chapter two

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CHAPTER TWO 2.1 ANATOMY OF THE HUMAN NECK. 2.1.0 INTRODUCTION The Neck (Latin; Collum, cervix) is the transitional area between the cranium superiorly and the clavicles inferiorly that connects the head to the trunk and the limbs (Moore and Dalley, 2006). It can also be said to be the portion of the body that separates the head from the rest of the body (Sandhyarani, 2011). The anatomy of the human neck encompasses the blood vessels, nerves, larynx, thyroid and the thyroid gland, cervical spine (bones of the neck) and the musculature of the neck. For the purpose of this work, only the bones, the muscles, the cartilages and the spinal nerves will be discussed. 2.1.1 THE CERVICAL SPINE The bones in the neck are referred to as the cervical spine. The cervical spine originates just below the skull or the cranium and it is made up of seven vertebrae and eight pairs of nerves (Sandhyarani, 2011). The seven vertebrae are represented by C1, C2, C3, C4, C5, C6, and C7. Anatomists divide them into two regions namely the upper cervical region (C1 and C2), and the lower cervical region (C3 through to C7). The first two cervical vertebrae have been given special names as well as the seventh cervical vertebra. They are atypical cervical vertebrae and the remaining four (C3 – C6) are typical cervical vertebrae (Moore and Dalley, 2006). C1 is called the atlas and C2 the axis. The seventh cervical vertebra is also known as the Vertebra Prominens (the internet encyclopedia of science). The cervical vertebrae are composed of cylindrical (vertebral bodies) that lie in front of the spinal cord, and work with the muscles, joints, ligaments, and the tendons of the neck to provide support, structure and stability of the neck (Ulrich, 2004). The four typical cervical vertebrae have the following characteristics:

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Page 1: CHAPTER TWO

CHAPTER TWO

2.1 ANATOMY OF THE HUMAN NECK.

2.1.0 INTRODUCTION

The Neck (Latin; Collum, cervix) is the transitional area between the cranium superiorly and the clavicles inferiorly that connects the head to the trunk and the limbs (Moore and Dalley, 2006). It can also be said to be the portion of the body that separates the head from the rest of the body (Sandhyarani, 2011). The anatomy of the human neck encompasses the blood vessels, nerves, larynx, thyroid and the thyroid gland, cervical spine (bones of the neck) and the musculature of the neck.

For the purpose of this work, only the bones, the muscles, the cartilages and the spinal nerves will be discussed.

2.1.1 THE CERVICAL SPINE

The bones in the neck are referred to as the cervical spine. The cervical spine originates just below the skull or the cranium and it is made up of seven vertebrae and eight pairs of nerves (Sandhyarani, 2011). The seven vertebrae are represented by C1, C2, C3, C4, C5, C6, and C7.

Anatomists divide them into two regions namely the upper cervical region (C1 and C2), and the lower cervical region (C3 through to C7). The first two cervical vertebrae have been given special names as well as the seventh cervical vertebra. They are atypical cervical vertebrae and the remaining four (C3 – C6) are typical cervical vertebrae (Moore and Dalley, 2006). C1 is called the atlas and C2 the axis. The seventh cervical vertebra is also known as the Vertebra Prominens (the internet encyclopedia of science).

The cervical vertebrae are composed of cylindrical (vertebral bodies) that lie in front of the spinal cord, and work with the muscles, joints, ligaments, and the tendons of the neck to provide support, structure and stability of the neck (Ulrich, 2004).

The four typical cervical vertebrae have the following characteristics:

The vertebral bodies are small and longer from side to side than anteroposteriorly; the superior surfaces are concave, and the inferior surfaces are convex.

Their vertebral foramina are large and triangular. The transverse processes of all cervical vertebrae (whether or not typical) have transverse foramina

referred to as foramina transversarium for the passage of cervical vessels (e.g., the vertebral vein, and except for C7, the vertebral artery).

Their superior facets of the articular processes are directed superoposteriorly, and the inferior facets are directed inferoposteriorly.

Their Spinous processes are short and bifid (Moore and Dalley, 2006).

The three atypical cervical vertebrae have different characteristics from the typical ones. The atlas is a ring – like. Kidney shaped bone. It lacks spinous process and body. It consists of two lateral masses connected by anterior and posterior arches. Its concave superior articular facets receive the occipital condyles (Moore and Dalley, 2006).

The C2 vertebra (axis) has a peg – like dens, also, called the odontoid process, which projects superiorly from the body. C7 is called the Vertebra Prominens because of its long spinous process which is not bifid.

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The transverse processes are large but its transverse foramina are small (Moore and Dalley, 2006). These features of the three cervical vertebrae make them atypical of a vertebra.

The first spine (the atlas) rotates around the second vertebral body (odontoid), (the internet encyclopedia of science). The cervical vertebrae closest to the skull are the smallest. All of the cervical vertebrae are smaller than those found in the thoracic spine and the lumbar spine (Moore and Dalley, 2006).

Below are plates showing pictures of the cervical vertebrae.

The cervical spine functions to provide strength and support. It also provides structure and controls certain types of movements in the neck (with the movements described in terms of the two vertebral bodies that are connected) including rotation and flexion as well as extension (Agur and Minj, 1999).

2.1.2 THE INTERVERTEBRAL DISCS

Out of thee 23 total cervical discs also called intervertebral discs, sis of them are in the cervical spine. Each cervical disc or intervertebral disc rests between two cervical vertebrae (Sandhyarani, 2011). They act as shock absorbers in the cervical spine and allow the neck to handle much stress (Clark, 1998). The intervertebral discs also hold the cervical vertebrae together and allow for flexibility and different movements of the neck.

