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New Type Of Exercises Quickly Heal Neck Pain Overview

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What is the treatment of whiplash injury

Whiplash injury is a term used to describe an acute cervical sprain or strain that results from acceleration and deceleration motion without direct application of force to the head or neck. Whiplash commonly affects the cervical facet joints and related musculature (trapezius, levator scapulae, scalene, sternocleidomastoid, and paraspinals). Although the symptoms of nonradicular neck and shoulder pain are often self-limiting (6-12 months), many people continue to experience more chronic symptoms. Treatment options include cervical traction, massage, heat, ice, ultrasound, isometric neck exercises, a soft cervical collar, and NSAIDs and or short-term analgesic use. Patients with persistent pain may have annular tears, coexisting degenerative joint and disc pathology, nerve root entrapment, spinal stenosis, or myelopathy. Neurologic symptoms or intractable pain symptoms that are not responsive to treatment indicate the need for further evaluation.

Prevalence of mechanical syndromes in neck pain patients

Two surveys have been conducted of consecutive patients seen by McKenzie educational faculty (May 2004a, 2004b). In total, details of over one thousand patients were included in the two surveys from nearly eighty contributing faculty members, which included 256 patients with neck pain. The results were similar in the two studies, with most neck pain patients being classified as derangement (80 ), fewer numbers in other mechanical syndromes (8 , mostly dysfunction) and some classified as non-mechanical syndrome (12 ). The minority of patients not receiving mechanical classification were mostly classified as mechanically inconclusive (4 ), trauma (4 ) and chronic pain state (3 ). Figure 7.5 Classification of 256 consecutive neck pain patients

Is surgery indicated for chronic neck pain

Indications for surgical treatment of patients with axial neck pain are uncommon. Surgery may be indicated for conditions such as instability, posttraumatic facet injuries, and C1-C2 osteoarthritis. Patients with discogenic-mediated neck pain secondary to degenerative disc disease can occasionally be treated surgically. Whitecloud has shown that 60 to 70 of patients improve following anterior discectomy and fusion. Before surgery, patients are evaluated by provocative cervical discography to confirm the source of pain. Poorer results are seen in litigation cases and cases involving more than two cervical levels.

Whiplash

Was the neck forced into back bend- The athlete is hit from behind the head remains still while ing then forward bending (whiplash) the body accelerates forward. The cervical spine is forced into (Fig. 2-10) excessive back bending that can be coupled with rotation The whiplash mechanism can subject the brain to a contrecoup phenomenon (the brain moves forward and backward in the cranium and trauma to the cortex or cerebellum can result). A full concussion evaluation should be done if a whiplash mechanism occurs. Fig. 2-10 Whiplash mechanism. Cervical back bending then forward bending. Fig. 2-10 Whiplash mechanism. Cervical back bending then forward bending.

Is whiplash real

There is controversy within the medical literature between those who believe in the validity of WAD and those who claim it to be a myth. It has been argued that 'whiplash syndrome', as opposed to brief and insignificant neck pain, is no more than a cultural construct within a biopsychosocial model of pain (Ferrari and Russell 1997, 1999). It is suggested that WAD exists only in cultures in which pain following RTA is expected, bred in an environment in which anxiety and fears are nurtured by health professionals, lawyers and patients alike. These authors believe that the 'whiplash syndrome' is an example of illness actually induced by society, in general, and by physicians in particular (Ferrari and Russell 1997). the lack of neck pain in those who crash cars for fun, or let themselves be involved in 'crashes' for the sake of experiment They attempt to show that reporting 'injuries' in part reflects compensation systems, and that the prevalence of chronic symptoms varies in different...

Neck pain

Neck pain is a commonly occurring complaint. Its yearly prevalence is comparable with low back pain and is about 50 in the adult population. Neck pain is the main complaint in about 3 of those who consult a physician. The yearly prevalence of cervical radicu-lopathy is 40-80 per 100000 12 . Repeated collision injuries in contact sports not resulting in fractures or spinal cord injuries are associated with neck pain and paresthesia. The symptoms are commonly recurrent, existing just for seconds during a match, and result from traction of the brachial plexus or nerve root irritation. In a large Finnish survey the neck and head accounted for 9 of all soccer injuries 13 . A heading in soccer involves hyperextension and compression of the cervical spine and may affect the vertebrae, intervertebral joints, disks, ligaments and muscles. Chronic complaints of pain and limited range of motion of the cervical spine were found in about 30 of former players from the Norwegian national soccer team...

Whiplash Injuries

The term whiplash refers to the mechanism of the neck injury, which can result from hyperextension followed by flexion that occurs when an occupant of a motor vehicle is hit from behind by another vehicle. Some clinicians use the term to also describe other types of collisions wherein the neck is subjected to different sequences and combinations of flexion, extension, and lateral motion. The term was first used in 1928. Other terms used include cervical sprain, cervical myofascial pain syndrome, acceleration-deceleration injury, and hyperextension injury. y Epidemiology and Risk Factors. In 1994, there were 11,200,000 motor vehicle accidents including 2,600,000 rear-end collisions in the United States. Although neck injuries can commonly occur after side or front impact collisions, rear-end collisions are responsible for about 85 percent of all whiplash injuries. Although only rough estimates exist, perhaps 1 million people sustain whiplash-type injuries per year in the United States....

What is whiplash

Whiplash is a familiar term to patients and clinicians. It generally denotes neck symptomatology that has commenced during or shortly after a motor accident. Strictly, the causal event for a true 'whiplash' injury is said to be a rear-end collision at a modest speed into a stationary vehicle in which the victim is facing forwards (Bogduk 1986). In practice, anyone involved in a car accident that develops symptoms is likely to be considered to have 'whiplash'. Neck pain that develops after a diving incident or some other high-velocity impact to the neck is also often included in the term. A major review (Spitzer et al. 1995) of the topic gave the following definition Whiplash is 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 tum may lead to a variety of clinical...

Severity and disability

The last study also reported on symptom severity. In those with continuous or recurrent pain (84 ), 11 reported this to be severe, but a further 10 reported severe episodes against a background of mild continuous pain (Picavet and Schouten 2003). A minority (6 ) reported partial disability from work and work leave greater than four weeks due to neck symptoms however, while 29 reported some limitation of daily living, the majority (80 ) reported no or minimal work loss (Picavet and Schouten 2003). High disability attributed to neck pain appears to affect the minority (< 10 ) of those with symptoms (Figure 11). Combined neck and arm pain have been reported as much more disabling than either symptom alone (Daffner et al. 2003). Figure l.1 Severity and disability grading of neck pain (N 1100)

Diagnosis Using the ICHD2

Location is not included in the diagnostic criteria. For example, neck pain, often thought to suggest TTH, is present in at least 75 of migraine patients. Forty percent of migraine is bilateral. Bilateral maxillary pain, often thought to suggest sinus headache, is a nonspecific symptom. In other words, do not make a diagnosis by location of pain alone. a. Neck pain in migraine is very common

Assessmentinterpretation

Unlike other joints of the body, there is rarely a singular mechanism of injury. Only occasionally does injury occur as one traumatic incident (i.e., a direct blow or whiplash). Usually there are multiple factors that cause low-grade microtrauma over a long period of time. The multiple causes of temporomandibular joint dysfunction are usually a combination of the following

Head And Spinal Cord Injury

One of the more common emergency conditions encountered during coverage of athletic events are head and neck injuries. Any athlete that has altered mental status, neck pain, or neurologic complaints should be considered to have a spinal cord or brain injury. By properly managing head and neck injuries, the medical team can lessen the chance of complications and expedite emergency transportation.

Treatment effectiveness

As with lumbar back pain, a wide range of treatment interventions are offered to patients with neck pain. These interventions have not appeared to affect the underlying prevalence or recurrence rates. A number of systematic reviews have been undertaken to evaluate the treatment effectiveness of interventions for neck pain, and their conclusions are summarised here. Evidence does not support the use of acupuncture for chronic neck pain of eight high-quality trials, five were negative (Kjellman et al. 1999 White and Ernst 1999). Subsequent trials have demonstrated short-term changes in pain, but outcomes no better than sham treatment (Irnich et al. 2001, 2002) or not clinically significantly better than placebo (White et al. 2004). High-quality studies demonstrated lack of effect for traction (Kjellman et al. 1999 Philadelphia Several reviews have provided limited to moderate support in favour of the short-term benefits of mobilisation and or manipulation for some types of neck pain and...

