Authored by MCN Neurologists
The cervical spine consists of the uppermost seven vertebrae surrounding and protecting the spinal cord. The top vertebra (C-1) connects with and supports the skull, and the lowest vertebra (C-7) sits just above the level of the shoulder blades. At each intersection of these seven bones, the cervical discs separate them in the front and the bones articulate with each other in the back. The entire series of bones is supported by numerous muscles and ligaments. Spaces are provided for the cervical nerves to exit the spine at each level. The cervical nerves supply sensation to the skull and scalp, as well as sensation and muscular control to the arms.
Generally, the anatomy of the cervical spine permits quite a range of flexibility and motion under normal circumstances, however it also allows a vulnerability to a number of physical forces. We often subject our cervical spines to unusual positions while sitting, driving and using the phone or computer. The cervical spine is especially vulnerable during traumatic injuries. This high level of mobility also encourages premature degenerative changes due to abuse and overuse. Certain problems are minor and short-lived, others more disabling, persistent, and threatening. Almost everyone suffers from some form of neck discomfort on occasion.
Symptoms of Cervical Spine Disorders
A neurologist looks for one of three types of cervical spine pathologies when evaluating an individual with neck and/or arm symptoms.
Muscular and Ligamentous Injury:
Neck pain of soft tissue origin tends to produce symptoms localized to the muscular tissues running up and down both sides of the cervical spine. The discomfort can expand out towards the shoulders, but rarely radiates down the arms. The symptoms are commonly worse with the head and neck in a fixed, or static, position and better with movement, ice or heat and massage. This tends to be a persistent type of pain, often precipitated by injury or overuse. The cause can be injuries to the muscles and ligaments or to the underlying bones and discs. Once injury occurs, there tends to be a tightening of the muscles, perhaps as a reflex designed to hold the head and neck stable, but this also creates enhanced muscle tone and discomfort from the chronic muscle spasm.
Headaches commonly accompany this form of cervical spine disorder. The tightness of the neck muscles pulls at their attachment to the skull. Chronic muscular tightness is often not recognized until it is longstanding and sufficient enough to cause head pain. The headaches can be more prominent and disabling for patients than neck pain and may be their presenting symptom. Headaches emerging from neck dysfunction often begin at the skull base, radiate up over the scalp and produce a pressure-like sensation over the entire head. The headaches can be quite frequent, even daily, and can range from mild to severe in nature. The headaches are treated with anti-inflammatory medications (ibuprofen, naproxen, etc.), heat, massage and movement.
Thoracic outlet symptoms are also common when cervical muscular and ligamentous injury is at its worst. With muscular spasm and tightness in the trapezius muscles just above the collar-bones, pressure on the bundle of nerves (the brachial plexus) and blood supply to the arms can occur and create symptoms of heaviness, aching, fatigue and numbness radiating down the arms to the fourth and fifth fingers. These symptoms are worse when the individual works with the arms lifting or reaching overhead, out in front of the body, such as driving, or sits with the head and neck in a static position (desk work or phone and computer activities). Patients may also awaken with these symptoms in the morning, but generally whenever they occur, the arm symptoms are quickly, albeit temporarily, improved by moving the arm and shoulders away from the body and loosening the muscles.
Degenerative Disc Disease:
Degeneration of the discs and arthritis of the spine are common issues. These conditions may be accelerated or precipitated by aging, trauma or repetitive use. Usually symptoms are localized to the spine itself, are of muscular origin and are similar to those described above. Since the underlying structures are damaged, the muscular symptoms of neck pain and headaches are particularly difficult to relieve, other than temporarily.
Most neck motion occurs between the fourth cervical vertebrae and the first thoracic segment. It is here that most degenerative changes occur. Any structural change that narrows the openings used by the nerve roots to exit the spinal canal will produce nerve symptoms into the arms. Unlike the lower back, there may be no recognition of a specific event with causes the nerve pain, and often individuals will notice arm pain spontaneously upon awakening one morning. Symptoms are generally worse in the mornings and improve with motion, however certain movements will precipitate nerve irritation. With nerve irritation, head movement will cause symptoms of arm, shoulder or shoulder blade pain and/or arm numbness and tingling or weakness. The pain may be severe and sharp or dull and achy. The numbness and tingling usually radiates down the arm to the hand and fingers, and the weakness is quite subtle.
The distribution of the pain and tingling may reflect which level or disc is the cause of the symptoms. Discs and nerves are named by the level of the cervical spine from which they are located. For example, the C-7 nerve root comes out of the neck between the 6th and 7th cervical vertebra and is contiguous with the C 6-7 disc. The location of the pain and numbness and the findings of weakness and reflex changes help the neurologist locate which nerve, disc and spine level are the likely cause, as well as how severe or damaging the situation is. In the example noted above, the individual would likely notice pain in the neck, shoulder blade and radiating down the under arm to the forearm and hand. There may also be numbness into the index finger and the neurologist may find weakness of the triceps and forearm accompanied by a decreased triceps reflex.