Fig.1a. Cervical Spine C1 – C7 Fig.1b. A typical Cervical Vertebra

Fig.1d. Atlas and AxisFig.1c. C7 Cervical Vertebra

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Each of the discs is composed of collagen and ligaments (Peter, 2004). The intervertebral disc has two parts and they are; (1) the annulus fibrosis and (2) the nucleus pulposus (Moore and Dalley, 2006). Below is a plate showing the structure of the intervertebral disc: fig. 2a is showing the outer annulus fibrosis and the inner gelatinous nucleus pulposus and fig. 2b is showing the arrangement of the fibrocartilage tissues.

The annulus fibrosis is the peripheral aspect of the intervertebral disc. It is made up of fibrocartilage in which the collagen fibres are arranged in concentric layers of sheath (Peter 2004). The collagen bundles pass obliquely between adjacent vertebral bodies and their inclination is reversed in alternate sheaths. More peripheral fibres are strongly attached to the anterior and posterior longitudinal ligaments of the vertebral column (Rosse and Gaddum-Rosse, 1997).

The central gelatinous part of the intervertebral disc is called the Nucleus Pulposus. In children and in the adolescents, it is an oval mass of gelatinous material containing large amount of fluid, small numbers of collagen fibres and few cartilage cells (Crimando, 2008). The nucleus pulposus is situated nearer to the posterior surface than to the anterior margin of the intervertebral disc (Agur and Minj, 1999).

The semifluid nature of the nucleus pulposus allows it to change shape and permit one vertebra to rock forward and backward on another e.g. as in flexion and extension of the neck. Sudden increase in compressional load (such as in falling from a height head down) on the vertebral column causes the They nucleus pulposus to flatten and lose resilience with increasing force leading to rupture of the annulus fibrosus and herniation of the nucleus pulposus into the vertebral canal (Bridwell, 2010).

The nucleus pulposus needs to be very well hydrated in order for it to be able to maintain its strength and softness and also to serve as the major carrier of the body’s axial load (Peter, 2004).

2.1.3 CERVICAL NERVES

The cervical spine has eight cervical nerves (C1 – C8). These nerves branch off of the spinal cord and control different bodily and sensory activities (Moore and Dalley, 1996). Each cervical nerve is named based on the lower cervical vertebra that it runs between (Peter, 2004). For example, the name of the root that runs between the 2nd and the 3rd cervical vertebrae in the neck will be described as the C3 nerve. Below is a plate showing the cervical nerves

Fig 2b Fig. 2a

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Fig.3.Cervical Nerves and their distributions to body part

The cervical nerves are responsible for relaying messages and ensuring that functioning to different body parts. More specifically, C1 and C2 control the head, C3 and C4 help control the diaphragm in breathing and respiration and C5 controls upper body muscles like the deltoid and the biceps. C6 controls the wrist extensors and also provides some innervation to the biceps. C7 controls the triceps and C8 the hands (Agur and Minj, 1999).

When any of the highly sensitive cervical nerves are irritated, neck pain and other symptoms may ensue with functions possibly affected in different ways (Peter, 2004).

2.1.4 MUSCLES OF THE NECK

The muscles of the neck extend both deep and superficially from the base of the skull to the back. The muscles function together to flex the head when nodding, take part in breathing and act in unison with the eye muscles causing the head to turn from side to side with the eye (Tam, 2006).

The muscles of the neck can be classified into deep and superficial muscles of the neck. They can also be classified based on the region of location into anterior and posterior muscles of the neck (Rosse and Gaddum-Rosse, 1997).

The muscles of the neck include the following;

The Platysma Muscle – this is wide, thin subcutaneous sheet of striated muscles. This muscle is located in the superficial fascia.

The Sternocleidomastoid Muscle – this is a broad strap – like muscle that is the key to the neck. This muscle runs superolaterally from the sternum and the clavicle to the lateral surface of the mastoid process (Tam, 2006).There are two of them; one on the left side of the neck and the other on the right side of the neck. The sternocleidomastoid muscle functions to tilt the head from side to side by drawing the mastoid process interiorly (i.e., it laterally flexes the neck and rotates it so that the face is turned superiorly toward the opposite side) when it acts singly. Acting together, these muscles (the left and right) flex the neck (Moore and Agur, 2000).

The Prevertebral Muscles – These deep muscles are covered anteriorly by the prevertebral fascia. They all flex the neck and the head. These muscles include the longus colli and the longus capitis.

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The next groups of muscles are the Suprahyoid Muscles. They are located superior to the hyoid bone in the neck. They include the mylohyoid, the geniohyoid, the stylohyoid and the digastric muscle.

The Infrahyoid muscles are inferior to the Suprahyoid muscles being separated by the hyoid bone. That is to say, they are inferior to the hyoid bone and hence the name. They are often referred to as “strap muscles”. This is due to their ribbon – like appearance (Tam, 2006). These muscles anchor the hyoid bone and depress the larynx during swallowing and speaking. They include sternohyoid, sternothyroid, omohyoid, and thyrohyoid (Moore and Agur, 2000).

The Scalene Muscle – The Scalenus anticus (anterior), the Scalenus Medius and the Scalenus Posticus (posterior) make up the scalene group of muscles.

Other muscles of the neck include the semispinalis capitis (deep muscle of the neck) and the Splenius Capitis (back muscle of the neck and joins the skull and the spine) (Tam, 2006).

Fig.4. are plates of muscles of the neck in the anterior, posterior and the lateral views.

Fig.4a. Anterior View of the muscles of the neck. Fig.4b. Lateral View of the muscles of the neck.

