Neck

History and Examination Summary

History

1. pain: where (neck v arm),rad,type,when,nocte,agg,rel,how long,headache
2. other: stiffness,deformity,numb,weak, face, eyes
3. function: coat,wash back,bra,toilet,comb,feed,high shelf, lift weight,throw,pull,work,sport,recr.
4. past hist: treatment,injury,surgery,similar episodes

Exam Shoulder

Exam

1. look: swelling,wasting,deformity,scars, scapula anomalies
2. feel: tenderness,lumps,musclespasm,anterior structures
3. move: flex,ext,lat flex,rotate
4. spec: Valsalva, foraminal compression, myelopathy, Adson's test
5. power,neuro,vascular

Special Tests

Radiculopathy maneuvres

Valsalva ( or cough or straining): increases intrathecal pressure (+ve in disc pathology or tumours)

Davidsons test

abduct shoulder,flex elbow and put hand to head radicular pain will improve, pain due to shoulder/ arm pathology will be worse or unchanged

Foraminal compression test

extension and lat tilt to affected side will make pain worse

Myelopathy maneuvres

Hoffman reflex +ve when the ipsilat IP jts of the thumb and index finger flex when the volar surface of the middle finger is flicked. Extension of the neck increases the sensitivity of this test

Inverted radial reflex

spontaneous flexion of the digits when the examiner attempts to elicit the brachioradialis reflex

L'hermitte sign

flexion or extension of the neck causes paraesthesias or shock sensations - usually in the legs, more often in flexion

Babinski sign

usually do not occur until myelopathy is severe

Thoracic outlet maneuvres

thoracic outlet stress test ER/abduction/ extension of shoulder produces numbness of fingers

Adsons test

reproduction of symptoms, loss of radial pulse or appearance of a subclavian bruit with the arm held at 90 deg abduction and in ER

Basilar Invagination

Primary (congenital)

assoc with vertebral anomalies eg

atlanto-occip fusion
hypoplasia of the atlas
Klippel- Feil

skeletal dysplasias

achrondroplasia
Spondyloepiphyseal dysplasia
Morqios Syndrome

Secondary

skull softening

severe osteoporosis
osteomalacia
rickets
Pagets
Osteogenesis imperfecta
RA
neurofibromatosis

Clinically

Odontoid may impinge on cord

medulla
cerebellum
Vertebral arteries (VBI)
Aqueduct of Sylvius (Hydrocephalus)

XRay

McRaes line:

connects ant + post margins of the foramen magnum
( Basion + Opisthion)
The odontoid should not project above this line

Chamberlains line:

From the post margin of the hard palate to the post margin of the foramen magnum
The tip of the odontoid should not project more than 3mm above this line

McGregors line:

From the post margin of the hard palate to the most caudal part of the occiput
The tip of the odontoid should not project > 4.5 mm above this line

Treatment

1. Preop Halo traction to reduce subluxations and pull the odontoid out of the foramen magnum
2. Occipito-cervical fusion - technique:
   1. midline incision - from ext occip protuberance to ~ C4 level
   2. subperiosteal dissection to expose occiput and cervical laminae
   3. wires passed:
      under C1 laminae
      through drill hole in C2 SP
      through hole in outer table at ext occip protuberance
      
   4. decorticate + make trough in occiput for graft
   5. BG from post iliac crest harvested, laid, wires passed through drill holes in graft and then tied over
   6. cervical orthosis for 3/12

Congenital Muscular Torticollis

Aetiology:

Unknown
The muscle may have suffered ischaemia form a distorted position in utero (supported by the association with breech presentation and CDH)
May be due to birth trauma

Incidence:

Males more than Females and Right more than Left
Associated with CDH and acetabular dysplasia in 10 - 20% and may be related to intra-uterine posture with an increased incidence in breach deliveries and difficult labours

Clinically:

In 20% a lump (sternomastoid 'tumour')is noticed in the first few weeks of life in the belly of the sternocleidomastoid on the side of the tilt
Usually well defined and may involve one or both heads of the sternomastoid
At this stage there is no deformity or loss of movement and deformity becomes apparent usually at 3 - 4 years of age
Shortening of the muscle results in the mastoid process approximating the sternal notch (the ear becomes lower and further forward) and the entire face is tilted down on the affected side- the face is shorter on the affected side
The sternomastoid feels tight and cord like