Defining traumatic brain injury TBI

Whiplash is a term first used in 1928 (Crowe, 1964a, 1964b) that describes the typical hyperextension followed by flexion of the neck that occurs when the occupant of a motor vehicle is struck from behind by another vehicle (Evans, Evans, & Sharp, 1994). Although neck injuries do occur following side or head-on collisions, approximately 85 of whiplash injuries occur as a result of rear-end impacts (Deans, McGalliard, & Rutherford, 1986).

Emergency Department Treatment and Disposition

Horner syndrome is often caused by vascular disease, trauma, or tumor associated signs and symptoms that help to localize the lesion. Cranial nerve abnormalities suggest brainstem or intracavernous pathology. Immobilize and image trauma patients with Horner syndrome. Because Horner syndrome is a primary presentation for malignancy, consider a chest x-ray in patients with risk factors. Neck pain in association with Horner syndrome raises the possibility of carotid artery dissection. Figure 2.46.

Pain from the Neck Up

Some days, when the pain of a headache gets bad, do you feel like unscrewing your head and asking for a refund Hopefully you won't need to do that after reading this chapter on pain from the neck up. We'll be discussing some of the most common pains that occur above the neck, and then look at the ways that oriental medicine identifies what's going on and treats it. Headaches, dental and neck pain, and fibromyalgia are open for your examination. So hold onto your hat (and your head) while you learn valuable tips for taking the dread out of your head.

Factors that affect the range of movement

Various factors can affect the cervical range of movement. Some of these are temporary whilst others can be structural and lead to permanent changes in range if no effort is made to prevent this from happening. Age, degenerative changes, posture and the advent of neck pain may all produce a temporary or permanent change in available range of movement. Another cause of temporary loss of range of movement is an episode of neck pain. Several studies have compared neck pain subjects with asymptomatic controls and found significant differences in range of movement, as well as the presence of pain on movement (Hagen et al. 1997b Jordan et al. 1997 Hanten et al 2000, Lee et al. 2003, 2005 Norlander and Nordgren 1998). One study found that in particular limited flexion and rotation, and pain on flexion, extension and rotation, were correlated with severity of pain and significantly different between symptomatic and asymptomatic groups (Hagen et al. 1997b). Also, significant reductions in...

Seeking pathoanatomical diagnoses

In a group of patients increasing levels of spinal degeneration shown on x-ray were related to increasing chronicity of complaint however, there was no simple relationship between degeneration and pain (Marchiori and Henderson 1996). Findings of degeneration on x-ray lack sensitivity, as degenerative changes are common in the asymptomatic population (Gore et al. 1986 Teresi et al. 1987 Matsumoto et al. 1998). Radiological changes increase with age (Friedenberg and Miller 1963 van der Donk et al. 1991 Matsumoto et al. 1998 Gore et al. 1986) as does neck pain it could be speculated whether this is causal or merely incidental. The increase in neck symptoms stabilises around the fifth to sixth decade. However, the prevalence of degenerative changes continues to increase. By age 60 to 65, 95 of men and 70 of women in a sample of two hundred without neck pain had at least one degenerative change on x-ray (Gore et al. 1986). Significant disc space narrowing was reported by magnetic resonance...

Classification systems

The proposal that matching sub-groups of non-specific spinal pain to specific interventions will lead to improved outcomes, although logical, has until lately been hypothetical only. However, two recent studies, which both use the concept of mechanically determined directional preference either wholly or as part of the classification system, have demonstrated that patients treated according to classification do better than if treated in a non-specific, even if best practice, way (Long et al. 2004 Fritz et al. 2003) Further studies also suggest that sub-groups respond better to one type of intervention than another (Childs et al. 2003, 2004b Haldorsen et al. 2002). These studies involve lumbar spine patients the same evidence is not available relating to cervical spine patients. However, there is every reason to believe that management could equally be improved using a classification system for patients with neck pain (Childs et al. 2004a). and the more recent triage classification...

Subgroup identification indications and contraindications for MDT

The majority of neck pain patients, including those with neurological signs and symptoms indicating cervical radiculopathy, are thus suitable for a mechanical evaluation using repetitive end-range motion and or static loading. Most of these will be classified in one of the mechanical syndromes, predominantly derangement, and a few with dysfunction and postural syndrome. The effect of repeated or static end-range loading on pain patterns can determine, often on day one, the potential of that patient to respond to mechanical therapy. Treatment response indicators can also be observed during the mechanical evaluation when a mechanically determined directional preference or other consistent mechanical response is sought - thus indicating the presence of one of the three mechanical syndromes (derangement most commonly, followed by dysfunction and then postural syndrome). The majority of patients with non-specific spinal pain can be classified

What is the natural history of cervical radiculopathy

Cervical radiculopathy most commonly results from nerve root compression due to a herniated disc and or cervical spondylosis. In most cases there is no preceding trauma. Patients commonly present with neck pain, headache, and sharp pain radiating to the upper extremity in a dermatomal distribution. Neck movement, cough, and Valsalva maneuvers tend to exacerbate pain symptoms. Numbness and paresthesias occur most commonly in the distal part of the involved dermatome. Patients may present with weakness of upper extremity muscles, depending on the specific nerve root that is affected. Other patients present with chronic neck pain, limited neck range of motion, and arm weakness. The majority of patients (70 -80 ) improve within several weeks. Patients with progressive or persistent neurologic weakness, myelopathy, or intractable pain should be referred for surgical evaluation.

What is the natural history of cervical spondylotic myelopathy

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in adult patients. Symptoms result from progressive compromise of the spinal cord secondary to degenerative changes in the cervical spine. The first symptoms of CSM are frequently poor balance and lower extremity weakness with resultant gait dysfunction. Patients may also present with gradual weakness and numbness of the hands and fine motor coordination deficits (clumsy hands). Some patients may complain of neck pain, although the condition is painless in many patients. Neck flexion may produce a shock-like sensation involving the trunk and upper extremities (Lhermitte's phenomenon). Bowel and bladder function may be affected in later stages of the disease. CSM is a disease with an unpredictable course. Progressive CSM may result in cord ischemia with paralysis due to cervical cord compression. The natural history of CSM has been characterized by long intervals of clinical stability punctuated...

Chronic Tension Type Headache CTTH

Clinically, CTTH is a featureless, low level headache that is never severe and generally lacks migrainous features. The ICHD-2 criteria do not call for neck pain as a criterion, a frequently mistaken quality ascribed to this diagnosis. Location does not define tension-type headache (TTH).

Fibromyalgia Tired of Being Sick and Tired

Now that youVe got the top part of your body in better shape let's move on to the rest. I have always felt it's better to have options in treating conditions such as headaches, dental, and neck pain. Fibromyalgia has also responded so favorably to treatment that I had to include it in the text. Go ahead to the next chapter to begin experiencing the relief for some of the most common shoulder and joint pains. V Say no way to neck pain through acupressure.

Mechanically determined directional preference

Mechanically determined directional preference describes the situation when postures or movements in one direction centralise, abolish or decrease symptoms and lead to an improvement in mechanical presentation. Very often postures or movements in the opposite direction cause symptoms and signs to worsen, although in part this is a response to the length of exposure to the provocative loading. The phenomenon of mechanically determined directional preference is characteristic of derangement syndrome and helps to identify the specific directional exercise that will lead to the best management strategy (Long et al. 2004). This study only involved patients with back pain, but it is a key study in demonstrating the importance of mechanically determined directional preference. It is proposed that mechanically determined directional preference will present in a similar way in patients with neck pain, although currently the evidence is limited. At randomisation patients were allocated to...

