NECK triangle is covered by the prevertebral layer of cervical fascia; and

from superior to inferior consists of the splenius capitis, levator

The neck is a tube providing continuity from the head to the trunk.
scapulae, and the posterior, middle, and anterior scalene muscles.
It extends anteriorly from the lower border of the mandible to the
VERTEBRAL COLUMN
upper surface of the manubrium of the sternum, and posteriorly
The major bones of the back are the 33 vertebrae. The number and
from the superior nuchal line on the occipital bone of the skull to
specific characteristics of the vertebrae vary depending on the body
the intervertebral disc between the CVII and TI vertebrae. Within
region with which they are associated. There are seven cervical,
the tube, four compartments provide longitudinal organization
twelve thoracic, five lumbar, five sacral, and three to four coccygeal
The visceral compartment is anterior and contains parts of the
vertebrae. The sacral vertebrae fuse into a single bony element, the
digestive and respiratory systems, and several endocrine glands.
sacrum. The coccygeal vertebrae are rudimentary in structure, vary
The vertebral compartment is posterior and contains the cervical
in number from three to four, and often fuse into a single coccyx.
vertebrae, spinal cord, cervical nerves, and muscles associated with
Typical vertebra: consists of a vertebral body and a vertebral arch.
the vertebral column.
The vertebral body is anterior and is the major weight bearing
The two vascular compartments, one on each side, are lateral and
component of the bone. It increases in size from vertebra CII to
contain the major blood vessels and the vagus nerve [X].
vertebra LV. Fibrocartilaginous intervertebral discs separate the
All these compartments are contained within unique layers of
vertebral bodies of adjacent vertebrae. The vertebral arch is firmly
cervical fascia.
anchored to the posterior surface of the vertebral body by two
The boundaries of the anterior triangle anterior border of the
pedicles, which form the lateral pillars of the vertebral arch. The
sternocleidomastoid muscle laterally, the inferior border of the
roof of the vertebral arch is formed by right and left laminae, which
mandible superiorly, and the midline of the neck medially.
fuse at the midline. The vertebral arches of the vertebrae are aligned
The boundaries of the posterior triangle anteriorly by the
to form the lateral and posterior walls of the vertebral canal, which
posterior edge of the sternocleidomastoid muscle, posteriorly by the
extends from the first cervical vertebra (CI) to the last sacral
anterior edge of the trapezius muscle, basally by the middle one-
vertebra (vertebra SV). This bony canal contains the spinal cord and
third of the clavicle, and apically by the occipital bone just posterior
its protective membranes, together with blood vessels, connective
to the mastoid process where the attachments of the trapezius and
tissue, fat, and proximal parts of spinal nerves. The vertebral arch of
sternocleidomastoid come together. The roof of the posterior
a typical vertebra has a number of characteristic projections, which
triangle consists of an investing layer of cervical fascia that
serve as:
surrounds the sternocleidomastoid and trapezius muscles as it
• Attachments for muscles and ligaments,
passes through the region. The muscular floor of the posterior
• Levers for the action of muscles, and
• Sites of articulation with adjacent vertebrae.
A spinous process projects posteriorly and generally inferiorly from
the roof of the vertebral arch. On each side of the vertebral arch, a
transverse process extends laterally from the region where a lamina
meets a pedicle. From the same region, a superior articular process
and an inferior articular process articulate with similar processes on
adjacent vertebrae. Each vertebra also contains rib elements. In the
thorax, these costal elements are large and form ribs, which
articulate with the vertebral bodies and transverse processes. In all
other regions, these rib elements are small and are incorporated into
the transverse processes. Occasionally, they develop into ribs in
regions other than the thorax, usually in the lower cervical and
upper lumbar regions.
Vertebral canal:-
The spinal cord lies within a bony canal formed by adjacent
vertebrae and soft tissue elements (the vertebral canal)
• The anterior wall is formed by the vertebral bodies of the
vertebrae, intervertebral discs, and associated ligaments.
• The lateral walls and roof are formed by the vertebral arches and
ligaments.
