Neck Pain

Myron M. LaBan

Clinical.Features Cervical Soft Tissuelnjuries

Cervical Disk, Pathology Ac,u,t,e„,C,e,r,vi,c,a,l,,D,isk „Herniations

Cervical, Spondylosis,, ,and „Stenosis

Bibliography

Neck pain has an encyclopedic list of causes, including trauma, degenerative disease, infections, neoplasms, congenital variations, inflammatory arthritis, and psychic tension. An evaluation of neck pain requires an understanding of the anatomy of the cervical spine. The cervical spine consists of seven vertebrae; the fifth through the seventh are alike in shape and size, whereas the first cervical vertebra (atlas) and the second (axis) differ in structure. The lower third through seventh vertebral bodies articulate with each other via their superior and inferior articular processes, enabling limited rotation and lateral flexion. The atlas (C1) supports the occipital condyles and the axis (C2). Its inferior articulations resemble the other inferior vertebral articulations. The dens and its stabilizing horizontal ligament enable rotation between C1 and C2. The transverse processes of each of the cervical vertebrae are perforated by a foramen through which the vertebral vessels pass. Topographically, the first cervical vertebra is located immediately behind the angle of the mandible, the transverse process of the atlas is positioned between the angle of the mandible and the mastoid process, the hyoid bone is anterior to the level of C3, the thyroid cartilage is anterior to C4, and the cricoid cartilage is at the level of the sixth cervical vertebra.

The muscles of the neck are compartmentalized into seven fascial planes. These planes normally enable pain-free movement of one muscle group on the other. Following acute neck trauma, petechial hemorrhages and edema within these same fascial planes may produce limited motion associated with complaints of stiffness, pain, and swelling.

The stable but flexible cervical spine is linked by both ligaments and disks. Because of major structural differences, the cervical disks are less likely than lumbar disks to prolapse. The cervical spine is more mobile, the superincumbent weight is less, the nucleus pulposus is more anteriorly displaced and, unlike the lumbar spine, the annulus is reinforced posteriorly in its entire width by the posterior longitudinal ligament.

The eight paired cervical spinal roots exit the intervertebral foramina between the superior and inferior pedicles, except for the upper two cervical roots. Unique to the cervical spinal roots, in over half the cases the ventral and dorsal roots are separate at the neural foramina. In these cases, isolated irritation of the dorsal (sensory) root posteriorly by an osteophyte may produce only sensory complaints. Similarly, ventral root (motor) compromise by a degenerative or herniated disk may produce only painless, progressive weakness. Segmental motor or sensory signs associated with a root disorder are called radiculopathies. Signs and symptoms of spinal cord disease are called myelopathies.

The sinuvertebral nerves from the dorsal root reenter the intervertebral foramina supplying sensory innervation to the ligaments of the spinal canal. Anteriorly, they supply the posterior longitudinal ligament and posteriorly the ligamentum flavum, meninges, and associated vessels. Ascending and descending branches also supply the zygoapophyseal joints, providing position sense.

The cervical portion of the spinal cord surrounded by spinal fluid is suspended laterally to the enveloping dura by 20 dentate ligaments. The dura in turn is attached cephalad to the rim of the foramen magnum and within the vertebral spinal canal is cushioned from trauma by epidural fat.

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