When is the use of longterm opioids considered appropriate in the management of spinal disorders

Long-term opioids are appropriate for spine patients with a well-defined structural stimulus that cannot be definitively treated. The pain level should be consistent with the structural disorder present in the spinal column. Aggressive rehabilitation and other appropriate interventions should be pursued, and their failure to relieve pain should be documented. There should be no significant psychological illness or history of addiction or drug abuse. Opioids should not be used to treat nonspecific back or neck pain.

Headache Due to Head or Neck Trauma

Following trauma to the head or neck, it is not uncommon for patients to report the onset of new headache. These posttraumatic headaches (PTHA) may be associated with mild, moderate, or severe head injury along with whiplash-type injuries. Traumas may worsen preexisting headache conditions. PTHA is frequently associated with other somatic, psychological, and cognitive symptoms which are referred to as posttraumatic syndrome (previously referred to as postconcussion syndrome) (see Table 4.7).

What are the pain generators of the spine

Soft tissue sprain or strain (muscle, tendon, ligament) is the most common disorder responsible for low back and neck pain. This diagnosis is generally based on clinical assessment without the need for interventional procedures. Frequently, the diagnosis of soft tissue sprain or strain is made by exclusion of more serious pathology and may alternately be described as nonspecific back pain syndrome. Facet joints (zygapophyseal joints or z-jointS) are paired synovial joints in the posterior column of the spine, which are innervated by medial branches of primary dorsal rami. Lumbar facet pathology may result in referred pain involving the buttock, groin, hip, or thigh. Cervical facet joint pathology can manifest as neck pain, referred pain involving the scapular area or headaches.

Imaging Of The Cervical Spine

Imaging of the cervical spine has been a topic of considerable debate in the athlete. The favorable natural history of neck pain and the high incidence of false-positive findings should temper the use of advanced imaging. Gore et al13 demonstrated that The radiographic evaluation of neck pain should begin with plain radiographs including anteroposterior, lateral, and oblique views. Evaluation should include a check of overall alignment (lordosis 21 13 degrees) as well as for instability (> 3mm translation, > 11-degree kyphosis), fracture, spondylosis, congenital malformations, or ankylosed segments. Radiographic clues to potential stenosis include canal diameter less than 17 mm, Pavlov ratio greater than 0.85 (sagittal canal diameter to sagittal vertebral body width), and encroachment of the facet joints on the spinolaminar line (Fig. 15-2). If plain films demonstrate fracture, computed tomography is recommended to improve detail of the extent of bony injury.17

Rheumatoid arthritis RA

If patients develop neck pain as a result of one of the systemic arthropathies such as RA or AS, they will generally have had symptoms for many years (Maghraoui et al. 2003). The cervical spine is an unlikely site for onset of symptoms, and the patient will generally be aware of the diagnosis. In patients with RA, neck pain has been reported in 40 - 88 cervical subluxations have been observed in 43 - 86 and neurologic deficit hasbeen reported in only 7 - 34 (Pellicci et al. 1981).

Upper cervical instability

Major trauma is the other possible cause of cervical instability. Radiography or imaging studies are not routinely needed for patients following whiplash or trauma, but it should be noted that a plain x-ray might miss significant bony injury (Barnsley et al. 2002). Serious injuries do occur during motor vehicle accidents, but these are rare and should be detected at the time of the accident (Robertson et al. 2002). Currently the most common way of investigating subluxation instability in the upper cervical region is by x-ray, with measurements taken of the atlas-dens interval in flexion, neutral and extension (Cattrysse ei al. 1997).

Extreme dizzinessvertigo

For dizziness to be deemed cervicogenic in origin, the onset and duration must parallel the neck pain and must be associated with neck movements. If with further questioning any of the symptoms listed in Table 8.4 are reported, pathology of the central nervous system should be suspected, further treatment is contraindicated and the patient should be referred to the appropriate specialist. See next section for fuller discussion about dizziness.

Headache Attributed to Carotid or Vertebral Artery Pain

Spontaneous dissection of the vertebral or carotid artery may produce head pain. The diagnosis should be considered in individuals reporting new onset of head pain along with neck pain. Clinical suspicion should be raised if the patient endorses a recent history of known provocative factors such as chiropractic manipulation, severe vomiting, or neck trauma, including whiplash-type injuries. Patients with collagen vascular disease or fibromuscular dysplasia are at particular risk. The headache tends to be ipsilateral to the side of dissection.

What injection techniques can help differentiate other pain generators that mimic cervical and lumbar pathology

Shoulder pain can frequently mimic cervical disorders. Careful examination of the shoulder joint should always be performed in a patient presenting with neck pain. Diagnostic injection into the subacromial space and the acromioclavicular joint can differentiate pain originating from the shoulder region from pain originating in the cervical spine. 4. Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain injections and surgical interventions Results of the Bone and Joint Decade 2000-2010 Task Force on neck pain and its associated disorders. Spine 2008 33 S153-S169.

Clinical Case 2 Degenerative Cervical Spondylosis

Figure 13-2 presents axial computed tomography (CT) myelogram images of a 79-year-old woman with moderate neck pain and progressive difficulty with ambulating during the past 4 years. At presentation, the patient was wheelchair bound with limited ability to transfer. Past medical history was significant for osteoarthritis, atrial fibrillation, and multiple peripheral neuropathies. Physical examination revealed gross lower extremity hyper-reflexia and weakness and was consistent with myelopathy. Her sensation was diffusely diminished in her hands and arms, but she did have normal sensation in the C4-C5 distribution. She did not have a Hoffman sign, but had extensive hand intrinsic muscle atrophy. She did have crossed adductor reflexes. She was able to flex and extend her neck to 35 degrees and laterally rotate to 40 degrees. The patient's CT myelogram demonstrated severe spinal cord compression at the C4-C5, C5-C6, and C6-C7 levels. There was anterolisthesis and osteophytic bulging,...

Clinical Case 3 Atlantoaxial Instability

Figure 13-3 presents images from a CT scan of an 85-year-old woman with severe neck pain and occipital neuralgia. The pain had been progressively worsening during the past 12-month period despite analgesia. Past medical history included hypertension, hypothyroidism, and osteoarthritis resulting in bilateral knee arthroplasties. On physical exam no weakness or evidence of myelopathy was detected. Dynamic imaging revealed a C1-C2 atlantodens interval of 4 mm in neutral, increasing to 5 mm in flexion and in extension. CT imaging (see Figure 13-3) demonstrated gross evidence of atlantoaxial instability including pannus. The patient received temporary relief with a greater occipital nerve block. Because of the overwhelming disability attributable to her neck pain and occipital neuralgia, the patient was considered for surgical intervention.

Cervical spondylosisstenosis

An important clinical point is that these changes, demonstrated on x-ray, can exist in a symptom-free population. Narrowing of joint space, disc herniation, anterior and posterior osteophytes, bony hypertrophy, foraminaI stenosis and even spinal cord compression are found in the asymptomatic population (Gore et al 1986 Friedenberg and Miller 1963 Teresi et al. 1987 Matsumoto et al 1998). Some of these changes are present in about 20 of individuals with no neck pain in their 30s, about 75 in their 50s and over 80 in their 60s (Gore et al 1986 Matsumoto et al 1998). No difference has been found in pain and disability levels between those with or without evidence of cervical spine degeneration (Peterson et al 2003). Thus, the same radiographic presentation can be found in a symptomatic or asymptomatic individual - this issue is discussed at more length in Chapter 5. Some individuals who have these radiographic changes also present with symptoms. Although cervical spondylosis may be a...

Surgery for cervical and thoracic problems

The scientific literature on surgery for neck pain and radiculopathy consists mostly of uncontrolled case series with varying periods of follow-up time (Carlsson and Nachemson 2000). Cervical radiculopathy caused by nerve root compression from disc herniation or spondylosis has been considered an indication for surgery however, there is no clear validation for this assumption (Carlsson and Nachemson 2000). Several prospective studies have in fact demonstrated the resolution of cervical radiculopathy with time andJor conservative management (Bush et al 1997 Mochida et al 1998 Maigne and Deligne 1994 Saal et al. 1996). Regarding the value of surgery for other cervical spine conditions, there were no randomised controlled trials evaluating surgery for whiplash associated disorders (WAD) (Carlsson and Nachemson A Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy found that the evidence was inadequate to provide reliable conclusions on the balance of risk...