Spinal nerves:-
The 31 pairs of spinal nerves are segmental in distribution and
emerge from the vertebral canal between the pedicles of adjacent
vertebrae. There are eight pairs of cervical nerves (Cl to C8), twelve
thoracic (Tl to Tl2), five lumbar (Ll to 15), five sacral (S l to S5),
and one coccygeal (Co). Each nerve is attached to the spinal cord
by a posterior root and an anterior root. After exiting the vertebral
canal, each spinal nerve branches into:
• A posterior ramus-collectively, the small posterior rami innervate
the back; and
• An anterior ramus-the much larger anterior rami innervate most
other regions of the body except the head, which is innervated
predominantly, but not exclusively, by cranial nerves. The anterior
rami form the major somatic plexuses (cervical, brachial, lumbar,
and sacral) of the body. Major visceral components of the PNS
(sympathetic trunk and prevertebral plexus) of the body are also
associated mainly with the anterior rami of spinal nerves.
In the adult, the spinal cord typically ends between vertebrae LI and
LII, although it can end as high as vertebra TXII and as low as the
disc between vertebrae LII and LIII. Spinal nerves originate from
the spinal cord at increasingly oblique angles from vertebrae CI to
Co, and the nerve roots pass in the vertebral canal for increasingly
longer distances. Their spinal cord level of origin therefore becomes
increasingly dissociated from their vertebral column level of exit.
This is particularly evident for lumbar and sacral spinal nerves.
JOINTS:-
The two major types of joints between vertebrae are:
• Symphyses between vertebral bodies,
• Synovial joints between articular processes.
A typical vertebra has a total of six joints with adjacent vertebrae:
four synovial joints (two above and two below) and two symphyses
(one above and one below). Each symphysis includes an
intervertebral disc. Although the movement between any two
vertebrae is limited, the summation of movement among all
vertebrae results in a large range of movement by the vertebral
column. Movements by the vertebral column include flexion,
extension, lateral flexion, rotation, and circumduction. Movements
by vertebrae in a specific region (cervical, thoracic, and lumbar) are
determined by the shape and orientation of joint surfaces on the
articular processes and on the vertebral bodies.
Symphyses between vertebral bodies (intervertebral discs):-
The symphysis between adjacent vertebral bodies is formed by a
layer of hyaline cartilage on each vertebral body and an
intervertebral disc, which lies between the layers. The intervertebral
disc consists of an outer annulus fibrosus, which surrounds a central
nucleus pulposus .
• The anulus fibrosus consists o f an outer ring of collagen
surrounding a wider zone of fibrocartilage arranged in a lamellar
configuration. This arrangement of fibers limits rotation between
vertebrae.
• The nucleus pulposus fills the centre of the intervertebral disc, is
gelatinous, and absorbs compression forces between vertebrae.
Joints between vertebral arches (zygapophysial joints):-
The synovial joints between superior and inferior articular
processes on adjacent vertebrae are the zygapophysial joints. A
thin articular capsule attached to the margins of the articular facets
encloses each joint.
In cervical regions, the zygapophysial joints slope inferiorly from
anterior to posterior. This orientation facilitates flexion and
extension. In thoracic regions, the joints are oriented vertically and
limit flexion and extension, but facilitate rotation. In lumbar
regions, the joint surfaces are curved and adjacent processes
interlock, thereby limiting range of movement, though flexion and
extension are still major movements in the lumbar region.
"Uncovertebral" joints:-
The lateral margins of the upper surfaces of typical cervical
vertebrae are elevated into crests or lips termed uncinate processes.
These may articulate with the body of the vertebra above to form
small "uncovertebral" synovial joints.
LIGAMENTS:-
Joints between vertebrae are reinforced and supported by numerous
ligaments, which pass between vertebral bodies and interconnect
components of the vertebral arches.
1) Anterior and posterior longitudinal ligaments
The anterior and posterior longitudinal ligaments are on the anterior
and posterior surfaces of the vertebral bodies and extend along most
of the vertebral column.
The anterior longitudinal ligament is attached superiorly to the
base of the skull and extends inferiorly to attach to the anterior
surface of the sacrum. Along its length it is attached to the vertebral
bodies and intervertebral discs.
The posterior longitudinal ligament is on the posterior surfaces of
the vertebral bodies and lines the anterior surface of the vertebral
canal. Like the anterior longitudinal ligament, it is attached along its
length to the vertebral bodies and intervertebral discs. The upper
part of the posterior longitudinal ligament that connects en to the
intracranial aspect of the base of the skull is termed the tectorial
membrane.