The pain and numbness associated with nerve root compression may be quite severe and disabling, so the weakness in the arm is often not noticed. It is the weakness or paralysis caused by damage to the nerve, however, that is the determinant of conservative versus surgical treatment. Accurate diagnosis and serial clinical evaluations are generally required to best manage this condition.
Compression of the Spinal Cord:
With degenerative disc and spine disease, there may also be compression of the central canal of the spine, which houses and protects the spinal cord. Pressure on the spinal cord occurs from bony and disc expansion posteriorly (towards the back) into the canal and from thickening of the internal ligaments within the canal anteriorly (towards the front). Either or both structural changes may be enough to impress the spinal cord and interrupt the messages traveling up and down the cord to the lower body.
Symptoms of this pathology are difficult for the patient to recognize, as they tend to occur from gradual forces on the spinal cord. Pain is not commonly intrusive and, instead, difficulties with mobility, bladder and sensation emerge. Balance problems, bladder control issues and weakness and fatigue with walking are the chief symptoms of spinal cord injury. They begin insidiously, progress slowly and are often attributed by the individual to other causes.
History and Physical findings establish neurological concerns. Symptoms of walking, balance and bladder problems accompanied by physical findings of reflex hyperactivity and difficulty with position sense lead the neurologist to suspect spinal cord issues. Though there are medical conditions which can create spinal cord symptoms, most of the disorders damaging the spinal cord in our patients is of structural origin and thus amenable to surgical intervention.
Neck Pain/Cervical Spine Disorders Examination and Tests
Neck Pain may be chronic or recent in onset. It may be confined to the neck or radiate to the arms. It may be described as mild or severe and dull or sharp and better or worse with certain physical maneuvers. These characteristics will help localize the issue and point towards its origin. On occasion the distribution of pain will suffice to establish the correct diagnosis.
Headache frequently accompanies cervical spine pathology and may be the most prominent complaint. The headache is usually daily, in the back of the skull and radiates forwards over the temples. It is generally mild and relieved with minor pain medications. When chronic, it can be quite severe and mistaken for “migraine”.
Numbness into the arm in a particular location provides clues as to which nerve is involved and, perhaps, also the exact location where the nerve is involved.
Weakness is less likely noticeable to the patient unless it is profound, although the neurologist will inquire if there are any particular muscles or groups of muscles that don’t seem to work well. Weakness in the arms is generally less noticeable than in the legs. Fatigue of certain motions may be more readily recognized and reported as weakness.
Bowel, Bladder, Gait and Balance difficulties are clues to spinal cord injury and symptoms of this nature are quite important.
Motor Function of almost all of the muscles in both the arms and legs are tested. The maximum power that each muscle can generate and the loss of muscle bulk (atrophy) are assessed.
Sensory Function is tested with either a pin-prick or light-touch method, looking for areas of numbness, tingling or burning.
Reflex Activity of the arms and legs is tested with the rubber hammer to provide insight to nerve, spinal cord and muscle function.
Gait Assessment is reviewed for balance and pattern of muscle power.
Coordination of both arms and legs is reviewed for both dexterity and balance.
Range of Motion of the spine, both passively and actively, is performed while assessing the musculature and identifying whether any nerve, spinal cord or pain difficulties emerge.
Electromyography (EMG) is a test that reveals whether certain muscles are receiving the correct electrical signals from their nerves. There are two parts to this test:
1. Nerve conductions are shocks that permit the reader to determine the rate of speed that the nerve is sending messages, and thus its general health.
2. Needle electrode testing is performed by sampling several muscles with an electrode to determine whether the muscles are receiving the correct electrical signals from any single nerve. When a specific group of muscles does not test normally, this informs the neurologist as to where the problem lies and the severity of the injury.
X-ray is the easiest means to image the spine. X-ray reveals alignment and degenerative changes of the bones. The spaces for the discs are seen as well, but no pictures are seen of the spinal cord, nerves or actual disc material. Unsuspected bony pathology, such as fractures, dislocations and cancer metastases, are quickly identified with x-ray.
CT Scan is useful for cross-sectional imaging of the spine and increased image detail of the spinal cord, nerves and discs, but less so than MRI imaging.
MRI is currently the best means of visualizing all of the important structures of the cervical spine. With a good MRI study, considerable detail is available of the bones, discs, spinal cord, ligaments and even the nerves. MRI studies are most likely the major determinant of the pathology causing the cervical spine difficulties, whatever their nature.
Blood work may be ordered if suspicion of spinal cord disease is present. Also, certain forms of arthritis (Rheumatoid) may be detected with blood work.
Bone density assessment assists in the diagnosis of a loss of calcium as seen in osteopenia and osteoporosis, conditions that weaken the bone structure everywhere.