Acute Cervical Strain Syndrome

At this time the soft cervical orthosis can be removed and gentle active ROM initiated. Cervical isometric neck strengthening exercises may also be started. With continued clinical improvement, functional and sports-specific exercises are introduced. Although commonly prescribed, the use of a soft foam cervical orthosis is controversial. In 2000 and 2003, Rosenfeld et al. published two articles that compared active neck exercises without cervical orthosis with a protocol involving rest, soft collar use, and self-mobilization these studies were performed in persons who had suffered whiplash injuries. The authors found that the patients whose clinical course did not involve orthosis use had less pain and fewer lost days from work.

Cervicogenic Headache

Headache may be a referred pain originating from the neck. This type of headache must be distinguished clinically from those patients with neck pain as an associated symptom of a primary headache disorder. Patients at risk for cervicogenic headache include those with a history of arthritis with cervical spondylosis and degenerative disc disease, or those with a history of neck trauma, particularly whiplash type injuries. Examination may reveal tenderness or muscle spasm of the cervical paraspinal and neck muscles, and limitations in cervical range of motion. The pain is most often unilateral and typically starts in the occipital region and radiates frontally. The unilaterality must be stressed as a key clinical symptom, along with the primary neck pain complaint, and the report that neck movement precipitates or aggravates the pain. Relief after cervical anesthetic blockade can confirm the diagnosis. The head pain likely originates from stimulation of the upper cervical roots leading...

Motor Vehicle Accidents Putting the Brakes on Pain

End the Backlash of Whiplash Whiplash is the common name for an injury that affects the neck and upper back. This injury normally occurs in an MVA when your auto hits something, you suddenly stop with a rapid flexion (head and neck launch forward), followed by a rapid extension (head snaps back), or vice versa. The damage from whiplash is often widespread throughout the neck and upper back. Symptoms range from a dull ache with stiffness to severe pain and frozen neck. Whiplash is often a difficult condition to treat, but I have found that Oriental Medicine with its bag of tools including acupuncture, moxibustion, herbs, Tui-Na, and acupressure can speed up recovery considerably. If you get whiplash, apply ice for the first 48 hours, along with massage and acupressure. You can start applying heat after about the first week. Take a look at Chapter 2, What to Expect on Your First Visit Does It Hurt for some of the acu-points to lessen the pain and speed up the gain. The two most common...

Patient demographics

Patients are more susceptible to certain problems at different times of life. Postural syndrome is more likely to be present in the young, whilst young to old adults have derangements and dysfunctions. Osteoporosis is generally only relevant in the elderly, esperially postmenopausal women, although there are exceptions. With increasing age spinal degeneration is more likely to be present, the intervertebral disc becomes dehydrated and fibrosed, and osteophytes and other bony changes can occur around the zygapophyseal and uncovertebral joints and vertebral bodies (Taylor and Twomey 2002). Such changes may predispose to spinal stenosis affecting nerve roots or the spinal cord. MalignanCies are also more common in the older age group. Completely new onset of headache or neck pain in older patients who have never experienced this before is also a possible warning symptom. Equally we should be aware of any normal sporting or recreational activities that they have stopped because of neck...

Cervical Cord Neurapraxia with Transient Tetraplegia

Transient tetraplegia most often results after an impact forcing the cervical spine into hyperextension, hyperflexion, or axial loading. Affected athletes experience tetraplegic symptoms of relatively short duration that include dysesthesias, and or weakness in both arms, both legs, or all four extremities. Individuals do not generally complain of neck pain. The clinical symptoms last for as short as 10-15 minutes and as long as 48 hours. The patient regains full function and ROM and radiographs show no evidence of fracture, but these players often have cervical canal stenosis. In individuals with a narrowed canal in the AP diameter, the pathophysiology is thought to be as follows. Hyperextension or hyperflexion of the cervical spine causes further narrowing of the canal with compression of the cord against adjacent bony or ligamentous structures. Torg et al. found the incidence of transient cervical cord neurapraxia with transient tetraplegia to be 7 per 10,000 football athletes.

What do you do now

Pain in the posterior neck or occiput is common, as is generalized headache. Pain often precedes neurological symptoms by hours, days, and, rarely, weeks. Many patients with vertebral artery dissections have only neck pain and do not develop neurological symptoms or signs. Transient ischemic attacks (TIAs), when they do occur, are most often characterized by dizziness, diplopia, veering, staggering, and dysarthria. TIAs are less common in patients with vertebral artery neck dissections compared to internal carotid artery dissections. Infarcts usually cause symptoms and signs that begin suddenly. The commonest locations of ischemic brain damage are the portion of the

Mechanical presentation

In patients with cervical spine disorders, pain, range of movement, disability and functional limitations have been found to correlate with each other (Hermann and Reese 2001). Although pain, impairment and disability are related to each other, there is not always a close correlation between these different aspects of a clinical presentation. In neck pain patients we cannot measure impairment or disability directly. Instead we get proxy measures of their neck problem by seeing what functional limitations patients report and demonstrate when we examine them. Current functional limitations associated with pain may be the result of an anatomical impairment. It should

Identifying responders

Certain aspects of the history provide clues as to the likely responsiveness to mechanical diagnosis and therapy Especially suggestive of a good response is a history of intermittent symptoms and variable pain behaviour in response to different postures and activities. Intermittent symptoms indicate that there are times during the day when, as a result of being in certain positions or performing certain activities or for no apparent reason, the patient has no pain. Even in those patients who have had symptoms for years and may be deemed chronic, intermittent symptoms indicate the likelihood of a good prognosis. Neck pain that behaves in this way is demonstrating mechanically responsive pain - certain positions or movements are causing strain on spinal tissues that generates pain, whilst other positions or movements reduce deformation of spinal tissues and relieve the pain. Frequently patients are very aware of postures that aggravate or relieve their symptoms, and educating them to...

Dorsal Root Radiculopathy

Radiculopathy is generally associated with back or neck pain radiating into an extremity. The pain is poorly localizing for nerve root level but typical in the fact that it is radiating. There will generally be a loss of all modalities of sensation in a dermatomal distribution, a corresponding weakness in a myotomal distribution (i.e., with ventral root involvement as well), and segmental hyporeflexia. The most common cause is a herniated disc or osteophyte compressing on a nerve root. A structural lesion such as a neurofibroma or a metastatic focus must also be taken into consideration as possible causes.

Describe the surgical treatment for flatback syndrome

Fixed sagittal plane imbalance, or flatback syndrome, refers to symptomatic loss of sagittal plane balance primarily through straightening of the normal lumbar lordosis. Symptoms include pain and inability to stand upright with the head centered over the sacrum without bending the knees. Patients typically report a sense of leaning forward, thoracic pain, neck pain, and leg fatigue. Surgical treatment options include osteotomies (Smith-Petersen type or pedicle subtraction type), combined anterior and posterior procedures, or vertebral column resection procedures.

Outcome and Quality of Life

The postoperative recovery period is highly variable. Based on a recovery recommended for 2 to 3 months, some patients feel eager and fit to take up their profession after as little as 4 to 6 weeks, whereas others continue to suffer from certain sequels, such as head and neck pains, tinnitus induced or worsened by noises and voices, dizziness, and general fatigue, for 6 months or even longer. On close examination, head and neck pain are found to originate from occipital nerve irritation (rare) or preexisting cervical osteochondrosis. Tinnitus is less common in patients with some preserved hearing, whereas it is increased or more irritating to patients with postsurgical deafness. Balance disturbances resulting from the unilateral loss of vestibular nerve

Posterior Fossa Meningiomas

Comedullary junction, and the vertebral artery and its branches, such as the posterior inferior cerebellar artery (PICA) (Figure 45-12). The typical clinical symptoms are suboccipital and neck pain, ipsilateral upper extremity dysesthesias, contralateral dissociated sensory loss, progressive limb weakness beginning in the ipsilateral upper extremity and progressing counterclockwise, and wasting of the intrinsic muscles of the hand.12 The far lateral approach is usually used for tumor resection.