X-Rays

Normal
Exclude a congenital cervical abnormality

Pathology:

The "tumur" is a white glistening structure consisting of fibrous tissue which usually disapears in 2 - 6 months

Treatment:

If a child has a sternomastoid tumour every effort should be made to prevent deformity developing, physiotherapy, stretching and splintage should be instituted
If deformity persists; surgery at 1 - 4 years, procedures include subcutaneous tenotomy (distal end) with care to avoid neurovascular structures or open division of either the upper or lower end (recurrence rate following surgery less than 5%)
Best time for operation is 18 months to 2 years
Operative release is indicated if conservative treatment fails or if late presentation with rigid deformity- post op the correction is maintained using a splint or collar worn for several mths until head is held straight

Prognosis:

5% recurrence rate and if correction before the age of 4 years the facial asymmetry can resolve

Secondary Torticollis

May also follow

skin scarring particularly burns
inflamed cervical glands
vertebral tuberculosis
ocular disorders
injuries of the cervical spine

The treatment is that of the underlying condition

Klippel-Feil Syndrome

Definition:

Congenital abnormality of the cervical spine characterised by deformity and fusion of adjacent vertebral segments and may be associated with local cervical instability.
Includes all variations of congenital failure of segmentation from simple fusion of adjacent vertebrae to involvement of the entire spine

Aetiology:

Developmental abnormality with failure of segmentation occuring during the third to eighth week of intrauterine life and associated with a number of other congenital abnormalities.

Clinically:

Classical clinical triad;

Short neck
Low hairline
Limitation of neck motion

Associated with

scoliosis (60%)- more than 1/2 of these require treatment
Sprengel's deformity (40%)
Renal anomalies - eg horseshoe kidney (35%)
Hearing impairment (30%)
congenital heart disease (14%)

Motion patterns:

Upper cervical spine instability and neurologic problems- most common with upper cervical anomalies eg C2-3 fusion
Lower cervical spine degenerative osteoarthritis

X-Rays

Posterior fusion first to be recognised
Flexion extension views best for identifying the fused segment and the site of maximal motion
Vertebral endplates often appear falsely as disc space

Prognosis:

Greater than four fused segments is associated with a higher incidence of problems and instability
Most have minimal symptoms and require no treatment

Congenital Anomalies of the Odontoid

may be

Aplasia: - rare
Hypoplasia: eg in achondroplasia, spondyloepiphyseal dysplasia
Os Odontoideum: may be congenital or traumatic

Clinically

instability of atlanto- axial jt pain,torticollis, neurologic compromise
vertebral artery compression seizures, mental deterioration, syncope, vestibular disturbances

X Ray

flexion - extension films show hypermobility- atlanto-dens interval more than 5mm in children
MRI shows cord damage
CT or plain tomogram demonstrate the degree of displacement

Treatment

C1-2 fusion

Atlanto - Axial Instability

Assoc with Morquios

Spondyloepiphyseal dysplasia
Achondroplasia
Downs- 25% have instability
pharyngeal infection in the normal child ( = Grisels syndrome)- due to hyperaemia causing demineralisation of the attachment of the transverse ligament to its attachment to the ant arch of the atlas
rotatory subluxation or anterior subluxation

atlanto dens interval

more than 5mm = instability
more than10mm = indication for surgery

Prolapsed Cervical Disc

Incidence:

Male : Female 1.4:1

Aetiology:

Associated with heavy lifting and smoking

Clinically:

Onset usually not related to severe strain and often occurs on stretching upon waking
Pain often radiates to the scapular region and sometimes the occiput
Radicular pain (brachialgia) to one (rarely both) arms in the distribution of innervation of involved segment
The neck may be tilted (torticollis), tender spots are palpated in the cervical musculature (trapezius and scapular region)
Some movements are restricted and painful but at least one movement is full and painless in all but the most severe cases
May be weakness of muscle groups innervated by the affected root
Foraminal compression test often positive and abduction / external rotation of the arm without changing neck position relieves the pain (hand behind the head)
The commonest level is above or below the sixth cervical vertebrae involving the C6 or C7 roots
Upper limb movements are full

