A Pain in the Neck - Root pain -Cervical Spondylosis
Neck pain is a common complaint and is almost always a benign condition. Over 10% of the adult population recalls at least 3 episodes of neck pain within a 3-year period.
One good
way to approach the subject is to consider source of pain based on anatomic
principles: what are the pain sensitive structures of the neck? To answer the
question one must have an understanding of the basic anatomy of the
neck/cervical spine and then consider what common or uncommon processes can
disturb normal function thereby causing pain and other disabilities such as
weakness or numbness.
Anatomy / Neck
Complaints/Cervical Spondylosis
The
cervical spine neck is composed of 7 blocks of bones (vertebral bodies) layered one on top of
another with discs which act as kind of shock absorbers between the bodies.
Behind the bodies lies a canal surrounded by bone, and in this canal lies the
spinal cord which extends from the base of the skull to the level of the lowest
rib. The spinal canal is lined by a
parchment like envelope called the dura which forms a long tube running from
the head to the tail bone. The spinal cord lies in bed of water (cerebrospinal
fluid) within the dura and has enough space around it to allow for some upward
and downward movement when the neck is flexed or extended. Small joints called
facet joints or apophyseal joints allow for movement of the neck in all
directions. The vertebral arteries which supply blood to the back of the brain
travel on the side of the vertebral column in their own own canals on each
side.
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A Pain in the Neck - Root pain -Cervical Spondylosis |
At multiple
levels nerves emerge from the spinal cord on each side and course towards the
neck and upper limbs to provide motor signals which cause the muscles to
contract, or sensory feedback from the structures of the arms and neck. Each
combined motor and sensory component originates from two sub-rootlets which are
attached to the cord itself: one is
attached to the back part of the cord (dorsal root) and subserves the function
of sensation; it has a small bump or nodule on it which contains the bodies of
the sensory nerves (dorsal root ganglia), and the other nerve rootlet is more
anterior (ventral root) and contains motor nerves. The two components merge to
form the mixed cervical roots. The autonomic (automatic) nervous system is
supplied by grey and white rami (branches) which leave the root close to the
junction of the dorsal and ventral components..
The
cervical vertebrae are separated one from another by disks. The outer part, or
rim of the disk, is tough and stringy (annulus fibrosus), and surrounds the
inner part of the disc which is softer and more amorphous (nucleus pulposus).
At the level of the disk, on each side is a small hole (root foramen), which
allows the nerve roots to pass from their attachment to the cord to the
structures of the arm and neck.
The boney
elements of the neck are held in place by ligaments which extend longitudinally
in front of and behind the vertebral bodies. The back of the canal is made up
of plates of bone (laminae), and again, a ligament holds them in place and courses down the
posterior aspect of the central canal (ligamentum flava). The whole structure is surrounded by muscles.
The nerve
roots are numbered from 1 to 8 and the prefix "cervical" or
"C" allows us to identify exactly what structure we are referring to.
Each motor nerve root supplies specific muscles in the arm (myotome) and when
the neurologist examines the muscles, based the pattern of weakness that he
finds, he can deduce which motor nerve root is faulty. Equally, each sensory
nerve root supplies a specific area of the skin (dermatome) and from the
distribution of sensory loss the level of dysfunction can be pinpointed. The
diagnosis can be a little tricky because of overlap of segmental innervation.
Pain Sensitive Structures:/
Neck Complaints/Cervical Spondylosis
Now that
the basic anatomy is understood we camn apply that knowledge to identifying the
pain sensitive structures which are: the surrounding muscles, sensory
components of the cervical roots, apophyseal joints, dura, bone, ligaments, and
the external rims of the discs.
Any
mechanical distortion, pressure, tumor, or infection that affects these pain
sensitive structures will signal its presence by causing pain.