Define os odontoideum and explain its likely etiology

Os odontoideum is an anomaly of the odontoid process that appears as an ossicle with smooth cortical margins separate from the body of the axis. The atlantoaxial joint becomes unstable as the odontoid becomes unable to function as a peg. Associated symptoms range from mild neck pain to myelopathy and sudden death secondary to minor trauma. Surgery is considered in the presence of neurologic deficit, C1-C2 instability greater than 10 mm on flexion-extension radiographs, or persistent neck pain. Some experts advise surgical stabilization for all patients with os odontoideum due to the risk of catastrophic spinal cord injury from minor trauma. Recent data support two separate etiologies for os odontoideum posttraumatic and congenital.

Diagnosis Clinical Presentation

Patients may also experience headache, ear pain, or neck pain. Symptoms such as hoarseness, difficulty swallowing, bronchial aspiration, aspiration pneumonia, shoulder weakness, tongue atrophy, and tongue fasciculation suggest the involvement of the lower cranial nerves. Deficits of these nerves are usually associated with large tumors. Patients with giant tumors may have facial palsy, Horner's syndrome, diplopia from invasion of the cavernous sinus, and posterior fossa symptoms such as ataxia, nystagmus, intracranial hypertension, papilledema, and occasionally paresis or plegias from brainstem compression.

Facet Joint Procedures

Intraarticular steroid injections have been shown to be no more effective than saline injections into the facet joints.26,30 Unfortunately the only prospective, double-blind, randomized, placebo-controlled trial for intraarticular cervical facet injections was limited to MVC-related whiplash sufferers.30 The authors screened patients for facet-mediated pain with double blocks and found no benefit from intraarticular steroid versus anesthetic. Results of this study, however, should not be applied to degenerative cervical facetogenic pain, which should be studied separately. A study by Kim et al.31 evaluated intraarticular cervical facet injections in a variety of diagnoses and found that those with disc herniation responded better than those with myofascial or whiplash pain syndromes. Intraarticular hyaluronic acid injections were compared to lumbar facet joint steroid injections by Fuchs et al,32 and no difference in efficacy was noted. In the cervical spine, one prospective,...

Preventative strategies

It is reasonable to advise patients about aspects of the epidemiology of neck pain. Not everyone with neck pain has future episodes, but a considerable proportion have future or persistent episodes. Warnings regarding the natural history of neck pain, which is commonly episodic or persistent, thus represent a responsible aspect of management. Most patients are interested in prognosis and clinicians are responsible for providing this information. Two main aspects should be discussed what can be done to try to prevent an episode and what can be done should an episode occur. Physical work factors have been shown to have a relationship with neck pain, although not all studies are consistent in their findings (Ariens et al. 1999). Working in static postures, especially involving neck flexion, sitting or driving, are biomechanical loads that have been implicated as risk factors for neck pain in some studies (Grieco et al. 1998 Vingard and Nachemson 2000 Makela et al. 1991 Andersen et al....

Prevention of recurrence

Advice concerning neck care in the future is always given to the patient during the treatment episode and prior to discharge. This should include discussion of the following aspects recurrent nature of neck pain, avoiding prolonged aggravating postures, practice of prophylactic exercises and importance of general fitness. use of exercises if neck pain re-occurs.

Management principles

Treatment principles are not necessarily stable throughout the reduction of a derangement, although they may be. In one situation it may occur that a patient reduces and then resolves symptoms with a loading strategy entirely in one plane. However, situations may also arise in which initial loading in extension exposes a relevant lateral component with a worsening of peripheral symptoms. The introduction of a lateral force produces rapid centralisation. The patient then requires extension to abolish the remaining central neck pain. In a few minutes the patient has required extension, lateral and extension loading.

Occipital Condyle Syndrome

Metastasis to the area of the occipital condyle is more common than to the jugular foramen. The clinical picture is uniform. This syndrome is characterized by continuous, severe, localized, unilateral occipital pain that worsens upon neck flexion. The pain sometimes radiates toward the ipsilateral temporal area or eye and is often associated with a stiff neck. Approximately half of the patients will complain of dysarthria, dys-phagia, or both, specifically related to difficulty in moving the tongue. The ipsilateral tongue is atrophic, and fasciculations may be noted.15,53 Seven of nine patients with the occipital condyle syndrome in Greenberg's series had the typical occipital pain, four had dysarthria, and two had dysphagia all had ipsilateral tongue weakness.28 Carcinoma of the breast in women and prostate carcinoma in men were the most common metastatic sites of origin in the 11 patients reported by Capobianco et al.15

Retropharyngeal Abscess Clinical Summary

And suppurative adenitis of the lymph nodes located in the prevertebral fascia and is seen on a soft tissue lateral x-ray of the neck as prevertebral soft tissue thickening. The RPA may be preceded by an upper respiratory infection, pharyngitis, otitis media, or a wound infection following a penetrating injury into the posterior pharynx. It is helpful for the examiner to be familiar with the normal laryngeal structures. The differential diagnosis includes pharyngitis, acute laryngotracheobronchitis, epiglottitis, membranous (bacterial) tracheitis, cervical adenitis, infectious mononucleosis, peritonsillar abscess, foreign body aspiration, and diphtheria. These patients may present with stiff neck mimicking meningitis.

Chromosomal Anomalies

The major neurological features of Down's syndrome are developmental delay and severe, diffuse muscular hypotonia, which affects most patients. Convulsive disorders are also more commonly present in these patients. The pathogenesis of the convulsive activity in this population is probably multifactorial and may result from a combination of medical risk factors and inherent neurological abnormalities. As individuals with Down's syndrome age, however, other neurological signs may appear. About 20 percent of patients complain of neck pain or discomfort, and they may demonstrate torticollis, gait impairment, or corticospinal tract dysfunction. These features are believed to be related to atlantoaxial subluxation and instability and result in compression of the medulla and spinal cord.

What are the major factors to evaluate in association with degenerative disease involving the cervical spine

The important anatomic structures in the cervical spine involved by the degenerative process include the intervertebral disc, facet joints, neurocentral joints of Luschka, and ligamentum flavum. The adverse effects of the degenerative process may be exacerbated by abnormal motion segment mobility, congenital narrowing of the cervical spinal canal, ossification of the posterior longitudinal ligament (OPLL), and kyphotic deformity. The degree and extent of neurologic compression requires detailed evaluation with high-quality neurodiagnostic imaging studies. The common clinical syndromes associated with cervical degenerative disease include neck pain, radiculopathy, and myelopathy.

Flexion principle previously Derangement

There may be certain clues found during the history-taking and physical examination that suggest the flexion principle should be used, which are listed in the previous chapter. The patient might report that they have anterior as well as posterior neck pain and that they have pain or problems with swallowing. Such derangements can result from road traffic accidents. On examination there will be marked loss of flexion, but full-range pain-free extension. This presentation is relatively rare.

Neck Back and Myofascial Pain

Recent randomized trials with good designs add to the potential armamentarium of interventions, although all of these results require confirmation by additional trials. For low back pain, osteopathic manual care and standard medical care produce equivalent results 140 bipolar magnets were no better than sham magnets 141 low energy laser treatment 3 times per week for 4 weeks is modestly better than sham treatment 142 40 units of botulinum toxin injected into 5 paralumbar sites is better than placebo for up to 8 weeks of less pain 143 neuromuscular electrical stimulation and TENS for 5 hours per day at 2-day intervals is better than placebo stimulation 144 percutaneous electrical nerve stimulation with acupuncturelike needles in the paraspinal muscles reduces the need for opioid analgesics more than sham treatment, TENS, or exercise 145 and facet injections with methylprednisolone are no better than placebo in patients who reported less pain after the facet was injected with local...

Discuss the indications and results of posterior foraminotomy and discectomy for a herniated cervical disc

Patients who have acute radiculopathy without long-standing chronic neck pain and posterolateral or intraforaminal soft tissue disc herniation are excellent candidates for posterior foraminotomies. The disc space height should be well preserved, and there should be no associated spinal instability. The advantages of this technique are avoidance of fusion and early return to function. The disadvantages are difficulty in removing pathology ventral to the nerve root, especially an osteophyte, and the potential for instability if more than 50 of the facet is removed. Satisfactory outcomes are seen in 85 to 90 of properly selected cases (Fig. 46-1).