X-Rays

Loss of normal cervical lordosis
Disc space is often narrowed

Differential diagnosis:

Cervical rib syndrome involving C8/T1 roots
Carpal tunnel syndrome where neck movements are painless
Supraspinatus tendon lesions or other shoulder pathology
Tumours of the cervical spine or region may present with radicular symptoms
Cervical spine infection
Neuralgic Amyotrophy where pain is sudden and severe with multiple levels involved

Pathogenesis:

Degenerate or traumatic tear of the annular fibres allowing prolapse of the intervertebral disc material

Treatment:

Rest, analgesics and anti-inflammatories (80 - 90% resolve)
A soft cervical collar may be useful in the short term to improve comfort
Cervical traction may also provide relief of symptoms and provide comfort while the condition resolves (should not exceed 10lbs which is the approximate weight of the head)
If symptoms severe and refractory operative decompression may be indicated via an anterior approach with subsequent stabilisation of the cervical spine with a bone graft +/- internal fixation

Cervical Spondylosis

Incidence:

More than 80% of the British population over 55 years have cervical spondylosis

Clinically:

Patient usually over 40 years
Complains of neck pain of gradual onset often worse in the morning
Pain may radiate widely to the occiput, shoulder and arm
First movement to be lost is extension and may have marked limitation of lateral flexion when upright which improves on lying down
Paraesthesia, weakness and clumsiness are occasionally features and very rarely may have signs of a cervical myelopathy with brisk reflexes in the lower limbs and increased tone
May have tenderness of cervical musculature and movements may be limited by pain

X-Rays

Reduced disc height
Cervical spondylosis (lipping of vertebrae and spondylophytes)

Pathology:

Osteophyte formation from the facet joints, the margins of the joints of Luschke and spondylophytes from the vertebral body margin

Rarely osteophytes develop on the neurocentral lip which may encroach on the vertebral artery ® vertebral artery syndrome of dizziness, vertigo, tinnitus and blurring of vision

Differential Diagnosis:

Referred pain:

Cervical disc degeneration (? not painful)
Apical tumours (Pancoast syndrome, Horners and pain down the arm)
Thalamic lesions (very uncommon)
Thoracic outlet syndrome

Local lesions:

Carpal tunnel syndrome
Neuralgic amyotrophy (brachial neuritis)
Shoulder problems (AC joint, rotator cuff, GH arthritis etc)

Treatment:

Rest analgesics and anti-inflammatories
A cervical collar may be necessary at times of acute episodes
Physiotherapy and local modalities
If associated with radicular symptoms or myelopathy may require decompression
In some cases cervical fusion may be indicated in the absence of radicular symptoms

Prognosis:

Restriction of movement usually persists but the discomfort resolves as time passes
Many people have similar X-Ray changes with no or little discomfort at any stage in their life
In dealing with predominant neck pain in the absence of neurological deficit and discrete radicular symptomatology the results of surgery do not significantly alter the natural history

Neuralgic Amyotrophy (Brachial Neuritis)

Aetiology:

Believed to be due to a viral infection of the cervical nerve roots as there is often a history of antecedent viral infection

Clinically:

Pain in the shoulder and arm is intense, has a sudden onset and may extent into the neck and down into the hand
Usually lasts several days but may continue for several weeks
Associated with paraesthesia of the arm and hand and weakness of the muscles of the shoulder, forearm and hand
Wasting of the shoulder and small muscles of the hand may be evident after only a few days and winging of the scapula is common
Shoulder movement is limited by pain and sensory loss in one or more of the cervical dermatomes is not uncommon
Differentiated from an acute disc herniation as it involves multiple root levels

Treatment:

No specific treatment and pain controlled by analgesics

Prognosis:

Usually good but full neurological recovery may take several months or even years

Cervical Rib (Thoracic Outlet Syndrome)

Incidence:

Cervical ribs occur in 0.4% of the population (70% are bilateral)
Only symptomatic in 10% of cases

Clinically:

Although congenital, symptoms rarely develop before the age of 30 years and are more common in women
Pain and symptoms usually evident in the distribution of the lower roots of the brachial plexus (C8 & T1)
The subclavian artery is rarely compressed but may be narrowed by irritation of its sympathetic supply. Acute angulation may also ® damage of the arterial lining and production of small emboli
Results in no general or local neck symptoms usually
Complain of pain in the ulnar forearm and hand worse after activity and carrying parcels
May be weakness and clumsiness and excessive sweating , blueness or coldness of the fingers with wasting of the small muscles of the hand
The shoulder on the affected side may be lower or both shoulders may sag
An abnormally elevated subclavian artery may be evident above the clavicle
Thoracic Outlet Stress test - putting hand behind head ie ER/Abduction/extension of shoulder produces numbness of fingers- positive in 80%
The neck and shoulder are fully mobile but traction on the arm and lateral flexion of the neck away from the painful side may exacerbate symptoms and obliterate the radial pulse (Adson's Test)- positive in ~ 20%

ref Glassenberg M " thoracic outlet syndrome" Angiology 32: 180-186, 1981

X-Rays

An occasional well formed rib is seen yet these are less likely to cause significant symptoms
Elongation of the lateral mass of C7; likely presence of a fibrous band (this sharp fibrous band is more likely to result in symptoms)

Investigations:

EMG not as good as clinical examination in establishing the diagnosis
X-Rays demonstrate the abnormality

Differential Diagnosis:

Carpal tunnel syndrome but the sensory and motor changes are not confined to the distribution of the median nerve
Ulnar tunnel syndrome, again the changes are not confined to the distribution of the ulna nerve
Pancoast syndrome (apical carcinoma of the bronchus) may infiltrate the structures at the root of the neck causing pain numbness and weakness of the hand. Clinically, large lump in the neck and chest X-Ray typical features of malignancy
Cervical spine lesions eg

disc prolapse or spondylosis where neck movements are limited
TB and mets- X-Rays usually differentiate the cause

Spinal cord lesions such as syringomyelia may cause wasting of the hand but other neurological features suggest diagnosis (dissociated pain and temperature loss)
Cuff lesions have painful shoulder and arm movements

Treatment:

Conservative: exercises to improve support of shoulder girdle associated with weight reduction are usually adequate
Operation indicated if the above fails in the presence of severe symptoms or there are significant neurological or vascular disturbances then excision of the rib or fibrous band

Rheumatoid Arthritis

Three types of lesion (instability) are common;

1. Erosion of the atlanto-axial joints and the transverse ligament with resulting instability
2. Erosion of the atlanto-occipital articulations allowing the odontoid to ride up into the foramen magnum
3. Erosion of the facet joints in the mid cervical region which may result in ankylosis but usually instability and subluxation

Clinically:

Usually a women with advanced rheumatoid disease
Has neck pain and may support her head in her hands and have marked restriction of movement
Symptoms and signs of root or cord compression may appear in the upper and lower limbs (cervical myelopathy)

X-Rays

Atlanto-axial instability is evident in the lateral view when taken in flexion and extension (greater than 5mm gap * sig instability)
Lateral views, tomograms or now MRI show the relationship of the dens to the foramen magnum
Flexion views show subluxation in the mid cervical region

Treatment:

Despite the X-Ray appearance serious neurological complications are rare
Symptomatic relief can usually be achieved by wearing a collar and with anti-rheumatic medication
Spinal fusion may be indicated if the disability is severe or there is progressive neurological involvement (occipito-cervical, Gallie or mid cervical fusion may be indicated)

Cervical Myelopathy

Clinically:

Patients may present with a variety of symptoms including neck pain, upper limb pain, gait disturbances, weakness, sensory changes etc
Urgency of micturition is a classical feature of cord pathology

Treatment:

Decompression is required
Motor and sensory deficits may or may not be fixed
Anterior or posterior approach used as appropriate for the pathology
Anterior decompression suitable for up to 3 vertebral levels, after that better off to approach from the back