1) Ligamenta flava:-
On each side, pass between the laminae of adjacent vertebrae.
These thin, broad ligaments consist predominantly of elastic tissue
and form part of the posterior surface of the vertebral canal. Each
ligamentum flavum runs between the posterior surfaces of the
lamina on the vertebra below to the anterior surface of the lamina of
the vertebra above. The ligamenta flava resist separation of the
laminae in flexion and assist in extension back to the anatomical
position.
2) Supraspinous ligament and ligamentum nuchae:-
The supraspinous ligament connects and passes along the tips of
the vertebral spinous processes from vertebra CVII to the sacrum.
From vertebra CVII to the skull called the ligamentum nucha is a
triangular, sheet-like structure in the median sagittal plane: The
base of the triangle is attached to the skull. The apex is attached to
the tip of the spinous process of vertebra CVII. The deep side of the
triangle is attached to the posterior tubercle of vertebra CI and the
spinous processes of the other cervical vertebrae. The ligamentum
nuchae supports the head. It resists flexion and facilitates returning
the head to the anatomical position. The broad lateral surfaces and
the posterior edge of the ligament provide attachment for adjacent
muscles.
1) Interspinous ligaments:-
Pass between adjacent vertebral spinous processes. They attach
from the base to the apex of each spinous process and blend with
the supraspinous ligament posteriorly and the ligamenta flava
anteriorly on each side.
BACK M USCULATURE:-
Muscles of the back are organized into superficial, intermediate,
and deep groups. Muscles in the superficial and intermediate
groups are extrinsic muscles because they originate
embryologically from locations other than the back. They are
innervated by anterior rami of spinal nerves:
a) The superficial group consists of muscles related to and
involved in movements of the upper limb they sometimes referred
to as the appendicular group. They attach the superior part of the
appendicular skeleton (clavicle, scapula, and humerus) to the axial
skeleton (skull, ribs, and vertebral column). Muscles in the
superficial group include the trapezius, latissimus dorsi, rhomboid
major and minor, and levator scapulae.
b) The intermediate group consists of muscles attached to
the ribs and may serve a respiratory function. It consist of two thin
muscular sheets in the superior and inferior regions of the back,
immediately deep to the muscles in the superficial group. Fibers
from these two serratus posterior muscles (serratus posterior
superior and serratus posterior inferior) pass obliquely outward
from the vertebral column to attach to the ribs. This positioning
suggests a respiratory function, and at times, these muscles have
been referred to as the respiratory group. Serratus posterior superior
is deep to the rhomboid muscles, whereas serratus posterior inferior
is deep to the latissimus dorsi. Both serratus posterior muscles are
attached to the vertebral column and associated structures medially,
and either descend (the fibers of the serratus posterior superior) or
ascend (the fibers of the serratus posterior inferior) to attach to the
ribs. These two muscles therefore elevate and depress the ribs. The
serratus posterior muscles are innervated by segmental branches of
anterior rami of intercostal nerves. Their vascular supply is
provided by a similar segmental pattern through the intercostal
arteries.
c) Muscles of the deep group are intrinsic muscles because they
develop in the back. They are innervated by posterior rami of spinal
nerves and are directly related to movements of the vertebral
column and head. They extend from the pelvis to the skull They
include:
• The extensors and rotators of the head and neck the splenius
capitis and cervicis (spinotransversales muscles),
• The extensors and rotators of the vertebral column-the erector
spinae and transversospinales,
• The short segmental muscles-the interspinales and
intertransversarii.
The vascular supply to this deep group of muscles is through
branches of the vertebral, deep cervical, occipital, transverse
cervical, posterior intercostal, subcostal, lumbar, and lateral sacral
arteries.
SPINAL CORD:-
The spinal cord extends from the foramen magnum to
approximately the level of the disc between vertebrae LI and LII.
The distal end of the cord (the conus medullaris) is cone shaped. A
fine filament of connective tissue (the pial part of the filum
terminale) continues inferiorly from the apex of the conus
medullaris. The spinal cord is not uniform in diameter along its
length. It has two major swellings or enlargements in regions
associated with the origin of spinal nerves that innervate the upper
and lower limbs. A cervical enlargement occurs in the region
associated with the origins of spinal nerves CS to T l, which
innervate the upper limbs. A lumbosacral enlargement occurs in the
region associated with the origins of spinal nerves L1 to S 3, which
innervate the lower limbs.