Discuss advantages and disadvantages of cervical laminectomy combined with posterior fusion and screwrod instrumentation

The addition of instrumentation and fusion can prevent postlaminectomy instability and improve neck pain. In addition, patients with flexible kyphotic deformities can undergo correction of their deformities following laminectomy by surgical repositioning and fusion in a more lordotic posture. Laminectomy and fusion provides a good alternative for select patients who require multilevel treatment for myelopathy associated with mechanical neck pain. Disadvantages of this approach include a higher rate of complications than alternative procedures such as laminoplasty (Fig. 46-4).

Flexion principle History and examination

A small group of patients with unilateral or asymmetrical symptoms to the elbow require the flexion principle clues that may suggest patients need this principle of treatment are listed in Chapter 18. There may be certain clues found during the history-taking and physical examination that suggest the flexion principle should be used. The patient might report that they have anterior as well as posterior neck pain, and that they have pain or problems with swallowing. Such derangements can result from road traffic accidents. On examination there is marked loss of flexion, but full-range pain-free extension. This presentation is relatively rare.

Are there any techniques that can be used to decrease the risk of construct failure when cervical corpectomies are

A corpectomy-discectomy construct. This patient with cervical myelopathy from three disc level disease was treated with C5 corpectomy and a C6-C7 anterior discectomy and fusion. This construct allowed for additional fixation into the intervening segment at C6 and provided greater stability compared with a two-level corpectomy of C5 and C6. (From Rhee JM, Riew KD. Evaluation and management of neck pain, radiculopathy and myelopathy. Semin Spine Surg 2005 17(3) 174 185. p. 182.)

Management of Derangements Cha Ter Twenty 339 Unilateral or Asymmetrical Symptoms Below the Elbow

This chapter describes the management of patients with symptoms in the forearm that are referred from the neck. These symptoms may be pain anc Jor paraesthesia and may be accompanied by pain in the arm, shoulder, scapular region or neck. These patients are those previously classified as Derangements 5 and 6, and comprise up to 20 of the neck pain population (McKenzie 1990). Specific cervical pain with clear aetiology is more likely in this group as it includes those with nerve root involvement. This may be suggested by pain patterns, paraesthesia, muscle weakness or reflex loss. Nerve root pathology may be caused by reducible derangements, which respond positively to mechanical therapy. It may be caused by irreducible derangements or degenerative lesions, such as stenosis around the intervertebral foramina. These will not respond directly, although they often settle over time. This group thus includes a number who, by the nature of their pathology, will be unresponsive to mechanical...

Experimental Case Studies

While driving on a freeway, an elderly couple was suddenly confronted by an 18 wheeler truck that plowed into the road divider and toppled onto the roof of their car. The wife dropped below the level of the window, but the husband felt the roof of the car collapsing on his head. The roof partially held, but they could not get out of the car. All was quiet for moments, then the roof and truck groaned and compressed the roof to the level of the bottom of the window before stopping again. He heard the voices of several men trying to figure out how to get to the car under the long cargo container that completely obscured it. One voice said, Nobody can be alive in there. The couple was pulled out several hours later by a crew of fireman and rescue workers. He had neck pain and arm weakness that led to the removal of a centrally herniated cervical disk. During the acute hospital stay, he seemed very anxious and detached from his wife, who had no injuries. He recalled little about the...

Clinical presentation and diagnosis

A high index of suspicion should be maintained for patients at risk for CNS infections. Prompt recognition and diagnosis are essential so that antimicrobial therapy can be initiated as quickly as possible. A medical history (including risk factors for infection and history of possible recent exposures) and physical examination yield important information to help guide the diagnosis and treatment of meningitis. Common signs and symptoms include fever, headache, nuchal rigidity (stiff neck), and photophobia. As common meningeal signs are not typically present in infants, nonspecific signs and symptoms including excessive irritability or crying, vomiting or diarrhea, tachypnea, altered sleep pattern, and poor eating should be noted. Depending on involved pathogens and disease severity, patients may also present with altered mental status, stupor, and seizures.

Stenosis in the Cervical Spine

A 63-year-old female presented to clinic with an 8-year history of worsening neck pain radiating to her bilateral shoulders and scapulae. The pain radiated primarily down her bilateral biceps and radial forearms into the thumb and index fingers of both hands. Additionally, she had noted a gradually worsening weakness in her legs, with loss of balance, worsening handwriting, and difficulty buttoning buttons and manipulating small objects with her hands. She had no bowel or bladder dysfunction. Despite nonoperative management that included activity modification, physical therapy, and nerve root and trigger point injections, her symptoms persisted and seemed to be worsening.

Clinical picture Onset

When severe neck pain or Significant trauma marked the onset of this episode some time will have elapsed at least six to eight weeks is probably necessary to allow dysfunction to develop. They may report involvement in a road traffic accident in the past. Since the onset the pain has eased considerably, but is now unchanging. When the onset has been insidious, the patient will be older, poor posture will be obvious, there may be an episodic history of neck pain in the past, and symptoms and functional impairment may well be worsening gradually over time. one exception, all dysfunctions present with local neck pain only this may be symmetrical, unilateral or asymmetrical.

Management of multiple direction dysfunction

Multiple direction dysfunction is usually the result of either a road traffic accident or spondylosis and poor posture. If the patient has incurred a whiplash injury and subsequently developed dysfunction, this will have been at least six to eight weeks previously. The original symptoms have eased, but there has been no further recent improvement. Symptoms are intermittent and several movements may be affected, although not necessarily equally. The patient fulfils all the normal criteria to confirm a dysfunction. For a full discussion of management of whiplash associated disorders (WAD) at all stages, see Chapter 25.

Development of adherent nerve root

Thus nerve root adherence is an uncommon complication that may arise following a cervical disc herniation. In an audit of mechanical diagnosis that included seventy-eight neck pain patients, one was classified as an adherent nerve root (May 2004a). Patients who remain cautious of resuming normal activity and movement are more likely candidates for this complication. If, despite overall improvement, the range of cervical flexion and or lateral flexion and arm movements remain limited and unchanging, patients may well have developed nerve root adherence. Assessment must differentiate between derangement and adherent nerve root. If adherence is the cause of the remaining symptoms, such patients should be provided with a structured exercise programme designed to remodel any structures that are adherent or contracted. That management is detailed below Obviously if symptoms are still the result of a derangement, the appropriate reductive forces must be found this management is described in...

Clinical Manifestations

Stage II of Lyme borreliosis may involve the neurological system. Of patients, 10 to 15 percent may have this involvement and present with a meningitis-type picture or have cranial nerve palsies. The most commonly involved cranial nerve is the seventh (facial) nerve, which results in an inability to control properly the facial musculature. In individuals with meningeal irritation, episodic headaches, neck pain, and stiffness may occur. Cerebrospinal fluid analysis frequently shows a predominance of mononuclear white blood cells. Occasional patients with stroke syndromes including hemiparesis as well as cases mimicking multiple sclerosis or encephalitis have been reported. Individuals may have associated confusion, agitation and disorientation, and memory loss. The symptoms and signs may wax and wane over weeks and months.

Physical examination

A patient with ANR has intermittent symptoms produced in positions that tension the nerve complex thus they should be pain-free in the neutral startingposition for the cervical examination. Most single and repeated cervical movements alone will have little or no effect on arm symptoms in most cervical ANR, although there may be some residual neck pain. Contralateral lateral flexion can be restricted and painful extension can be full and pain-free. Only if the adherence were especially severe would flexion by itself produce symptoms, but this is rare. Obviously if there is any suggestion of symptoms worsening or peripheralising, derangement should be suspected.