“A Pain in the Neck”
The usual
cause of neck pain is neck muscle spasm. The muscles at the back of the neck
become tight and tense, and tender to pressure. This might happen after an
injury – so called “whiplash,” It might occur because the nerve roots are
irritated or compressed which triggers reflex muscle spasm, or the spasm can
result just from psychological stress. In young people the cause is likely
stress, in older folks it is almost always from disk degeneration and secondary
bone spurring and pinched nerve roots (cervical spondylosis).
The pain is
usually felt at the back of the neck, sometimes on the sides, it may be dull
and acheing or sharp, and is worse with neck movement. It radiates from the
back of the neck to the back of the head and even further forwards when it
causes a headache sometimes called “muscle contraction headache” or
“tension-type headache.” The headache is variously described as a feeling of
pressure, tightness, or bursting anywhere over the head or even around the
eyes.
The pain
can be temporarily relieved by heat applied to the back of the neck or by
gentle massage. The physician prescribes muscle relaxant drugs to help the
muscle unwind, but often simple over the counter analgesics are sufficient. If,
in a young patient when there is no obvious organic cause, some form of psychotherapy
or muscle relaxation techniques may be effective.
Root pain/ Neck
Complaints/Cervical Spondylosis
If the
sensory part of the nerve root is disturbed, pain will be felt in the
distribution of that root. The pain radiates down the arm (brachalgia), may be
dull and acheing or sharp and shooting and classically is aggravated or
relieved by changing neck posture. It can be extremely severe and warrant
fairly powerful analgesic medication. At the other end of the spectrum, sensory
root symptoms may consist of only numbness or tingling.
The usual
cause of root pain is pressure on the nerve root by a ruptured disk or
arthritis of the apophyseal joints which abut the nerve root foramina.
Occasionally
shingles, a virus infection by Herpes Zoster, affects the cervical nerve roots.
The virus grows in the dorsal root ganglia, causes severe root pain, to be
followed in a few days by a skin rash in the dermatome involved. The rash is
blistery and is a restricted form of chicken pox.
Cervical Spondylosis
Cervical
spondylosis is a degenerative arthritic like condition of the cervical spine.
Disks degenerate, the disk spaces between the vertebrae become narrowed, and
the adjacent bones react by growing arthritic
spurs. This kind of arthritis is
akin to osteoarthritis, not to systemic forms of inflammatory arthritis. An
acute disk rupture will put pressure on the adjacent nerve root or, if the
herniation is very large, it can even compress the spinal cord. An acute disk
herniation is sometimes called a “soft” disk, whereas the boney spurring and
ligamentous swelling or hypertrophy is
referred to as “hard” disk.
Cervical
spondylosis is common. It is estimated to be prevalent in about 50% of people
at age 50, and 75% of people over 65.
The sign of
asymptomatic spondylosis is restriction of neck movement. One should normally
be able to twist ones neck so that the chin approximates the point of the
shoulder. Of people older than age 50, 40% have some limitation of neck
movement.
Spondylosis may be the
cause of:
Local pain in the neck
Root dysfunction
(radiculopathy)
Cord dysfunction
(myelopathy).
Each will be discussed.
Radiculopathy:
Dysfunction
of the nerve root leads to radicular pain as described above, weakness in the
muscles of that particular the myotome, and loss of the appropriate tendon
reflex. Tendon reflexes are elicited by the neurologist who taps on a tendon
with a reflex hammer at the wrist and in front of and behind the elbow. Sensory loss for pin prick or light touch is
in the distribution of the dermatome, that is the area of skin supplied by the particular
nerve root involved. The table details the main myotomal distributions of the
nerve roots and the demonstrates the
dermatomes of the arm.
Myelopathy Neck
Complaints/Cervical Spondylosis
Cord
compression can occur both from anterior or posterior structures. Anteriorly an
acute disc rupture may compress the cord from in front, or reactive bony
spurring and ridging of the vertebral bodies distorts the anatomy so that the
anterior margins of the spinal canal look for all the world like a wash board
with transverse ridges at the levels of the discs. The ligamentum flava lines
the back of the canal and can become thickened so that the cord is pincered
between the anterior osteophytes in front and the ligament behind. The risk of
cord compression is related not only to the severity of the pathology as
described above but also to the baseline diameter of the spinal canal. Some
people are born with wide canals and some have narrow canals. If the canal
starts off being narrow, spurs are more likely to impinge on the cord. On an x-ray image the canal diameter from in
front to behind (antero-posterior) can be measured. Anything less than 12-13mm
qualifies for a diagnosis of canal narrowing or spinal stenosis. Less room =
more risk.