Spinal nerves:-
Each spinal nerve is connected to the spinal cord by posterior and
anterior roots:
• The posterior root contains the processes of sensory neurons
carrying information to the CNS-the cell bodies of the sensory
neurons, which are clustered in a spinal ganglion at the distal end of
the posterior root, usually in the intervertebral foramen.
• The anterior root contains motor nerve fibers, which carry signals
away from the CNS-the cell bodies of the primary motor neurons
are in anterior regions of the spinal cord.
Medially, the posterior and anterior roots divide into rootlets, which
attach to the spinal.
A spinal segment is the area of the spinal cord that gives rise to the
posterior and anterior rootlets, which will form a single pair of
spinal nerves. Laterally, the posterior and anterior roots on each
side join to form a spinal nerve.
Each spinal nerve divides, as it emerges from an intervertebral
foramen, into two major branches: a small posterior ramus and a
much larger anterior ramus:
• The posterior rami innervate only intrinsic back muscles and an
associated narrow strip of skin on the back.
• The anterior rami innervate most other skeletal muscles of the
body, including those of the limbs and trunk, and most remaining
areas of the skin, except for certain regions of the head.
CERVICAL SPINE EVALUATION:- History:
A) Routine screening questions. A screening to cover these
should be included routinely if the patient does not address
these activities or postures spontaneously: Activities involving
sustained flexion, reading or driving, Activities involving
cervical extension, hair washing in the hairdresser’s wash
basin or computer work, Effect of carrying loads or carrying a
bag over the shoulder, Activities involving rotation, turning
the body when driving the in reverse and Sleeping postures.
Cervical symptoms are often increased when a firm or very
firm pillow is used, as a result of loss of cervical lordosis or
abnormal pressure placed against the neck or lack of support.
B) Headaches. Problems at the first cervical level cause
headaches in a characteristic pattern at the top of the head. The
second cervical level tends to refer ipsilateral pain retroorbitally
in the temporal region. Lower cervical problems will frequently
refer to the base of the occiput.
C. Determine if neuritis or neuralgia causes pain. It is
Unrelated to activity or trauma. Superficial, stimulating in
quality, or electric. Follows the pattern of Innervation of a
cranial or peripheral nerve.
D. Evaluate upper limb pain. If complaining of upper limb pain,
is it in the pattern of a nerve root or peripheral entrapment?
Physical Examination:
I. Observation: Posture: General alignment, Does the head deviate
from the optimal posture, Function. How willing is the patient
to turn the neck when dressing, undressing, or filling out
paperwork
II. Skin. Neck, shoulder girdle, and upper extremity Colour,
Moisture, Redness or swelling and Scars or blemishes.
III. Palpation The examiner palpates the cervicothoracic spine, the
temporomandibular joint and musculature of the jaw, thoracic
spine and any other relevant areas.
IV. Craniovertebral stability and joint integrity tests: General
compression, reproduction of pain with compression suggests:
An end plate fracture, fracture of the vertebral body, disk
problem or acute arthritis of the zygapophysial joint.
V. General distraction: is applied in the neutral position first and
then in flexion and extension. Reproduction of pain with
distraction suggests: A tear of a spinal ligament, particularly
implicating the tectorial membrane, tear or inflammation of
the annulus fibrosis, n irritated dura.
VI. Joint tests include joint integrity and active and passive
physiologic movements of the cervical spine and other
relevant joints. Joint play (accessory) movements complete the
joint tests.
VII. Muscle Tests: include resistive isometric contractions,
muscle strength, control, and length.
VIII. Neurologic examination: involves :
A) Integrity of the nervous system:
1. Dermatomes/peripheral nerves.
2. Myotomes/peripheral nerves.
 3. Reflex testing: C5–C6—bicepsm C7—triceps.
4. Sensory testing.
B) Mobility of the nervous system:
IX. Special Tests: Carpal tunnel test, Tests for thoracic outlet
syndrome
X. Functional Tests: Swallowing, Breathing.
COMMON DISORDERS
Trauma and Whiplash-Associated Disorders:-
A common clinical presentation of patients with cervical trauma is
the whiplash syndrome. It can result from all types of motor
vehicle accidents. Typical mechanism involves rear-end collision
with neck hyperextension. Injuries include disruptions of the
anterior longitudinal ligament, disk, or articular facet capsule,
muscular strains (sternocleidomastoid, longus colli, scalene),
retropharyngeal hematoma, intraesophageal haemorrhage.
from axial torque. If there is little coupling, lateral flexion will
compress the ipsilateral articular facet joint and distract the
contralateral joint.