Treatment and Prevention of Muscular/Ligamentous Syndromes and Degenerative Joint and Disc Disease of the Cervical Spine
Rest, massage and ice or heat are certainly the first step in treating the acute onset of cervical spine pain, particularly if muscular in origin. Sometimes several weeks are necessary for resolution. If the symptoms seem to be gradually improving, no medical intervention may be necessary. Avoiding poor neck posture and positions is essential. Sitting up straight and keeping the head centered over the chest while sitting improves posture. Helpful modifications include: (1) avoid working with the arms up overhead or the neck in a persistently flexed position, (2) avoid frequent twisting or turning, (3) avoid carrying a computer or heavy bag over one shoulder or cradling the phone to one ear, and (4) try to sleep with fewer pillows and avoid sleeping on one’s stomach. Massage may loosen up the muscles. Ice may calm the inflammation at the onset of difficulties and heat may later relax the muscles.
Exercise in some form is also useful if the dysfunction is mild, postural and muscular in origin. Often best used for prevention of future difficulties, some forms of exercise may be tried in the acute phase as long as they are gentle and focus more on flexibility, toning and posture. Swimming, health club exercise machines (Nautilus, Ther-X, Cybex, etc.), stretching programs (Pilates, Yoga, etc.) and other home programs all have some utility when done correctly. Again, this approach is probably best done under professional supervision and also best used for protection from further injury.
Stress management should not be overlooked as psychological tension can be focused on the neck region as can work stress with long hours at the computer or desk. Poor sleep often accompanies stress, and the neck muscles don’t relax well when sleep is poor, thus perpetuating the symptoms of neck pain.
Anti-inflammatory agents, analgesics and muscle relaxants work best for most spine discomfort, though no single agent is curative. Some are available over the counter (ibuprofen, naproxen, aspirin and Tylenol), but the stronger agents are by prescription only, including the stronger pain medications and muscle relaxants. At best, this approach is a temporary fix until the anatomy and mechanics of the spine dysfunction are identified and corrected. Side effects and hazards from long-term use of these medications are common.
Physical Therapy is the mechanical intervention medical doctors prefer when external mechanical forces and instruction need be applied to the spine to rectify the source of neck disorders. A wide range of therapeutic options are available to the Physical Therapist (P.T.), whose skill set includes a separate professional assessment of the neck dysfunction. Based upon the referral from the Medical Doctor and the diagnostic testing and diagnosis, a P.T. will select both passive and active therapies best suited for the patient’s particular issues. Exercises for flexibility, toning, strengthening, stability and restoration of range of motion may be selected. Professional instruction in home and/or health club exercise programs is available. Hands-on treatments with ice, heat, manual techniques, ultrasound, traction and electrical stimulation may also be included in the regimen. Often, several visits are necessary to get the best treatment and management strategies in place. A discharge plan tailored to each patient’s needs is developed for prevention of future problems.
Exercise in some form tends to be the best prevention for recurrent mechanical spine difficulties. Correcting posture and mechanical stresses comes first. Spine health depends on a balance of the flexors and extensor muscles of the spine, good posture and good tone and flexibility of the muscles. Active exercises designed, not so much for enhancing power in the neck muscles, but instead for promoting better tone and flexibility, work best. There are a number of exercise programs available, but the critical feature is not so much the particular one used, but that the individual finds a program that they will perform consistently. Professional instruction is probably best and can be accomplished by Physical Therapists, Exercise Physiologists and even Personal Trainers, depending on the underlying medical pathology. Health club machines are often employed, but many home exercise alternatives are available too. Yoga, Pilates and other forms of stretching may also be useful, dependant on one’s particular situation. Professional advice is suggested.
Complementary Medicine may play a role particularly when stress is a causative factor. We never argue with the success of any form of therapy, as long as outcome goals are achieved. Various treatments as mainstream as Acupuncture and Acupressure, and as marginal as magnet therapy, have been successful for SOME individuals. Reflexology, meditation, Tui Na massage and vitamin, enzyme and other supplements may benefit some individuals. As long as these remedies are reviewed with your physician, harmful side effects can be minimized.
Surgical and Interventional Treatments:
Epidural Injections may be tried when there is substantial irritation of the nerve root or other structures. Epidural injections are useful for pain relief, but do not generally create enough change in the underlying pathology to create permanent relief.
Facet Blocks may be used when there is suspicion that degeneration has occurred in the joints connecting the vertebral bodies and is the source of discomfort. Generally they are tried as a diagnostic event with lidocaine first. If successful, more long-lasting radiofrequency blocks can be performed. This is not a permanent solution, but can be quite helpful to a select group of patients.
Neurosurgical intervention is likely to be required when there is irreversible injury to the spinal cord or the nerve roots. Generally reserved as the “last resort”, surgical intervention may be inevitable in certain circumstances and attempting conservative treatment first may be futile. Careful clinical evaluation is the determining factor between continuing with conservative treatment and proceeding with surgical intervention.
January 1, 2010
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