The spinal
cord is the cable that sends electrical messages from the brain to the body and
relays messages from the body to the brain. The signs and symptoms of
myelopathy may therefore be primarily motor, sensory or mixed. The motor and
sensory descending and ascending pathways are called tracts and the different
parts of the body are represented discretely in the tracts (somatotopic
representation).
The cord
contains many ascending and descending tracts. The clinician can test
descending motor pathways by evaluating strength, and ascending pathways for
pain, temperature, touch by stimulating with pin, a warm or cold object, or a
wisp of cotton respectively. Position sense is tested by asessing the ability
to tell the position of a toe with the
eyes closed when it is passively flexed or extended. If the cord is compressed
or distorted in any way the resultant dysfunction in any particular tract is
random, no matter the direction of the compressing force.
Motor signs
and symptoms include increased tone and stiffness of the lower limbs, together
with weakness. The weakness has a specific distribution: it affects primarily
hip flexion, toe and foot extension, and knee flexion. Other movements are less
or not at all affected. Because of toe or foot weakness the patient may scrape
the tips of the shoes on the ground when walking and the tips of the shoes wear
out.
The sensory
modalities that lend themselves to easy testing are pin prick, light touch,
vibration sense (as provided by a tuning fork), and position sense. The
distribution of pin prick sensory loss in myelopathy is variable depending on
which part of the tract is dysfunctional, so that any particular level of loss
on, say, the trunk does not necessarily denote pathology at that particular
level, but could reflect partial tract dysfunction at a higher level.
Consequently, when examining the patient the only way to define the precise
level of dysfunction in the cord is to demonstrate root dysfunction which
accurately pinpoints the level.
In cervical
spondylosis the tendon reflexes in the arms may or may not be present, and in
the lower limbs there will generally be an enhancement of the reflexes at the
knees and ankles. The response to scraping the sole of the foot is
important: extension of the toes - an
extensor plantar response or Babinski reflex indicates a problem with the
pyramidal tract, one of the main motor descending pathways..
When the
cord is compressed, bladder function may be compromised. With cervical cord
dysfunction there is frequency of urination, urgency to pass, and even
incontinence associated with the urgency. This represents a small spastic
irritable bladder.
Investigation /Neck
Complaints/Cervical Spondylosis
The mode of
choice for study of the cervical spine is magnetic resonance scanning
(MRI). The MRI demonstrates bone, disc,
and cord effectively.
If MRI is
not available, CT (computed tomography) scanning will suffice, particularly if
combined with injection of an iodinated dye into the spinal canal (myelography),
but with xrays, the patient is exposed to radiation. The CT does demonstrate
the bony change more effectively than MRI.
Regular
x-ray images will demonstrate the state of the bones and disk spaces and allow
for measuring of the central canal diameter. X-rays made with the neck flexed
or extended are used to explore stability of the spine and abnormal movement of
one vertebra on another is called subluxation.
Electrophysiological
studies are sometimes requested. These are used to measure the velocity of
electrical conduction along the nerves of the arm. This test is designed to
pick up on a pinched nerve or nerve root. Pinching causes slowing of
conduction.. The Electromyogram (EMG) is performed by needling muscles of the
arm with an electrode that picks up electrical activity in the muscle. Damage
to the nerve or nerve root results in a specific pattern of abnormality in the
muscle and this, depending on its distribution, can help to localize which
nerve roots are dysfunctional. EMG and nerve conduction studies are
particularly useful to diagnose peripheral entrapment complicating cervical
spondylotic radiculopathy. This combination is sometimes called “double crush.”