Other associated disorders following whiplash injury may include
temporomandibular disorders, whiplash induced headaches
(posttraumatic headache), cord injuries, traumatic brain.
Acute phase begins at the moment of the accident and may last as
long as 2 to 3 weeks. There is generally little pain and fairly free
ROM immediately after the accident, with painful stiffness
gradually developing over 24 to 48 hours. There is a possibility of
fracture, traction injury to the nerve roots, contusion to the spinal
cord, head injury, or tearing of the supporting ligaments of the
upper cervical spine. These conditions cannot be ruled out
definitively without.
Goal:

The extent of damage seen in hyperflexion (head-on collisions) 1. Allow the cervical musculature to rest without becoming
injuries is similar. Injuries include tears of the posterior cervical stiff
musculature, sprains of the ligamentum nuchae and posterior 2. Progress to the subacute phase as rapidly as possible.
longitudinal ligament, articular facet joint disruption, and posterior
Treatment:
intervertebral disk injury with nerve root hemorrhage.
a) soft tissue techniques (e.g., soft tissue mobilization and
Lateral flexion of the cervical spine between C2 and C7 is strictly
strain/ counter strain)
coupled to rotation of the cervical disks. If an external forces
b) Joint mobilization (grades I–II) including specific traction
laterally flex the neck, the structures at risk of injury will
with the intent of pain relief.
be determined by the extent to which coupling occurs. If the force
c) use of heat or ice
simply reproduces physiologic movements, the articular facet joint
capsules on both sides and intervertebral disks will be most at risk
 d) Supported postures at home and in the use of a soft cervical
collar.
e) Active rotation of the cervical and thoracic spine, and upper
limbs within limits of pain to maintain joint ROM.
f) Explanation of the mechanics of the acceleration injury,
including the information that most cases are completely
healed in 4 to 5 weeks.
g) Encourage patient to be as active as possible and should be
rechecked at approximately 1-week intervals.
The exercises are not intended to increase ROM. Consequently,
they are gentle repetition within the pain-free range. Once a
relatively pain-free passive ROM can be achieved, it is important
to have the patient activate the cervical musculature to maintain
motion. Active assisted range of motion can be accomplished with
the patient in the supine position with the clinician supporting the
head and assisting the patient to move.
Subacute Phase: lasts 2 to 10 weeks, the larger muscles have
healed and are no longer swollen or tender. General muscle
guarding will be reduced; muscle pain originally experienced has
gone away but has been replaced by deep aching pain that may be
referred to the head, the interscapular area, or the upper limbs. The
large cervical muscles will no longer feel warm, rubbery, and
swollen. There will be focal areas of intense tenderness in the
sternocleidomastoid, suboccipital, multifidi, and deep anterior
neck muscles. These areas of tenderness may refer pain to the
head, shoulder, or upper limb when palpated. Active ROM will
have increased considerably. The end feel will be capsular muscle
guarding. If the articular facet joints have been injured, there will
be capsular restriction of the neck with limitation of joint play
when tested. The patient should be given a complete neurologic
screening, which in most cases will be negative. The major muscle
groups of the neck should be carefully palpated noting tenderness,
guarding, spasm, or anatomical shortening.
Goal: to restore flexibility to the cervical muscle groups and
articular facet joints, if they are involved.
Mechanical treatment is most effective in the subacute phase
because muscle guarding has subsided, and stretching and
mobilization will be fairly comfortable.
a) Sternocleidomastoid muscles will be shortened, treated by
stretching massage and soft tissue manipulations.
b) Lordosis is a dynamic position and cannot be restored
passively. Strengthening of the multifidi is the best way to
restore cervical lordosis and to stabilize the midcervical
spine. Multifidi strengthening through isometric exercise
should be started as early as possible. The large posterior
neck musculature should be strengthened but not stretched.
c) Sensorimotor training and cervical stabilization should be
emphasized with the purpose of improving the efficiency
and effectiveness of the common movement patterns
The following guidelines are useful in treating the articular facet
joints during the subacute phase:
1. During the acute phase, the patient should be instructed in
active rotation within limits of pain to be done every hour.
