaneous radiofrequency neurotomy of
medial branch nerve to facet joint is effective
for chronic neck pain due to cervical
zygapophysial joint pain.
5. MEDICATION:
○ NSAIDs are 1st line of R for most cervical conditions.
○ Muscle relaxants to control muscle spasm.
○ Oral corticosteroids.
Full recovery within weeks

36. Cervical sublaxation & dislocation:
• Spontaneous or 2ry to injury.
• Types:
1. Cong. failure of fusion of odontoid body with axis
vertebra.
2. Inflammatory softening of trans lig of atlas.
3. Instability dt previous injury or RA.
Displacement
of atlas with
dens
Displacement of atlas
on axis
Sublaxation
of v over 1
below

37.  Clinical features:
 Discomfort stiffness
& muscle spasm.
 Radiology:
 Displacment.
Treatment:
 According to cause:
Traction or plaster collar
or operative fusion.

39. Tumours in relation to Cx spine:
 Site:
1. In the spinal Column.
2. In the meninges or rarely spinal cord.
3. In the fibrous components of PN (neurofibroma).
4. In adjacent soft tissue.
 Type:
 Malignant > benign.
 Usually metastatic.
 Examples:
 Meningioma -> uncommon to compress the cord.
 Neurofibroma in IV foramen -> cord compression.
 Clinical features:
 Of compression on CORD, interference with BRACHIAL PLEXUS or
local destruction & collapse.

40. Ankylosing spondylitis:
 It creeps up the spine from below.
 Cause:
 Unknown.
 Pathology:
 Begins with SIJ usually extends upwards to involve lumber, thoracic &
cervical spine, in severe cases hip or shoulder involvement.
 Articular cart., synovium & lig. Show ch. Infl changes & then
ossification.
 Clinical features:
 Men, 16-25 yrs.
 Aching pain in low back with increasing stiffness then extends
upwards to neck.
 Treatment:
 Patient education.
 Exercise.
 Support cervical spine by plastic collar.

41. Rheumatoid Artheritis:
 It is chronic infl of joints associated with mild
constitutional symptoms. Usually affected in
rheumatoid polyartheritis, especially in sero –ve
disease.
 Cause:
 Unknown. Maybe autoimmune or infection.
 Importance:
 IVD destruction leads to gradual forward sublaxation.
 Risk of atlanto-axial sublaxation dt softening in transverse
lig of atlas.
 Radiological:
1-Errosions of IV joints. 2-Sublaxation.
 Treatment:
 Support cervical spine by plastic collar or in some cases
local IV fusion.
Diagnosis:
1. Simultaneous
involvment of
other joints.
2. Raised ESR.
3. RF +ve.

42. TB of cervical spine
• Less common than in thoracic spine &
lumbar region.
• Pathology:

43.  Clinical features:
 Child, & young adults.
 Pain in neck and occiput, aggravated by motion.
 + 1 of following: diff of
swallowing, abcess, sinus, neurological sympt. from cord
dysfunction (UL before LL)
 On examination:
○ Cervical muscle spasm. Prominent 1 or more spinal process.
○ Local tenderness on deep palpation over spinal process. Limited
painful neck ROM.
 Investigations:
 ESR -> raised. Mantoux test: +ve. Tb bacilli in pus.
 Radiological: 1-Dec disc space. 2-Bone destruction.
3-Abscess shadow.
 Treatment:
 Principle R: Antibacterial therapy.
 Local R: support Cv spine (plaster of Paris or plastic collar.
 Operative R: drain abscess, decompress spinal
Diagnosis:
1. History(contact or septic focus).
2. Muscle spasm with limited ROM.
3. Radiological findings.

44. Pyogenic infection(Pyogenic cervical spondylosis):
 Uncommon in cervical vertebrae or IVD.
 Cause:
 staph., strept., pneumococci & less commonly salmonella or
brucella.
 Pathology:
 As TB.
 Clinical features:
 Acute or subacute with fever.
 As TB but more rapid course .
 Investigations:
 ESR -> raised. PNL-> raised
 Radiological: 1-Dec disc space. 2-Bone destruction.
3-Abscess shadow. 4-osteoperosis.
 Treatment:
 Principle R: Proper a antibaiotic therapy.
 Local R: support Cv spine (plaster of Paris or plastic collar.
 Operative R: spontaneous fusion usually makes it unnecessary.

45. Infantile torticilis
 Tilting & rotation of head by contarctures of
sternomastoid muscle of 1 side.
 Causes:
 ?? Interference in blood supply of sternomastoid muscle, dt
injury during birth.
 Pathology:
 Muscle fibers replaced by fibrous tissue.
 Clinical features:
 Child, 6m-3yrs, head held to 1 side.
 On examination:
○ Contracted sternomastoid muscle (cord like).
○ In long standing cases: Retarded facial development on same side
(facial asymmetry).
 Treatment:
 In sternomastoid pseudo-tumour stage: Stretching of
muscle.
 In established stage: Surgical division with postoperative
Diagnosis:
1. History.
2. Cord like.
3. Facial asymmetry.

47. THANK YOU.

48. Examination of the neck:

49. ROM
 Fix the head with one hand while you examine neck
 Inspection
 Note the normal concavity of cervical spine
 Identify Transverse process of C7
 Observe Trapezius and Sternomastoid muscles
 Palpation
 Feel each spinous process looking for focal areas of tenderness
 Joint
○ Feel for crepitus during passive motion
 Para spinal muscles
 Range of motion
 Active
○ Touch chin for flexion
○ Throw head back for extension
○ Touch each shoulder with ears for lateral flexion
○ Touch each shoulder with chin for lateral rotation
 Passive
○ Feel for crepitus during passive motion
 Normal:
 30 degree rotation, able to touch chest with chin, 55 degree extension
and 40 degree lateral bend.

50. CERVICAL MUSCLES FUNCTION NERVE
Sternocleidomastoid
Extends & rotates head, flexes vertebral
column
C2, C3
Scalenus Flexes & rotates neck Lower cervical
Spinalis Cervicis Extends & rotates head Middle/lower cervical
Spinalis Capitus Extends & rotates head Middle/lower cervical
Semispinalis Cervicis Extends & rotates vertebral column Middle/lower cervical
Semispinalis Capitus Rotates head & pulls backward C1 – C5
Splenius Cervicis Extends vertebral column Middle/lower cervical
Longus Colli Cervicis Flexes cervical vertebrae C2 – C7
Longus Capitus Flexes head C1 – C3
Rectus Capitus Anterior Flexes head C2, C3
Rectus Capitus Lateralis Bends head laterally C2, C3
Iliocostalis Cervicis Extends cervical vertebrae Middle/lower cervical
Longissimus Cervicis Extends cervical vertebrae Middle/lower cervical
Longissimus Capitus Rotates head & pulls backward Middle/lower cervical
Rectus Capitus Posterior Major Extends & rotates head Suboccipital
Rectus Capitus Posterior Minor Extends head Suboccipital
Obliquus Capitus Inferior Rotates atlas Suboccipital
Obliquus Capitus Superior Extends & bends head laterally Suboccipital
Muscles of the Spinal Column

51. • However, because it is less protected than the
rest of the spine, the neck can be vulnerable
to injury and disorders that produce pain and
restrict motion.