Clinical Manifestations and Pathology

Meningitis, however, is the more common result, occurring when bacteria travel through the blood to infect the membranes of the brain and spinal cord. Fever, violent headache, stiff neck, and vomiting are typical symptoms, and, as in meningococcemia, many victims show a petechial rash due to blockage of small blood vessels. A thick, purulent exudate covers the brain, and arthritis, cardiac damage, and shock may develop. Coma, convulsions, and delirium are frequent, and death rates for untreated cases range from 50 to 90 percent. Even in epidemic conditions, however, only a small minority of persons harboring the organism develop clinical disease. It is not known why most people remain healthy carriers whereas others become desperately ill. Individual susceptibility, damage to mucous membranes, and concomitant infections with other bacteria may all play a role.

Postural syndrome aggravating factor lying

Individuals frequently awake with neck pain, presumably arising from end-range or awkward positions of the head and neck assumed and maintained during sleep. Derangements can arise in this way and symptoms will persist for a few days or more and be accompanied by restricted painful movements. Pain from cervical postural syndrome fades away once the individual gets up, and there are no effects on movements. However, this may occur regularly if the person sleeps in an awkward position that sustains the neck in an end-range posture or uses unsuitable pillows.

Clinical Features and Associated Findings

Patients who developed paralytic poliomyelitis may initially have had clinical symptoms of fever, malaise, headache, and gastrointestinal or upper respiratory tract symptoms. These symptoms subsided, only to recur after several days in association with increasing signs of meningeal irritation, headache, and stiff neck. When the illness progressed to the paralytic form, muscle soreness was prominent, particularly in the back and neck. Patients who developed paralysis usually did so on the second to fifth day after meningeal signs and fever became evident. Once weakness began, it typically progressed for only the first few days after its onset. The fever persisted for several days but often subsided before the paralysis was complete. Patients complained of severe muscle pain and spasms with asymmetrical flaccid muscle weakness that usually affected a lower extremity. Severe bulbar weakness occurred in 10 to 15 percent of patients with paralysis. The disease was most common in...

Signs And Symptoms

Children with cervicomedullary tumors often develop symptoms and signs that can occur for several months or years before discovery of the tumor.25 Signs and symptoms generally fall into one of three major syndromes medullary dysfunction, spinal cord dysfunction,24 and hydrocephalus.25 Medullary dysfunction can lead to symptoms attributable to cranial nerve dysfunction such as facial nerve palsy or weakness,25 dysphonia, dysarthria, dysphagia, palatal deviation, and recurrent aspira-tion.21 Children may also complain of facial pain19 and torticollis.9 Severe neck pain may be a child's only complaint.7,21 The respiratory centers in the medulla may also be affected, causing apnea, or irregular nocturnal breathing patterns19 pulmonary edema and hiccups.25

Classification of WAD

As the identification of specific pathology without the use of intrusive injection technology is highly problematical, classification is usually based on symptomatology. Most commonly this is related to duration of symptoms, which are described as either acute or chronic. The Quebec Task Force (QTF) classification attempts to portray some level of the severity of symptoms resulting from a whiplash injury (Spitzer et al. 1995) . No neck pain Neck pain, stiffness or tenderness only Neck pain and Neck pain Neck pain and

Vertebroplasty

Vertebroplasty is the percutaneous augmentation of a vertebral body using polymethylmethacrylate. Polymethylmethacrylate (PMMA) was first introduced in 1970 by Charnley for orthopedic use in total hip replacements.13 In 1984, Deramond and associates113 in France performed percutaneous bone augmentation using PMMA. They placed the PMMA in the cervical vertebra of a 50-year-old woman who had a C2 vertebral hemangioma with a long-term complaint of neck pain. The patient reported complete pain relief. The procedure was then called percutaneous vertebroplasty.113 In 1988, Duquesnel 13 used percutaneous vertebroplasty for treatment of compression fractures caused by osteoporosis or malignancy. In the United States, Dion introduced percutaneous vertebroplasty at the University of Virginia in 1993 to treat compression fractures.13 113

Neurological examination

Neck pain may be the first clinical symptom of a slowly growing acusticus neurinoma, with absent corneal reflex being the first sign. Patients with referred pain in the region of trigeminus nerve pain commonly present an underlying pathology of the upper cervical spine, often observed in at-lanto-axial instability due to rheumatoid arthritis 38, 42 .

Management of WAD literature

Several systematic reviews of conservative treatments for acute whiplash have recently been conducted. The general conclusions of all are similar - early activity is best, and the use of collars or rest leads to poorer outcomes. Peeters et al. (2001) concluded that active treatments show a beneficial long-term effect, and that 'rest makes rusty'. Bogduk (2000) found a home exercise programme better than rest, and stated that traction, electromagnetic therapy, collars, TENS, ultrasound, spray and stretch and laser should not be used. Magee et al. (2000) found studies indicated a weak-to-moderate positive effect for exercise, educational advice on posture and manual therapy. The QTF supported the use of exercises, advice on posture and mobilisation to help promote activation (Spitzer et al. 1995). Guidelines for physiotherapy management of whiplash derived from the available evidence recommended active interventions such as education, exercise therapy and training of functions and...

Describe the clinical presentation of pyogenic vertebral osteomyelitis

The most consistent symptom is back or neck pain, which is noted in 90 of patients. In contrast with pain due to degenerative spinal problems, pain is typically unrelated to activity. Fever is documented in approximately 50 of patients. Neurologic deficits are present in up to 17 of patients at presentation. Radicular pain occurs in 10 of patients. Weight loss is common and occurs over a period of weeks to months. Spinal deformity may be a late presenting finding. A delay in diagnosis is common, with 50 of patients reporting symptoms for more than 3 months before diagnosis. The lumbar region is the most common site of pyogenic vertebral osteomyelitis (48 ), followed by the thoracic region (35 ) and cervical region (17 ).

What operative approach is recommended for an epidural abscess

Epidural abscess in a 36-year-old man with a history of fever and severe neck pain due to infection with gram-positive coccus. The epidural abscess extended from C-2 to the sacral region. A, The epidural abscess (arrow) is located posterior to the spinal cord in the cervical region. B, C, The epidural abscess circumferentially surrounds the neural elements in the lumbar region. (From Urrutia J, Rojas C. Extensive epidural abscess with surgical treatment and long-term follow-up. Spine J 2007 7(6) 708-11.) Figure 67-3. Epidural abscess in a 36-year-old man with a history of fever and severe neck pain due to infection with gram-positive coccus. The epidural abscess extended from C-2 to the sacral region. A, The epidural abscess (arrow) is located posterior to the spinal cord in the cervical region. B, C, The epidural abscess circumferentially surrounds the neural elements in the lumbar region. (From Urrutia J, Rojas C. Extensive epidural abscess with surgical treatment and...

What is the natural history of rheumatoid cervical disease

Understanding of the natural history of rheumatoid cervical disease is incomplete. Neck pain is common and can be present in more than 80 of patients. AAS develops in 33 to 50 of patients within 5 years of diagnosing RA. However, up to half of patients with cervical radiographic instability are asymptomatic. The most common early instability pattern is AAS. Disease progression causes the AAS to become fixed. Erosion of the C1-C2 and occiput-C1 joints leads to superior migration of the odontoid (AAI) and can eventually cause brainstem compression. Two percent to 10 of patients with AAS develop myelopathy over the next 10 years. Once diagnosed with myelopathy, 50 die within a year. SAS is less common than the other deformity patterns and typically develops after AAI or following C1-C2 fusion or occipitocervical fusion.

What are the indications for surgical treatment for RA involving the cervical spine

Indications for surgical treatment include neck pain, neurologic dysfunction, or abnormal imaging parameters (instability). Often patients present with a combination of these factors 1. Pain Neck pain or occipital pain has multiple etiologies. If pain is secondary to spinal instability or neurologic compression (e.g. radiculopathy, myelopathy), surgery is recommended

Advanced Trauma and Life Support ATLS

ATLS also calls for flexion projections of the cervical spine under supervision of an experienced doctor, prior to full 'clearance' of the spine in patients who are alert and neurologically normal but suffering neck pain. Flexion of the spine in an injured patient should be undertaken only under medical supervision.