2. Joint mobilization in the subacute phase should not be painful to
the patient or cause lingering discomfort after treatment.
3. Hypermobile areas should be identified and mobilization
avoided.
4. Gross passive stretching of the head and neck should be avoided
because of the possibility of overstretching hypermobile
segments. ROM should be restored by segmental joint
mobilization and gentle AROM exercises.
Chronic Phase: begins when the acute healing process is over.
The large muscle groups will have completely healed, but they
may be shortened and fibrotic. The longus colli may remains in
chronic spasm and be acutely tender to palpation. The longus colli
exerts a force that gradually flattens the cervical spine and may
lead eventually to cervical instability. The multifidi at the
C5 or C6 segment will be in constant contraction and may feel
rubbery and inflamed as a result of overwork, in an attempt to
stabilize the lower cervical spine.
The patient will complain of symptoms, which are consistent with
irritation of the deep somatic structures. The pain will be deep,
aching, vague, and often referred to the head, shoulders,
interscapular area, or upper limb. It is common to have a headache
in the suboccipital area. The patient will have hypertrophy of the
sternocleidomastoid muscles. The patient often have a forward-
head posture with protraction of the scapula and superior
angulation of the clavicles. Active range of motion of the neck
may be limited. Active and passive ranges of motion will be
approximately the same. Neurologic testing will generally be
negative, but there is the possibility of nerve-root irritation or
thoracic outlet syndrome. There may be tenderness and spasm of
the suboccipital muscles.
Treatment: Muscles will respond well to gentle repetitive
stretching, but attempts to overstretch will result in increased
swelling and scarring. Restore cervical lordosis by mobilization
into extension and specific segmental strengthening of the
multifidus at the hypermobile segments. Normal muscle balance
restored by stretching the large anterior neck musculature,
retraining motor control of the deep cervical flexors, and
strengthening of the deep the posterior neck musculature.
Cervical Zygapophyseal Joint Pain:-
Cervical zygapophyseal (articular facet) joints, particularly in the
upper cervical spine, where they can cause local neck pain and
pain referred to the head. Joints between C3–C7 can refer pain to
the supraspinous process and into the arm. The patient may
experience headaches. The atlanto-axial joint involvement may
also cause ear pain. Cervical zygapophyseal joint pain is typically
unilateral and described as a dull ache. Limited range of cervical
motion owing to soft tissue dysfunction and restrictions either
diffusely or segmentally will be noticed by the patient or can be
confirmed easily on examination. Palpation just lateral to the
midline often indicates regional soft tissue changes. Pain can be
referred into the craniovertebral or interscapular regions and may
mimic cervical disk disease or shoulder pain. Osteoarthrotic
changes (joint space narrowing, sclerosis and osteophytosis) may
or may not be evident on plain radiography.
TREATMENT: Segmental articular restrictions generally
respond well to manual therapy mobilization techniques unless
there is excessive degeneration of the bony structures. Early on,
grades I and II are used to relieve pain to the involved segments
and grades III–V to hypomobile segments above and below.
Specific traction may be performed at the involved segment(s).
Other treatments may include soft tissue mobilization, strain-
counter strain and muscle energy or postisometric muscle
relaxation therapy for ROM and pain reduction. As the patient’s
condition improves, progress graded traction to the irritable joints
and graded II–V mobilization to the hypomobile segments. Self
articulations (mobilization) exercises are a useful adjunct to
treatment as well. as self-resisted strengthening, active ROM
exercises and cardiovascular conditioning.
Cervical Disk Dysfunction:-
May cause symptoms similar to those of articular facet
involvement and/or neurologic signs cause by root or cord
compression. Disk herniation typically occurs in a disk that has
had some pre existing degeneration. It primarily involves the
cervical levels of C5–C6, C6–C7, and C4–C5. When radial
annular tears coalesce; the nucleus pulposus may protrude into the
spinal canal to compress the spinal cord or spinal nerves. Although
the herniated disk may cause local nerve root damage of the spinal
cord, it may also just cause pain with no neurologic symptoms.