Indications for imaging/ Neck
Complaints/Cervical Spondylosis
If only nerve root dysfunction is diagnosed,
it is not essential to image at oncebut if there is no resolution within a
month or so, imaging is indicated. Some physicians image early.
The finding
of cord signs or symptoms prompts early imaging, not only to confirm the
diagnosis of cervical spondylosis, but also to exclude other potential causes
of cord compression.
If
myelopathy is present but the MRI does not show cord compression,
flexion/extension films of the cervical spine are made to exclude subluxation
which might intermittently compress the cord.
“Red
Flags”:
Imaging in
patients with myelopathy is indicated urgently in the presence of fever or a
history of cancer. If the diagnosis turns out not to be cervical
spondylosis,but some other cause of cord compression the appropriate treatment pathway will be
followed.
Treatment of Neck
Complaints/Cervical Spondylosis
Only a
minority of patients with cervical spondylosis will be offered surgery, and
despite the fact that spondylosis is so common, there is not much literature by
way of controlled trials to support the notion of surgery as as viable
treatment option unless there is severe anatomical cord pinching with
supporting signs. In general, therefore the management will be conservative
Treatment of neck pain and
radiculopathy:
The best
treatment for benign neck problems with neck pain and radiculopathy is rest and
symptomatic medication.
Patients aggravate their necks at night while
sleeping and will often complain of a stiff neck on awakening in the morning.
They settle rapidly in a hot shower.Correction of sleeping posture is often
successful in alleviating pain.Th That means that the neck should be supported
at night in bed. Two hard, cheap, feather pillows (or synthetic if the patient
is allergic to feathers), not down, usually help . Some patients respond to a
buckwheat husk pillow which serves the same function. If there is no
improvement, the patient should sleep in a soft cervical collar. Proprietary
commercial neck pillows with hollows designed to accommodate the head only
occasionally help. Local heat helps, as does gentle massage.
Cervical
traction was frequently prescribed in the past; its effectiveness has been
questioned, but occasionally a patient responds to over the door traction with
a water bag weight filled to weigh about 10 pounds.
Chiropractic
manipulation, although sometimes of symptomatic value, is mentioned only to
point out that it carries a significant risk of complications. The main
vertebral artery is occasionally injured by chiropractic manipulation,
resulting in a stroke.
Analgesics
should be used as necessary. If the pain is very severe stronger medication is
necessary.
Muscle
relaxant medication may be prescribed. In the list of choices are diazepam,
cyclobenzaprine, and methocarbamol. All carry the potential risk of sedation.
Patients
with chronic pain often respond to antidepressants, which alter central pain
pathways.
In acute
“soft disk” herniation a burst of oral corticosteroid is often helpful.
In the
absence of cord compression and with resistant neck or root pain, a visit to
the pain clinic is worth considering. An injection of corticosteroid locally
often tides the patient over. Corticosteroid may be injected around the dura
(epidural injection), or around the facet joints which themselves are a
significant source of pain.
Treatment
of myelopathy:
Acute disc
herniation with severe cord compression and clinical signs of myelopathy is
best treated surgically.
For the
chronic patient with mild myelopathic symptoms and signs, immobilization in a
soft cervical collar should be the first therapeutic intervention. The collar prevents flexion and extension of the
neck. Imaging studies have shown that with flexion the cord is driven forwards
and may bowstring on projecting bone spurs or osteophytes. The collar should be
worn all day and all night for about 3-4 weeks and the patient should then be
reassessed. Many patients respond to sleeping in a collar long term. In the
interim, an MRI will have been done and the precise state of the cord defined.
About 80-90% of patients improve with conservative therapy
The role of
surgery:
There are
very few prospective controlled trials of surgery for spondylotic myelopathy.
Retrospectively there is some evidence that patients with surgery do better,
but retrospective studies are not considered the “gold standard.”
The only
extant trial of surgery for mild to moderate spondylotic myelopathy was
conducted in the Czech Republic and the conclusion was that patients did the
same with and without surgery.