Fig.4c. Posterior View of muscles of the neck Fig.4d. Cadaveric material showing anterior deep muscles of the neck

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2.1.5 LIGAMENTS OF THE NECK

Various ligaments provide for structural connection between the adjacent vertebrae, while also helping to restrain movements. The most important of these are the anterior longitudinal ligament, the posterior longitudinal ligament, the ligamentum flavum, the supraspinous ligament, and the interspinous ligaments. The specialized region of the upper Cervical spine (i.e. the occipitoatlantal and atlantoaxial joints) has its own specialized ligaments: the apical ligament of the dens, the transverse ligament of the atlas, the alar ligaments, the tectorial membrane, as well as, the anterior and posterior atlanto-occipital membrane. The specific location of each of these ligaments dictates the role provided in affording support and restraining movements (Pt Connection, 2000).

The alar ligament – this ligament connects the sides of the dens of the axis to the tubercle on the medial side of the occipital condyles (Stedman’s medical dictionary, 2000). This ligament is also known as the “check ligament” (Moore and Arthur, 2000). The ligamentum alar checks the side – to – side movements of the neck.

The anterior atlantoaxial ligament – this is a strong membrane which is fixed above, to the lower border of the anterior arch of the atlas and below to the front of the body of the axis. It connects the tubercle on the anterior arch of the atlas to the body of the axis (Elsevier, 2008).

Apical Odontoid Ligament – this is also known as the ligament of apical dentis. This ligament extends from the tip of the odontoid process to the anterior margin of the foramen magnum (Moore, Keith and Dalley, 1999).

Other ligaments of the neck include hyoepiglottis ligament, the medial palpebral, median thyrohyoid, periodontal, cricothyroid, cricotracheal, thyroepiglottic, and transverse and the cruciate ligament of the atlas (Federative Committee on Anatomical Terminology, 1998).

Showing below are plates of ligaments of the neck.

Fig.5a. some ligaments of the cervical spine Fig.5b. Ligaments of the neck.

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2.2.0 OVERVIEW OFCERVICAL SPONDYLOSIS

2.2.1 WHAT IS CERVICAL SPONDYLOSIS?

To some extent, humans develop some degree of degeneration in the vertebrae and the discs as we grow older. As the discs degenerate over many years, they become thinner.

Cervical spondylosis is a common degenerative joint condition or disorder of the cervical spine (Sandeep, 2010). It is most likely caused by age – related changes in the cervical spine. The deterioration of the cervical spondylosis also affects the cartilages; a slippery substance that helps the bones to move easily, and the cervical discs, which are pillow – like tissues that allow for and cushion movements of the neck (Emery, 2001).

Cervical spondylosis can therefore be defined as the condition whereby there are degenerative changes in the bones (vertebrae), the intervertebral discs and the cartilages of the cervical spine (Young, 2001). Cervical spondylosis frequently comes with associated degenerative changes in the facet joints, hypertrophy of the ligamentum flavum, and ossification of the posterior longitudinal ligament. These can contribute to impingement on pain – sensitive structures such as the cervical nerves and the spinal cord which leads to various clinical syndromes (Rena, 2010).

Spondylotic changes are often observed in the ageing population. However, only small percentage of patients with radiographic evidence of cervical spondylosis is symptomatic in the early years. The changes in cervical spondylosis can lead to cervical osteoarthritis and other complications that can result in difficulties performing daily activities and disability in some cases (McCormick, Steirnmetz, and Benzel, 2003).

Treatment of cervical spondylosis is usually conservative in nature; the most commonly used treatments are anti – inflammatory drugs (Non-Steroidal Anti – inflammatory drugs – NSAIDs), physical modalities and lifestyle modification. Surgery is occasionally performed in cases whereby there are intractable pain, progressive neurologic deficits, and documented compression of nerve roots or of the spinal cord that leads to progressive symptoms and when other treatment protocols such as medications and physiotherapy fail (Rena, 2010).

2.2.2 AETIOLOGY/RISK FACTORS OF CERVICAL SPONDYLOSIS

Cervical spondylosis is caused by chronic or repeated wearing away (degeneration) of the cervical spine, including the intervertebral discs and the joints between the cervical spine (Ma and Zhao 2009). These changes can, over time, compress one or more of the nerve roots. In advance stages of the condition, spinal cord may be involved. This can affect not just the arms but also the legs as well (Moore and Blumhardt, 1997).

The major risk factor is ageing. By age 60, most women and men show signs of cervical spondylosis on x – ray (Feske and Cochrane, 2007). Other risk factors of the disorder include past neck injury (often occurs several years before), severe arthritis, Smoking and past spinal surgery (Polston, 2007). Repeated occupational trauma such as carrying axial loads and poor neck posture during work can also result in cervical spondylosis (Hassan, 2009).

Familial cases have been reported (Hassan 2009). Conditions that contribute to segmental instability and excessive segmental motion such as congenitally fused spine, Down syndrome and cerebral palsy can lead

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to cervical spondylosis. A congenitally narrow spinal canal increases the risk of developing cervical spondylosis with myelopathy. With a narrow spinal canal, the spinal cord has less space to fit inside the column of bone it occupies. Spinal canals also narrow as a result of the age-related changes of thickening of spinal ligaments and bone. This type of narrowing has the same effect as congenital narrowing (Hill et al, 2004).

Several varieties of excessive segmental motion such as atlantoaxial instability, often present in persons with Down syndrome, cerebral palsy and rheumatoid arthritis, are known risk factors (Al-Shatoury et al, 2009).