Cervicogenic Headache and Occipital Neuralgia

This is a controversial entity whose existence has been questioned. Pain from cervical structures is referred to the head through the C1 to C4 cervical roots. Accepted causes of head pain from the neck include developmental abnormalities, tumors, ankylosing spondylitis, rheumatoid arthritis, and osteomyelitis. Controversial causes include cervical disc herniations, degenerative disc disease, and whiplash injuries. y Occipital neuralgia is thought by some to occur as a result of an injury to the occipital nerve, which may be vulnerable to compression as it passes through the semispinalis capitis muscle. Referred pain of cervical origin has often been referred to as occipital neuralgia, modifying the definition of this disorder. The prevalence of cervicogenic headache and occipital neuralgia is unknown. Risk factors include whiplash injury.

Clinical presentation and Imaging

In elderly patients who complain of slowly increasing pain which occurs also during sleeping in the low back region, gluteal region, groin, knee, or generally in the lower extremity, may have a hip or knee problem, however, remain suspicious for a metastatic bone cancer, specifically if they have a tumor history or clinical signs of a consuming disorder. Also newly appearing neck pain in an elderly person should be taken seriously by the first consulted physician and not just automatically considered as an expression of a degenerative cervical spine disease.

Syndromes of Lesions Involving Peripheral Branches of Cranial Nerve V

Crescendo orbital pain or frontal headache can herald impending internal carotid artery occlusion presumably from irritation or ischemia to peripheral trigeminal branches. Similarly, a cluster of symptoms including facial, orbital, or neck pain or facial paresthesias in association with an ipsilateral Horner's syndrome may reflect dissection of the cervical portion of the internal carotid artery. y These symptoms may also be prodromal. Excruciating pain in the supraorbital headache in association with a pupil involving third nerve palsy is almost pathognomonic for an intracranial (especially posterior communicating artery) aneurysm. Ipsilateral orbital or ocular pain has also been reported in association with posterior cerebral artery occlusion, which may reflect ischemic damage to regions of the tentorium adjacent to the occipital lobes that are innervated by V1.

Other Headache Syndromes

Thunderclap headache is defined as the sudden onset of a severe headache that reaches maximum intensity within 1 minute. It can be further defined by the absence of a subarachnoid hemorrhage. This can be due to acute onset migraine and is very difficult to differentiate from a sub- arachnoid hemorrhage. y , y An extensive neurological evaluation, including CT and lumbar puncture, is indicated in patients presenting with their first or worst headache, particularly one associated with focal neurological signs, stiff neck, or changes in cognition. CT can miss subarachnoid blood in as many as 25 percent of cases, particularly if it is not performed until days after the onset of headache.y MRI is unreliable in detecting an acute subarachnoid hemorrhage. Only with a lumbar puncture can one unerringly diagnose subarachnoid hemorrhage. Day and Raskin' have stated that all patients presenting with severe,

Degenerative Mechanics

The atlantoaxial junction is a common site for arthritic changes, most commonly seen in rheumatoid arthritis. Although classically not associated with osteoarthritis, atlantoaxial osteoarthritis has been reported to have a prevalence ranging between 5 and 18 of patients with spinal osteoarthritis.6 True symptomatic prevalence is probably much smaller. Arthritic changes can affect the lateral mass articulations and the atlantodens articulation. Degeneration at the atlantodens articulation can produce a pannus, similar to that seen in rheumatoid arthritis, causing myelopathic symptoms due to cord compression. More commonly, osteoarthritis at the atlantoaxial junction results in neck pain. This pain generally originates in the suboccipital region. It can radiate both cranially and caudally and can present with severe occipital pain. In general, occipital pain or subaxial neck pain without a suboccipital component most likely does not represent pain from atlanto-axial osteoarthritis, and...

Painful de Quervains Thyroiditis

Painful thyroiditis occurs more commonly in women (malefemale ratio of 1 3 to 1 6) between 30 and 40 years of age. It is characterized by the sudden or gradual onset of unilateral or bilateral pain in the neck, which may radiate toward the mandible or ear and is exacerbated by swallowing or neck movement. Many patients report a preceding upper respiratory tract infection with low-grade fever, neck pain, dysphagia, and flu-like symptoms with malaise and myalgias.

Drug Therapy of Chronic Migraine CM

Dose or for acute exacerbations May be given intravenously as a loading dose or for acute exacerbations Effective with or without fluoxetine for CDH in one study anxiolytic and sleep promoting. Other antidepressants (nortriptyline, protriptyline, doxepin, or imipramine) have been used in our clinic and are most effective when utilizing their assets to treat comorbid conditions insomnia, anxiety, and or depression, muscle and neck pain, fibromyalgia, etc. Effective for CDH in one controlled blinded study

Acute Suppurative Thyroiditis

Acute suppurative thyroiditis is more common in children and young adults and occurs equally in both sexes. The disease is often preceded by an upper respiratory tract infection or otitis media. It is characterized by severe neck pain radiating to the jaws or ear, fever, chills, odynophagia, and dysphonia. Infants may present with respiratory distress and stridor secondary to tracheal compression caused by a thyroid abscess.12 Rarely, acute suppurative thyroiditis may cause transient vocal cord palsy.13

Cervical radiculopathy

Cervical radiculopathy is a specific lesion affecting the cervical nerve roots in which neck pain is accompanied by upper limb pain and possibly neurological symptoms and signs (Radhakrishnan et al. 1994). This section presents some details about the epidemiology, pathology and recognition of cervical radiculopathy. For its management refer to Chapter 20, where it is included in the derangement category with referred arm pain below the elbow. The radiculopathy is most often attributed to cervical disc herniation or spondylosis, classified often as soft or hard discs respectively (Wainner and Gill 2000 Radhakrishnan et al. 1994). However, it should be noted that a number of case studies mention less common causes that include serious spinal pathology, such as tumour and arteritis (Vargo and Flood 1990 Sanchez et al. 1983 Wainner and Gill 2000). Clinical recognition of cervical radiculopathy has been made traditionally by pain pattern and accompanying paraesthesia or muscle weakness...

Differential diagnosis

Two items of history are important in helping to determine the source duration of episode and frequency of symptoms. If neck and arm pain are of recent onset, only derangement or stenosis need be included in the differential diagnosis. An adherent nerve root is a secondary product of derangement or some other trauma and takes time to form. Dysfunction of adherent nerve root is unlikely unless two to three months have passed since the beginning of the episode. Onset of the episode is from the time arm symptoms started, not simply neck pain. neck pain only.

Accreditation Commission for Acupuncture and Oriental Medicine AGAOM

Neck pain, 64-65 neck pain, 64-65 new mothers infertility, 157-158 insomnia, 227 insurance, 261-262 magnetics, 9 menopause, 171-172 migraine headaches, 61 nasal congestion, 126-127 nausea, 152 neck pain, 64-65 Oriental Medicine, 94-96 palm pressure, 30 postpartum depression, 163-164 pressure types, 32-34 Q , 8 literature, 257-258 magnetics, 9, 40-41, 74 migraine headaches, 61 morning sickness, 158-159 moxibustion, 41-42 MS, 106-107 nausea, 149-152 neck pain, 64 needles, 38-41 new mothers, 162-163 Oriental Medicine, 94-96 ovarian cysts, 179-181 PMS, 166-167 backlash, whiplash, 94-96 back pain, 82 bursitis, 70-71 neck pain, 64 ovarian cysts, 179-180 sciatica, 86 tennis elbow, 71-72 uterine fibroids, 180

Overview of Treatment for Ossification of the Longitudinal Ligament and the Ligamentum Flavum

Opll Operation

With regard to medication, NSAIDs and muscle relaxants are considered effective for local pain and stiffness. However, the only medication available for OPLL and OLF is bisphosphonate 9 , which is believed to prevent OPLL progression after surgery. In practice, when symptoms and signs of myelopathy are absent or are slight and do not limit activities of daily life, conservative treatment is indicated. In particular, when patients with cervical OPLL complain mainly of neck pain, radicular pain, or both, physicians should select conservative treatment. It is important to advise patients with OPLL not to hyperextend the neck and to be vigilant regarding trauma and falls due to sports activities or excessive alcohol intake. 5. Birch S, Jamison RN (1998) Controlled trial of Japanese acupuncture for chronic myofascial neck pain assessment of specific and nonspecific effects of treatment. Clin J Pain 14 248-255

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