Each
patient referred for a surgical opinion should be evaluated individually and
the surgeon will come to a judgement about the need for surgery and the type of
operation offered. Surgery may be diskectomy (removing the disk), laminectomy
(decompression from the rear by removing the lamina which unroofs the vertebral
canal), or a fusion procedure where two vertebrae are joined together.
Fusion can be achieved either by
operating from behind or from the front of the neck. Surgery should be
considered for patients with spondylotic myelopathy or subluxation which does
not respond to conservative treatment.
Prognosis of Neck
Complaints/Cervical Spondylosis
The natural
history of neck pain and muscle contraction headache has never been studied. In
general the course of spondylotic radiculopathy is one of intermittency.
Relapses and remisions occur unpredictably. Patients with myelopathy are
encouraged to sleep in the collar, “for ever”.
Whiplash
Injury:
The Quebec
Task force on Whiplash Associated Disorders defined whiplash as:
An
acceleration-deceleration, mechanism of energy transfer to the neck. It may
result from rear-end or side impact motor vehicle collisions but can also occur
during diving or other mishaps. The impact may result in bony or soft tissue
injuries (whiplash injury), which in turn may lead to a variety of clinical
manifestations (whiplash-associated disorders).
Rear end
collisions are responsible for 85% of whiplash injuries; the incidence varies
from country to country but ranges in the region of 13 to 106/100,00
inhabitants.
The
pathology ranges from a trivial muscle/nerve stretch to ligament or disk
rupture, tearing of the vertebral end plates, fractures, and injury to the
facet joints.
If
neurological signs of root or cord dysfunction are present, the injury is
considered to be severe. If there is no neurological deficit the damage is
accordingly mild. Headache comes on in about 6 hours in 2/3 of the patients but
can be delayed for 72 hours. Muscle contraction headache is present in about
80% at 1 month. Other complaints include dizziness, numbness/tingling,
cognitive and psychological complaints. Pain is related to the severity of the
injury and can persist for years. Cognitive complaints are likely psychological
in origin. Dizzyness or a mild feeling of imbalance is secondary to neck muscle
spasm, and true spinning sensations (rotary vertigo) are likely ear related.
The
influence of pending litigation on symptoms remains controversial, but it is
worth considering the case of Lithuania where no insurance existed. Here almost
all reported patients with whiplash became aymptomatic spontaneously. The
inference is that the expectation of disability and compensation may be a
significant factor in persistent whiplash symptoms. Conversely settlement of
litigation does not always cure the patient so the issue is far from resolution
A
reasonable approach would be to separate out those patients with whiplash who
have neurological signs on examination and support the notion of a significant
injury in that cohort. Whiplash is
essentially a benign condition and treatment should be as described for mild
cervical spondylosis. Persistence beyond 6 weeks after the injury indicates
further study and treatment.
Cervical
spondylosis is a general term for age-related wear and tear affecting the
spinal disks in your neck. As the disks dehydrate and shrink, signs of
osteoarthritis develop, including bony projections along the edges of bones
Cervical
spondylosis is also called cervical osteoarthritis. It is a condition involving
changes to the bones, discs, and joints of the neck. These changes are caused
by the normal wear-and-tear of aging. With age, the discs of the cervical spine
gradually break down, lose fluid, and become stiffer.
Feel
free to help our community and tell us your experience about these questions:
What is the main cause of spondylosis?
Can
cervical spondylosis cured?
What is
the best treatment for cervical spondylosis?
What
happens if cervical spondylosis is not treated?
Is walking good for spondylosis?
How do
you sleep with spondylosis?
Is
massage good for spondylosis?
Does
spondylosis get worse?
What is the most serious complication of spondylosis?
What is
the best exercise for cervical spondylosis?
Can I do
push ups if I have cervical spondylosis?
Does
weight loss help cervical spondylosis?
Can you still run with spondylosis?
What
should be avoided in cervical spondylosis?
Does
cold weather affect cervical spondylosis?
Is milk good for cervical spondylosis?
Can I lift weights with cervical spondylosis?