Disk herniation can happen suddenly or insidiously. Repetitive
micro-trauma or an excessive single load occurrence may cause an
annular fissure or herniated pulposus. Herniation can cause
radiculopathy either by local compression or, more commonly, by
focal chemical irritation to the nerve root. This can cause
symptoms and nerve damage. Depending on the size and location
of the lesions and the significance of any inflammation, or
compression of local nervous or vascular tissue, the patient may
develop axial pain, referral zone pain, radicular pain,
radiculopathy, or even myelopathy if the spinal cord is
compressed. Chronic radiculopathy may develop because of
progressive narrowing of the intervertebral foramen over time.
Abnormal posture or trauma aggravates the symptoms and cause
exacerbations. The pain is usually unilateral and may be felt
anywhere in the cervical or scapular area. 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. Patients with a herniated nucleus without radiculopathy
will complain of increased pain with cervical extension or flexion
and will usually experience relief with traction.
Radiculopathy will include radicular pain, paresthesia, and
weakness in the appropriate myotome, as well as associated
changes in reflexes. In the acute stages, disk dysfunction can
manifest with painful limitation of active ROM in all planes, pain
on cough or sneeze, and painful cervical muscle contraction due to
compression loading. The symptoms may be worsened by the
Valsalva maneuver, with positional foraminal compression
maneuvers and with cervical extension and rotation. The pain
maybe relieved with cervical distraction.
TREATMENT:- ULTT following treatment to the intervertebral joint, one may
choose to begin exercises to increase the mobility of this structure.
In radiculopathy, early treatment involves resting the neck, which
Mild, non-progressive cases of cervical myelopathy can be treated
is achieved through education about proper resting positions to
similarly to radiculopathy. Gentle flexion exercises may help to
unload the compressive forces on the cervical spine. Avoid
open up the spinal canal.
aggravating activities such as straining, bending or lifting. Stool
softeners decreases the straining associated with bowel Degenerative Joint Disease/Cervical Spondylosis:-
movements. A soft collar can help restrain the patient from
Is a chronic and progressive degeneration of the cervical articular
aggravating movement and may give some support to the neck.
facet joints and/or the intervertebral disk. The cause is unknown
Therapeutic modalities may be useful to help alleviate the
but may be accelerated by trauma, overuse, or genetic
inflammatory response and decrease muscle spasms.
predisposition. It is associated with heavy lifting, smoking, diving
Diaphragmatic breathing exercises encourages an optimal
and driving. It preferentially affects the C5–C7 vertebrae and
breathing pattern and unloads the cervical spine. Soft tissue
affects the intervertebral disk and the facet joints. Degenerative
mobilization and joint mobilization (grade I or II) may be used
joint disease must be considered a normal aging process. In many
with the intent of pain relief. Pain may also be relieved with
cases, this degenerative process remains asymptomatic, but in
specific traction at the involved segment performed in the
others, symptoms develop spontaneously or after postures
position of comfort. After a few days or weeks, gentle range-of-
involving sustained extension or flexion. Lateral canal stenosis,
motion (avoiding excessive extension or rotation) can be
which is frequently referred to as cervical spondylosis, is the
instituted. Joint mobilization may be progressed to grades III-V
second most common cause of cervical radiculopathy and may
to appropriate cervical and upper thoracic segments. More
cause symptoms of neck pain, shoulder pain, radiating pain in the
vigorous exercises, including strengthening, stretching,
arm, numbness in the extremity, or muscle weakness. These
cardiovascular conditioning and functional activities, are
symptoms occur as a result of the degenerative process, which in
instituted over a period of 2-8, week as tolerated. Stability testing
part involves the development of hypertrophic spurs along the
at the affected segment may detect increased motion because of
margins of the disk. This spur formation is often associated with
the disk’s inability to control transitional forces in the spine. This
hypertrophy of the ligamentum flavum. If the spurring continues,
impairment must be addressed with a progression of stabilization
it eventually compresses the contents of the spinal canal. If it
exercises. With a chronic cervical nerve root condition, it often
encroaches on the spinal canal, it is called central (or spinal)
necessary to assess neuromeningeal extensibility and to use ULTT
stenosis as opposed to narrowing of the intervertebral foramina as
as a form of treatment. For example, if there is no change in the
in lateral stenosis. Central stenosis can lead to cervical
myelopathy, a condition of ischemic compression of the spinal because almost everyone older than 50 years of age has some
evidence of it. It can be demonstrated on plain x-ray, computed tomography (CT), or
canal can result in radiculopathy. In most people, degenerative magnetic resonance imaging
joint disease is a painless process and occurs without consequence. (MRI).30 The clinical picture varies considerably. Hypomobility of the lower cervical spine is
common in all cases. This may
One of the paradoxes of degenerative joint disease is that the progress to the stage at which loss of mobility interferes with
patient may have lateral stenosis for many years without daily activities; loss of extension and rotation make it difficulty
symptoms and then suddenly begin to have neurologic signs and to turn the head while driving. The patient will generally have
a forward-head posture. Often stiffness of the cervicothoracic
symptoms. After treatment with traction or passage of time, these region causes the development of a kyphotic (dowager’s hump)
signs or symptoms may resolve. Clearly the bony changes have deformity. The pronounced kyphosis of the upper thoracic
spine may cause the midcervical spine to increase its ROM.