Below is a MRI showing the cervical spine of a patient with degenerative changes in the cervical vertebrae (Rena, 2010)

Fig.6 below shows a 48-year-old man presented with neck pain and predominantly left-sided radicular symptoms in the arm. The patient's symptoms resolved with conservative therapy. T2-weighted sagittal MRI shows ventral osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.

2.2.3 EPIDEMIOLOGY

The risk of developing cervical spondylosis increases with increasing age of the individual. It affects both males and females equally but may develop earlier in males than in females (Chloe and Hayley, 2010).

The prevalence in males in their third decade is 13%. This increases to nearly 100% by age 70 years. In females, the prevalence ranges from 5% in the fourth decade to about 96% in women older than 70 years (Rena 2010). X-ray findings suggest that 90% of men older than 50 years and 90% of women older than 60

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years have evidence of degenerative changes in the cervical spine (Al-Shatoury et al, 2009). The boundary between normal ageing and disease process is difficult to define (Okada et al, 2009).

A study showed that at age 60 years, half the men and one third the women had significant degenerative changes in their cervical spine (Holt and Yates, 1966). Also, another study has shown that spondylotic changes are common in persons older than 40 years. Eventually, greater than 70% of men and women are affected but the radiographic changes are more severe in males than in females (Rahim and Stambough, 1992).

Cervical spondylosis is the most common cause of spastic paraparesis or quadriparesis in people (Rena, 2010).

2.3 PATHOPYSIOLOGY

Cervical spondylosis is the result of discs degeneration. As we age, the discs fragment, lose water and collapse. Initially, this begins in the nucleus pulposus of the intervertebral discs. As a result of the loose in water, the fragmentation, and the collapse of the discs, the central annular lamellae buckles inward while the outer external concentric bands of annulus fibrosis bulge outward. This leads to increased stress at the cartilaginous end plates at the vertebral body lip (Rena, 2010).

The next mechanism is the formation of subperiostal bone. This forms osteophytic bars that extend along the ventral aspect of the spinal canal, and in some cases encroaches on the nervous tissues (McCormack, 1996). The development of the osteophytes most likely is to stabilize adjacent vertebrae, which are hypermobile as a result of the lost disc materials (Young, 2000).

In addition, hypertrophy of the uncinate process occurs, often encroaching on the ventrolateral portion of the intervertebral foramina (al-Mefty, 1993). Nerve root irritation may also occur as intervertebral discs proteoglycans are degraded (Furman et al, 2010). Ossification of the posterior longitudinal can occur with cervical spondylosis. This condition can be an additional contributory source of severe anterior cord compression (Emery, 2001).

Cervical spondylosis can also occur as a result of several important pathophysiological factors. These include static – mechanical, dynamic – mechanical, spinal cord ischaemia, and stretch – associated injuries. As ventral osteophytes develop, the cervical cord space become narrowed and may compress the spinal cord and the spinal nerves resulting in the clinical symptoms of cervical spondylosis (Rena, 2010).

Also, age – related hypertrophy of the ligamentum flavum and the thickening of the bones may result in further narrowing of the cord space (Fehlings and Skaf, 1998). Additionally, degenerative kyphosis and subluxation are fairly common findings that may further contribute to cord compression in patients with cervical spondylosis (McCormick, Steinmetz, and Benzel, 2003).

Dynamic factors relate to the fact that normal flexion and extension of the cord may aggravate spinal cord damage initiated by static compression. During flexion, the spinal cord lengthens resulting in it being stretched over the ventral osteophytic bars. During extension, the ligamentum flavum may buckle into the cord, pinching the cord between the ligaments and the anterior osteophytes which results in pains (Young, Weaver, and Mishra, 1999).

Stretch –associated injury has been implicated as pathologic factor in cervical spondylosis. The narrowing of the spinal canal and abnormal motions seen with cervical spondylosis may result in increased strain and shear forces, which can cause localized axonal injury to the cord leading to pain (Henderson et al, 2005).

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2.4 SYMPTOMS AND SIGNS

The symptoms the patient may experience include cervical pain which becomes worsened by movement. Referred pain (occiput, between the shoulder blades, upper limbs), retro-orbital or temporal pain (from C1 to C2), cervical stiffness - reversible or irreversible, vague numbness, tingling or weakness in upper limbs are the common symptoms the patient may experience in cases of cervical spondylosis. There may also be poor balance (Binder, 2007).

During assessment of the patient, the physician or physiotherapist may find signs such as limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides). There may be minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy). Poorly localised tenderness is also seen in patients with cervical spondylosis (Hoving et al, 2004).

Radiculopathy signs are also seen in clinical practice in patients with cervical spondylosis. This is suspected where there is unilateral neck, shoulder, or arm pain approximating to a dermatome. There may be accompanying changes in sensation or weakness in related muscles. It should be noted that pain or paraesthesia radiating into the arm is a nonspecific sign for nerve root pain (Vos et al, 2007).

There may be postural asymmetry with the patient flexing their head to decompress the nerve root. Neck movement may be restricted. Dural irritation can be demonstrated with the Spurling test (flexion of the neck laterally, rotation

and pressure on the top of the patient's head) - typical radicular pain is reproduced if the test is positive.

The most commonly affected nerve roots are between the C5 to C7 levels. Sensory symptoms (shooting pains, numbness, and hyperaesthesia) are more common than

weakness. Reflexes are usually diminished at the appropriate level (biceps - C5/6, supinator - C5/6, or triceps -

C7) (Neck pain - cervical radiculopathy, 2009).

In patients with cervical spondylosis, chronic suboccipital headaches are experienced by them. Although the C1 through C3 dermatomes are represented on the head and it would seem likely that occipitoatlantal and atlantoaxial degeneration would cause the pains in these areas, no contributions to these joints occur from the dorsal rami of C1 – C3. In addition, the greater occipital nerve cannot usually be compressed by bony structures. Regardless, headache can be the dormant symptom in a patient with degenerative cervical disorder (Heller, 1992). The headaches associated with cervical spondylosis are usually suboccipital and may radiate to the base of the neck and the vertex of the skull (Ellenberg, Honet, and Treanor, 1994).

2.5.1 DIAGNOSIS

In addition to a medical history and physical examination, diagnosis is made by using radiological methods. Although the X-ray of spinal cord is most profitable and most accessible method of radiological diagnosis, it is not specific or sensitive enough to set a definite diagnosis. Because of that, magnetic resonance imaging as non-invasive method that displays all structures of spinal cord and its immediate surroundings is always the method of choice in diagnosing cervical spondylosis. In addition, computerized tomography is often used to supplement the findings of magnetic resonance imaging.

2.5.2 MEDICAL HSITORY

Obtaining a detailed history is important to establish a diagnosis of cervical radiculopathy. The examiner should ask the following questions:

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First, what is the patient's chief complaint (e.g. pain, numbness, weakness, location of symptoms)? A visual analogue scale from 0-10 can be used to determine the patient's perceived level of pain.

What activities and head positions increase or decrease symptoms? This information can be helpful for both diagnosis and treatment (Nordin, Carragee, and Hogg-Johnson, 2010).

When did the injury occur, what was the mechanism of injury, and what was done at that time? Has the patient experienced previous episodes of similar symptoms or localized neck pain? Does the patient have symptoms suggestive of a cervical myelopathy, such as changes in gait,

bowel or bladder dysfunction, or lower-extremity sensory changes or weakness? What previous treatments (prescribed or self-selected) has the patient tried? These may include: the

use of ice and/or heat, medications (e.g. acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]), Physical therapy, traction, or manipulation, injection and past surgical operations on the neck (Malanga, 2009).

A social history should include the patient's sport and position, occupation, and the use of nicotine and/or alcohol (Soubrier et al, 2002).

The typical patient with cervical radiculopathy presents with neck and arm discomfort of insidious onset. The discomfort can range from a dull ache to a severe burning pain. Typically, pain is referred to the medial border of the scapula, and the patient's chief complaint is shoulder pain. As the radiculopathy progresses, the pain radiates to the upper or lower arm and into the hand, along the sensory distribution of the nerve root that is involved (Malanga, 2009).

The older patient may have had previous episodes of neck pain or give a history of having arthritis of the cervical spine. Acute disc herniation and sudden narrowing of the neural foramen may also occur in injuries involving cervical extension, lateral bending, or rotation and axial loading. These patients complain of increased pain with neck positions that cause foraminal narrowing (e.g. extension, lateral bending, or rotation toward the symptomatic side) (Nordin, Carragee, and Hogg-Johnson, 2010).

2.5.3 PHYSICAL EXAMINATION

Key to coming out with the right diagnosis of cervical spondylosis is physical examination of the patient. Examination findings include neck pain, radicular signs and myelopathic signs. Patients with neck pain often present with neck stiffness. If during history taking, the history is compatible with cervical radiculopathy, a careful search for signs of muscle atrophy in the supraspinatus, infraspinatus, deltoid, triceps and the first dorsal interosseus muscles is very helpful (Rena, 2010).

The scapula is also observed to find out if there is winging. Winging of the scapula may be present because it can occur with C6 or C7 radiculopathy. Palpating all the muscles is very important because this may allow easier detection of wasting than visualization can provide. Muscle testing is very important because muscle findings have more specificity than sensory or reflex findings (Nikolaidis et al, 2010 and Rena 2010).

Also, detailed sensory and reflex examinations in patients with cervical spondylosis are done during physical examination. Care is taken since radicular findings during sensory examination do not strictly conform directly to textbook dermatomal charts. Patients often experience pain proximally in the limbs while distally; they experience parathesias (Rena, 2010). Physical evidences of other causes of radiculopathy such as tenderness lateral to the neck in the supraclavicular fossa and Tinel sign (a sign to detect nerve irritation) are also examined (Furman MB et al, 2010).

Physical examination of the hands and limitation of ROM of the neck of the patient presenting with cervical spondylosis is also very important. In these patients, weakness is most commonly seen in the

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triceps and or the hands’ intrinsic muscles where upper extremity symptoms typically begin. Thus, wasting of the intrinsic hand muscles is also a typical finding. Hence, thorough examination of the intrinsic muscles of the hand is performed. In examining the patient’s hand, he/she is asked to make a fist and release it 20 times in 10 seconds. Observation of impairment or clumsiness in the hand may suggest cervical spondylosis (Rena, 2010). The finger escape sign may also be present. To assess this, the patient holds his or her fingers extended and adducted. If the ulnar digit drifts into abduction and flexion within 30 – 60 seconds, cervical spondylosis is suspected (Farooqi, Doran, and Buxton, 2006).

Neck range of motion in patients with cervical spondylosis may also be limited. The examiner therefore measures the range of neck motion during physical examination of the patient.

2.5.4 SPECIAL TESTS

Special tests are conducted to confirm diagnosis or make differential diagnosis. These tests include Spurling test or sign, Pectorialis Muscle Reflex test, Distraction test, the vertebral artery test and the shoulder abduction test (Borton and Willacy, 2010).

2.5.4a SPURLING TEST OR SIGN

This test is also known as neck compression test. It is usually used to confirm the disorder and also nerve root compression (Rena, 2010). The test has three aspects or stages and once one stage tests positive, there is no need to further proceed.

The test is conducted with the patient in the seated position. The first stage of the test is, with the patients neck in the neutral position, an over pressure is applied on the head. If pain is elicited or worsens, the test is positive. If the first stage of the test is negative, the examiner proceeds to the second stage of the test. T

The next stage is to side flex the neck passively and overpressure is applied. The test is positive if there is pain or the pain worsens. If the second stage too is negative, the third stage is performed. In the third stage, the examiner, rotates and laterally flexes the neck of the patient after which an overpressure is applied. Pain or worsened pain means the test is positive and cervical spondylosis is diagnosed (Woodward, and Best, 2000). The Spurling test is very much used by clinician since it has nearly 100% specificity (Rena, 2010).

2.5.4b DISTRACTION TEST

The distraction test is also referred to as axial manual traction test. This is performed with the patient sitting in a chair and well relaxed.

The test is done by gently pulling the head directly up and sustaining it for about 30 seconds. Reduction in pain after leaving the head means the test is positive and cervical spondylosis radiculopathy can be said to be the problem. Constant pain after leaving the head makes the test negative (Raj, 2006).

2.5.4c VERTEBRAL ARTERY TEST

The testing position is for the patient to lie supine, and the examiner sits with both hands supporting the subject’s head. The examiner slowly extends, rotates, and laterally flexes the subject’s cervical spine to each side. The examiner then observes the subject for dizziness, blurred vision, nystagmus, slurred speech, or loss of consciousness. Each position is held for approximately 30 seconds (Mitchell et al, 2004).

Positive findings include dizziness, blurred vision, nystagmus, slurred speech, or loss of consciousness. These are indicative of partial or complete occlusion of the vertebral artery. This test is conducted by the examiner to help him/her to eliminate certain treatment protocols. If the aforementioned signs and

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symptoms are seen in the patient after doing this test, traction and joint mobilizations are contraindicated in such patients (Zaina et al, 2003).

2.5.4d PECTORIALIS MUSCLES REFLEX TEST

Another occasionally useful test is the Pectorialis muscle reflex test. This confirmatory test is done by eliciting the Pectorialis reflex. The reflex is elicited by tapping the Pectorialis tendon in the deltopectoral groove, which causes adduction and internal rotation of the shoulder if hyperactivity is present.

A positive test suggests compression on the upper cervical spine (C2 – C4). If the patient exhibits diffuse hyperflexia, then, the jaw jerk may distinguish an upper cervical compression from lesions that are above the foramen magnum (Rena, 2010).

2.6 IMAGING STUDIES

Imaging studies are also very helpful in the diagnosis of cervical spondylosis. Imaging studies that can be used for cervical diagnostic purposes include plain radiographs, Computerized Temography (CT) Scan, and the Magnetic Resonance Imaging (MRI) (Rena, 2010).

2.6.1 PLAIN RADIOGRAPHY

Radiography of the cervical spine is usually the first diagnostic test ordered in patients who present with neck and limb symptoms, and more often than not, this study is diagnostic of cervical disc disease as the cause of the radiculopathy. The American College of Radiology recommends plain radiographs as the most appropriate initial study in all patients with chronic neck pain (American College of Radiology). For the diagnostic purpose of cervical spondylosis, lateral, anteroposterior, and oblique views of the plain radiograph of the cervical spine are ordered.

On the lateral view, disc-space narrowing is looked for by comparing the level above and below. Typically, the cervical disc spaces get larger from C2-C6, with C5-C6 being the widest disc space in normal necks, and C6-C7 slightly narrower. Besides narrowing, subchondral sclerosis and osteophyte formation can also be observed in this view (Malanga, 2009).

On oblique views, foraminal stenosis at the level of the suspected radiculopathy can be looked for by comparing it with the opposite foramina, if uninvolved. For example, in a patient with pain or sensory changes along the right C6 nerve distribution; look for narrowing of the right C5-C6 neural foramina as compared with the left side (Furusawa, et al, 2001).

On the anteroposterior view of the plain radiograph, the disc spaces and degenerative changes can also be observed in this view.

Plain radiographs are very important diagnostic tools however, there are limitations associated with them. There are problems with both specificity and sensitivity. Correlations of findings on plain radiographs and cadaver dissections have found a 67% correlation between disc-space narrowing and anatomic findings of disc degeneration. However, radiographs identified only 57% of large posterior osteophytes and only 32% of abnormalities of the apophyseal joints that were found on dissection (Malanga, 2009).

2.6.2 CT SCANING

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CT scanning provides good visualization of bony elements and can be helpful in the assessment of acute fractures. It can also be helpful when C6 and C7 cannot be clearly seen on traditional lateral radiographic views. The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation (Malanga, 2009).

CT scanning with myelography has an accuracy approaching 96% for diagnosis of cervical disc herniation. Furthermore, the addition of contrast material allows for the visualization of the subarachnoid space and assessment of the spinal cord and nerve roots. CT scanning with myelography is preferable to plain CT for assessment and localization of spinal cord compression and any underlying atrophy. This study can also determine the functional reserve of the spinal canal in evaluating athletes with possible cervical stenosis (Rena, 2010).

Even with myelography, however, soft-tissue visualization with CT is inferior to that provided by magnetic resonance imaging (MRI). For that reason, MRI is replacing CT scanning for imaging of most cervical spine disorders (Malanga, 2009).

2.6.3 MAGNETIC RESONANCE IMAGING (MRI)

MRI has become the method of choice for imaging the neck to detect significant soft-tissue pathology, such as disc herniation. The American College of Radiology recommends routine MRI as the most appropriate imaging study in patients with chronic neck pain who have neurologic signs or symptoms but normal radiographs (America College of Radiograph). MRI can detect ligament and disc disruption, which cannot be demonstrated by other imaging studies. The entire spinal cord, nerve roots, and axial skeleton can be visualized. This study is usually performed in the axial and sagittal planes (Boden, et al, 1990).

2.6.4 OTHER DIAGNOSTIC TOOLS

Myelography and electromyography (EMG) are among the other diagnostic tools that can be used for the diagnosis of cervical spondylosis.

Myelography is a useful imaging for demonstrating nerve root lesions and hence very important in using it to diagnosis cervical spondylosis. It is particularly more useful in patients who are may need surgical intervention (Alexander, 1996).

EMGs are important in identifying physiologic abnormalities of the nerve root and in ruling out other neurologic causes (Malanga, 2009). They are useful in the study of radiculopathy because they demonstrate a close correlation with neuroimaging and operative findings. They can provide anatomic distribution of abnormalities thus, facilitating the differential diagnosis of cervical radiculopathies from other similar causes of radicular symptoms (Rena, 2010).

2.7 DIFFERENTIAL DIAGNOSIS

In patients with typical symptoms and radiographic features, the diagnosis of cervical spondylosis is quite straight forward and is unlikely to be confused for other disease entities. However, in less straight forward cases, there can be misdiagnosis and hence other conditions should be considered and ruled out appropriately.

Some of these conditions that may be mistaken for cervical spondylosis include the following: Amyotrophic Lateral Sclerosis, Migraine Variants, Ankylosing` Spondylitis, and Multiple Sclerosis

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Arteriovenous Malformations, Muscle Contraction Tension Headache, Brainstem Gliomas, Polyarteritis Nodosa, Cluster Headache, Radial Mononeuropathy, Diabetic Neuropathy, Reflex Sympathetic Dystrophy, Median Neuropathy, Subarachnoid Hemorrhage, Meningioma, Syringomyelia, Metastatic Disease to the Brain, Thoracic Outlet Syndrome, Metastatic Disease to the Spine and Related Structures, Torticollis, Migraine Headache, and Migraine Headache: Neuro-Ophthalmic Perspective (Malanga, 2009).

Other conditions that may be also considered are Acromioclavicular pathology, Acute posterior cervical strain, Adhesive capsulitis, Aortic disease, Arachnoiditis, Arteriovenous malformation, Back pain, Bicipital tendonitis - Rotator cuff tears, lateral epicondylitis, Brainstem syndromes, Calcareous tendonitis,Cervical disk syndromes, Cervical lymphadenitis, Cervical rib, Congenital spinal lesion, Diskitis, Double crush syndrome, Epidural abscess, Extrinsic neoplasia (usually metastatic), Fibrositis syndromes, Frozen shoulder syndromes, Gallbladder disease, Glenohumeral arthritis, Gout (infrequently), Heart disease, Hyperabduction syndrome, Intervertebral osteoarthritis, Idiopathic brachial plexopathy (neuralgic amyotrophy), Intrinsic neoplasia, Lung disease, Meningitis, Musculoligamentous injuries to the neck and shoulder, Neoplasms, Neoplasms of the shoulder, Nerve injuries, Occipital neuralgia, Osteomyelitis, Osteoarthritis of apophyseal joints, Paget disease, Pancoast tumor, Pancreatic disease, Peptic ulcer disease, Pharyngeal infections, Posttraumatic facet fracture with narrowing of the foramen, Postural disorders. Psychogenic disorders, Rheumatic fever (infrequently), Rheumatoid arthritis, Rib-clavicle compression, Rotator cuff tears and tendonitis, Scalene muscle, Septic arthritis, Spinal cord tumors, Sternocleidomastoid tendinitis, Subacromial bursitis, Synovial cysts, Tabes dorsalis, Thoracic disk, Thoracic outlet syndrome and Tropical spastic paraparesis (Rena, 2010)

2.8 TREATMENT AND MANAGEMENT

Treatment of cervical spondylosis is mostly conservative. Medical treatment and management include neck immobilization, pharmacologic treatment, lifestyle modifications, and physical treatment and management (physiotherapy). Surgical management may also be indicated in some cases (Rena, 2010).

Little is known about the natural history of cervical spondylosis and associated radiculopathy, and there are few controlled randomized studies comparing operative with nonoperative treatment for this condition. A best-evidence synthesis by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders concluded that there is not clear evidence that surgical treatment of cervical radiculopathy provides better long-term outcomes than nonoperative measures (Nordin et al, 2008).

Initial treatment is directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and measures that reduce the forces compressing the nerve root: relative rest; avoiding positions that increase arm and/or neck symptoms; manual traction; and, if necessary, mechanical traction (American Society of Interventional Pain Physicians, 2009).

In addition, a cervical collar can be used for patient comfort and some support. A cervical pillow at night can be helpful in maintaining the neck in a neutral position and limiting head positions that cause narrowing of the neural foramen. Manual and, if necessary, mechanical traction can be used to reduce radicular symptoms by decreasing foraminal compression and intradiscal pressures (Kuijper et al, 2009).

Kuijper et al found that, with patients in the early phase of cervical spondylosis and its associated radiculopathy, the use of a semi-hard cervical collar and rest for 3-6 weeks, or physiotherapy accompanied by home exercises for 6 weeks, reduced neck and arm pain substantially compared with a wait-and-see policy (Kuijper et al, 2009).

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2.8.1 NECK IMMOBILIZATION

Neck immobilization (with a soft collar, Philadelphia collar, rigid orthoses, Minerva or molded cervical pillow for support) is a common, nonoperative treatment for neck pain and suboccipital pain syndromes caused by spondylosis and cervical radiculopathy (Sampath, 2000).

A soft collar, if worn properly maintains relative flexion in the neck. This helps to reduce the intensity of the pain by giving an amount of traction to release pressure on the nerve roots. The collar is worn as long as possible during the day. However, the patient’s comfort is key. As the symptoms improve, the collar can be worn only during strenuous activities. Eventually can be discontinued (Rena, 2010).

More rigid collars and devices may better limit motion of the cervical spine, but they may reduce muscle tone and cause muscle neck stiffness from disuse. The patient is therefore advised to do a daily cervical exercise program to limit loss of muscle tone (Griffiths et al, 2009).

Below is a plate showing a patient with cervical spondylosis using cervical collar for immobilization.

Fig 7.0: A patient wearing cervical collar.

2.8.2 PHARMACOLOGICAL MANAGEMENT

In cervical spondylosis, much of the pain is secondary to inflammation of the nerve root, usually due to a mechanical irritation of the nerve. Therefore, pharmacological treatment and management of cervical spondylosis aims at pain relief and inflammation control. Pharmacological management includes the prescription of Nonsteroidal Anti – inflammatory Drugs (NSAIDs), opioid analgesics, muscle relaxants, antidepressants and steroids (Malanga, 2009).

NSAIDs are the mainstay of pharmacologic treatment of cervical spondylosis. They are effective in reducing the effect of inflammation mainly pain. Most NSAIDs work by inhibiting the enzyme Cyclooxygenase (COX – both COX – 1 and COX – 2). These enzymes act to aid the release of other

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inflammatory mediators such as prostaglandins (PGs) which when released cause pain. Hence, once inhibited, it relieves pain due to inflammatory process (Rena, 2010)

The use of NSAIDs such as aspirin, Diflunisal, Salsalate, Ibuprofen, Naproxen, Diclofenac, Proxicam, etc. should be well monitored for adverse effect such as gastropathy, renal toxicity, hypertension, liver abnormalities and bleeding (Rena, 2010)

Antidepressants especially tricyclic antidepressants (TCAs) are usually administered to patients who present with more chronic pain symptoms. Common side effects include dry mouth, sedation, urinary retention and constipation (AGS Panel on Persistent Pain in Older Persons, 2002).

Muscle relaxants such as carisoprodol and cyclobenzaprine may also be beneficial in patients with spasms in the neck muscles (which can be due to the spondylotic changes). Opioids can be considered in patients who have moderate to severe pain due to significant structural spondylosis and those who have failed nonopioid agents. Also, for those who are at high risks for NSAIDs toxicity especially the geriatrics (AGS Panel on Persistent Pain in Older Persons, 2002). However, they should be avoided if the patient has a history of substance abuse or mood disaster (Rena, 2010).

High dose of oral steroids are given to patients with severe radiculopathy. This will rapidly reduce the pain and shorten the course of symptoms. Patients with progressive cervical spondylotic myelopathy may also benefit from steroids. Epidural injections of steroids may help patients with radicular symptoms. Also, patients who present with acute central cord injury (which can partly be due to ventral osteophytes) may benefit from high doses of the steroid methylprednisolone (Rena, 2010).

2.8.3 LIFESTYLE MODIFICATION

Lifestyle modification (e.g. neck schools, instruction in body mechanics, relaxation techniques, postural awareness, and ergonomics and or workplace modifications) may also help alleviate the symptoms of pain. Neck school is a form of small group therapy that provides techniques to patients who are willing to actively work toward recovery. Instruction in body mechanics focuses on the concept of low – loads. These concepts include avoiding forward bending and rotation of the neck, avoiding prolonged extension of the neck, avoiding prolonged sitting or standing and making a selection of a proper chair (Rena, 2010).

Workplace modification and ergonomics serve to reduce strenous neck positions during work and leisure.

2.8.4 PHYSIOTHERAPY TREATMENT AND MANAGEMENT

The use of physical modalities in the management of cervical spondylosis is one of the oldest therapeutic methods of cervical spondylosis (Rena, 2010). The aim of the physiotherapist in the treatment and management of cervical spondylosis include; relieving pain, restoring movements, strengthening muscles around the neck, educating and teaching proper posture and behavioural graded activities (BGAs) (Aarti, 2010).

The modalities the physiotherapist uses to achieve these aims include:

2.8.4a CERVICAL MECHANICAL TRACTION

This is commonly used for cervical radiculopathy management. In addition to cervical joint distraction, cervical mechanical traction may loosen adhesions within the dural sleeves, reduce compression and irritation of disc, and also improve circulation within the epidural space (Swezey, Swezey AM, and

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Warner, 1999). In tracting neck of patients with cervical traction, initial weight of about 10 pounds is recommended, eventually increasing to about 20 pounds as tolerated by the patients (Wilson, 2010).

Studies about the efficacy of intermittent traction and static tractions are conflicting with intermittent traction probably being more effective than static traction (Rena, 2010). Cervical spondylosis has been found to provide symptomatic relief of pain in patients with mild to moderate pain (Swezey, Swezey AM, and Warner, 1999).

Cervical traction is contraindicated in patients who have myelopathy, a positive Lhermitte sign or rheumatoid arthritis with atlantoaxial subluxation (Rena, 2010).

2.8.4b NECK EXERCISES

Neck exercises are also very effective in the management of cervical spondylosis. