OUR NECK REGION:
- The most sensitive part of the body to trauma,
- The part of our body that moves in three dimensions,
- Frequently accompanied by headaches,
- It consists of seven vertebrae. The first two play an important role in carrying and turning the head and are different from the normal vertebrae structure.
- The veins that go to the brain pass through the neck bones.
Movements;
The cervical spine has different movement patterns
Occipitoatlantal junction (C0-C1)-Forward flexion-extension
Atlantoaxial junction (C1-C2)-Rotation
Most movement C5-C6
Movements and stretched tissues;
Flexion-axial compression:
Posterior column elements
Capsular ligaments
Supraspinous Ligament
Interspinous Ligament
Erector spinae
Trapezius
Lateral flexion:
Nerve roots
Brachialis
scalenus
Extension or axial rotation:
Anterior column elements
ALL
Outer fibers of the disc
Facet joints
Sternocleidomastoid
Disorders that cause neck pain; 1-Cogenital anomalies
• Cervical rib
• Block vertebra, Klippel-Feil syndrome
• Spina bifida
2-Tumors
• Cervical cord tumors. Intramedullary and extramedullary
• Primary and metastatic bone neoplasms
3-Trauma
• Cervical strain
• Whiplash syndrome
• Compression fractures
4-Osteoporosis, Paget disease
5-Degenerative disorders
• Cervical spondylosis
• Cervical disc herniation
• Cervical canal stenosis
6-Infectious lesions
• Tuberculosis, brucellosis, staphylococcal lesions
7-Fibrositis syndrome
8-Thoracic outlet syndromes
• Scalenus anterior
• Cervical rib
• Costoclavicular syndrome
• Hyperabduction syndrome
9-Rheumatoid arthritis, ankylosing spondylitis
10-Psychoneurotic disorders
11-Referred pain from internal organs
• Coronary artery disease
• Pancreatic tumor
• Hiatal hernia
• Gallbladder diseases
Neck pain;
Approximately 10% of adults experience neck pain at some point in their lives.
Approximately 70% of those with neck and arm pain recover within a month. However, about one-third recur.
Neck pain is less common and less disabling than low back pain.
WHIPLASH Syndrome;
It is an injury to the neck that occurs as a result of whiplash, usually seen in traffic accidents, without direct trauma to the head.
In whiplash syndrome, subluxations and, in later stages, osteophytes are encountered in the anterior and posterior corners of the vertebral corpus.
WHIPLASH Syndrome;
It is the injury that occurs in the neck as a result of whiplash, usually seen in traffic accidents, without direct trauma to the head.
In whiplash syndrome, subluxations and later osteophytes are seen in the anterior and posterior corners of the vertebral corpus.
Cervical Strain;
It is a clinical picture characterized by local pain and stiffness in the neck that develops as a result of traumas and poor posture.
Making an unusual movement, sports activities, typing, keeping the neck in a fixed position for a long time, such as reading a book, watching television while lying down, lying on an inappropriate pillow and bed can cause cervical strain.
It can be acute or chronic depending on the duration of the strain.
Normal cervical lordosis flattens due to muscle spasm.
Movements are painful and limited.
Radiological examinations are usually normal.
It is thought that the pathology is in the soft tissue and in the initial period of degenerative changes.
Cervical Spondylosis;
It is a clinical picture that occurs as a result of degeneration of the structures forming the cervical vertebral column and includes neurovascular disorders related to this. Cervical spondylosis includes changes in the intervertebral disc, facet and lamina hypertrophy and segmental instability.
Etiology and Pathogenesis:
Progressive changes in the intervertebral disc begin in the third decade.
The degenerated disc holds less water and is less adaptable to pressure changes.
Disc degeneration begins with circumferential tears parallel to the center in the annulus.
The circumferential tears combine to form radial tears.
The elastic nucleus pulposus softens and enters the tears.
The corpus expands, articular protrusions, lamina and ligaments hypertrophy.
The hypertrophy of the corpus, articular processes and ligamentum flavum and osteophytes narrow the intervertebral foramen from the front and back and compress the nerve root passing through it.
Enlargement of the corpus and lamina may cause central canal stenosis and may press on the medulla spinalis.
In the early period, the pressure is not caused by the osteophytes themselves but by the surrounding swollen periosteophytic tissues.
Spondylotic changes may press on the outer fibers of the annulus of the intervertebral disc, ligaments, dura, the dura sheath surrounding the nerve root, roots, medulla spinalis and vertebral arteries.
The spinal motion segments most tightly affected in cervical spondylosis are the C5-C6, C6-C7 and C4-C5 segments, where the motion is the most. The C2-C3 intervertebral disc, where the motion is the least, is the disc that is the least degenerated.
Clinical features:
1- Local signs and symptoms;
• The main signs and symptoms are neck pain, stiffness, muscle spasm, tenderness and limited movement
• Pain is caused by nerve root irritation, deep connective tissue, muscle, joint, bone and disc disorders.
• Pain originating from the disc (discogenic pain) radiates to the neck, shoulders and scapular area.
• There are no changes in strength, sensation and reflexes.
• Discogenic pain occurs with stimulation of the sinuvetebral nerve endings in the annulus fibrosus and posterior longitudinal ligament.
• It increases with head and neck movements, coughing and sneezing.
• It is often accompanied by neck and arm pain, occipital and cervical paresthesia.
2- Radiculopathy;
• These are symptoms related to nerve root compression.
• Symptoms originating from structures between C1 and C4 radiate to the head and upper cervical region, and those originating between C5 and T1 radiate to the lower neck, shoulder and arm.
• It is difficult or even impossible to distinguish root compressions above C4.
• In radiculopathy, sensory symptoms are at the forefront.
• Motor symptoms are much less common.
• The most common symptoms following nerve root irritation are pain and paresthesia.
• Reflex and motor changes are rare.
• Depending on the level of root compression, pain radiates to the head, neck, scapular and pectoral areas, shoulder and arm.
• Radicular pain is stabbing, severe and intermittent.
Treatment of Cervical Spondylosis;
1- Acute Painful Period:
• Rest (Average 7-10 days),
• Cervical corset,
• Isometric exercise,
• Local superficial heat application.10-20 minutes,
• Local cold application,
• Medications (SOAEs, myorelaxants, tranquilizers, local injection)
2- Subacute and chronic period:
• Superficial and deep heaters,
• Traction,
• TENS, diadynamics, galvanic, exponential currents,
• Massage,
• Exercises (Stretching, ROM, neck and shoulder elevator muscle strengthening exercises)
• Education (Good posture and regulation of daily life activities)
Disc Herniation;
Especially in young people (+)
Increased pain with neck movements (+)
Can shoot to arms.
Numbness, tingling occurs.
It is severe.
Weakness in the arm (+)
Pain spreads to the sensory area of the affected nerve root.
Motor loss occurs depending on the root involved.
Osteoarthritis; 50% over the age of 50 (+)
Symptoms: With the spine itself; with nerve root compression, with myelopathy
Cervical spondolytic myelopathy;
Myelopathy or spinal stenosis is a syndrome caused by the compression of the spinal cord by a narrow spinal canal.
It usually becomes widespread after the age of 50.
While cervical spondylosis is common, spondylotic myelopathy is rarely seen.
It is more common in men.
The cervical spinal cord is compressed from the front by the protrusion of the vertebral body and degenerated intervertebral disc backwards; and from the back by the thickening of the ligamentum flavum and lamina.
In adults, if the anteroposterior diameter of the spinal canal between the posterior surface of the vertebral body and the spino laminal line is 10 mm or less radiologically, the mudulla spinalis may be compressed.
The most common initial symptoms are dysesthesia in the hands, weakness and clumsiness in hand functions, and weakness in the lower extremities.
There is usually numbness and tingling in the fingertips.
Neck movements are usually limited and symptoms increase with hyperextension. Although there is no neck pain, there is often radicular pain.
Second motor neuron disorders occur at the level of the lesion, and first motor neuron disorders occur below the lesion.
Vibratory and joint position sense may be lost in the lower extremity.
If spastic paraparesis develops, the patient walks with their legs open, taking small steps as if jumping.
Deep tendon reflexes increase on the lower side.
Clonus and pathological reflexes become positive.
Superficial reflexes decrease or may disappear.
Vertebral artery insufficiency;
The vertebral artery, which branches off from the subclavian trucus, enters the transverse foramen of C6 and proceeds upwards in front of the cervical nerves up to C2.
The vertebral artery is accompanied by the vertebral venous plexus and sympathetic fibers.
Symptoms that occur with neck and head movements, mainly rotation, extension and lateral flexion, are rotatory vertigo, tinnitus, blurred vision, headache, horizontal and rotational nystagmus.
Weakness in the legs, drop attack, numbness on one or both sides of the body, dysphagia, dysarthria, diplopia, hemianopsia, ataxia are rare symptoms.
Anipulation is harmful in vertebrobasilar insufficiency.
Thoracic outlet syndromes:
The area where the nerve-vascular bundle going to the arm passes through the cervical and thoracic regions to enter the axilla is called the thoracic outlet.
Patients with thoracic outlet syndrome usually benefit from physical therapy.
Traction, superficial and cool heaters help to relieve scalene muscle spasm.
Scalenus anterior syndrome;
Small variations in the diameter, contour or attachment site of the anterior scalene muscle and muscle spasm narrow the triangle through which the nerve-vascular bundle passes and create pressure on the nerve-vascular bundle. Thus, scalenus anterior syndrome occurs.
Since the lowest trunk of the brachial plexus is exposed to the most pressure, symptoms are seen in the areas innervated by the C8 and T1 nerve roots, i.e. on the ulnar side of the forearm and hand.
Adson test is positive in scalenus anterior syndrome.
Cervical rib;
The cervical rib is an extra rib that congenitally articulates with the transverse process of the seventh cervical vertebra.
Normally, the vascular-nerve bundle passing over the first thoracic rib will have to pass over the cervical rib and will remain suspended.
If the shoulder drops down, as it happens with advancing age and carrying a heavy load, clinical symptoms will occur because the suspension and therefore the pressure will increase.
Pain and paresthesia are felt on the ulnar side of the hand, in the ring and little fingers.
Paresthetic complaints in the form of numbness and tingling are attributed to circulatory insufficiency.
Adson test is positive in some cases.
There may be a feeling of coldness in the arm.
The cervical rib can be felt in the supraclavicular fossa with palpation.
Costoclavicular syndrome;
Anomalies of the first rib and clavicle, fracture sequelae and decreased muscle tone narrow the costoclavicular space. Thus, the vascular-nerve bundle is compressed between the first rib and clavicle.
There are paresthesias such as numbness and tingling in the arm, along with pain and a feeling of fullness.
The veins in the shoulder and arm become prominent.
Reynaud phenomenon is seen in some cases.
The costoclavicular maneuver, in which the patient presses the shoulder back and down (soldier’s pose), is positive.
Hyperabduction or pectoralis minor syndrome;
It is a clinical picture that occurs when the vein-nerve bundle is compressed under the pectoralis minor tendon before opening to the axilla.
The symptoms are similar to those in costoclavicular syndrome.
The hyperabduction maneuver is positive, that is, if the radial pulse is palpated in the neutral position and the arm is hyperabducted, the pulse decreases or disappears.