not improved, so what accounts for the sudden appearance and
There will be capsular restriction of the lower cervical spine
disappearance of symptoms? Pain from compression of nerve (limited active rotation and lateral flexion as well as extension) with possible ankylosis. The
roots is complex. In an experimental study, ligatures were placed mobility of the upper cervical spine is generally quite good.
The stiff lower cervical joints may be a source of pain, which
around nerve roots is often described as a burning pain across the base of the neck,
at the time of surgery so that pressure could be applied after the or the mobile midcervical joints may become symptomatic, the
typical complaint being central, deep midcervical pain. 261 Pain
surgical incision had healed. When pressure was applied to the
maybe experienced in the midcervical region. 38 Pain is worse
healthy nerve roots, there were no symptoms of pain or in the morning and is improved with moderate activity. The
paresthesia. When pressure was applied to injured nerve roots, area over the cervical facet joints may be tender to palpation.
Compression testing worsens symptoms, whereas distraction
there was a gradual onset of anesthesia, diminished reflex, and may relieve them (Figs. 19-17 and 19-18). In most patients
eventually motor weakness. If, however, the nerve root was these symptoms and signs stabilize and lessen in time, as the
spine becomes stiffer (but more stable). 30
ischemic, very light pressure by the ligature produced immediate
There may be diminished reflex, motor weakness, anesthesia, or muscle atrophy owing to
pain and paresthesia in the arm.275,276 A model of nerveroot irritation then might be that osteophyte irritation and
some unusual activity, compression of the nerve roots.
probably involving extension or sidebending of the neck causes TREATMENT
the nerve root to swell. With impingement of the blood supply Conservative treatment is almost always successful in uncomplicated osteoarthritis of the
to the nerve root, it becomes extremely sensitive. When pressure is removed by traction or neck. ROM exercises, nonsteroidal
proper positioning, swelling of anti-inflammatory drugs (NSAIDs), and modalities such as heat
the nerve root diminishes, and the symptoms disappear. This and cold and cervical pillows are the mainstays of treatment.
would also seem to explain some of the complexities of peripheral entrapments. If the nerve Many patients will respond well to cervical traction. In the case
root has slight compression and of nerve root pain positional traction is useful. The head is positioned in flexion and
is ischemic, the nerve would be considerably more sensitive to sidebending away from the painful side
pressure at the shoulder, wrist, or carpal tunnel. (Fig. 19-59) with reduction of symptoms being the best indicator of proper position.
EVALUATION Mobilization of the hypomobile
The diagnosis of degenerative spine disease is straight forward, segments may reduce some of the mechanical forces on the
involved segments of the lower cervical spine and the hypomobile segments of the kyphotic
posture of the upper thoracic
spine when present. Self-mobilization exercises are a useful
adjunct to this treatment (Fig. 19-60). Segmental stabilization
techniques are helpful for the hypermobile segments often
found in the midcervical spine.
With a long-standing forward head posture, there is often
an associated poking chin with posterior cranial rotation with
adaptive shortening of the suboccipital muscles and weakness
of the short flexor muscles group (see Fig. 17-19). One of the
more common soft tissue manipulations used in myofascial
release is the bilateral suboccipital release technique (Fig.
19-46), which releases some of the long and particularly the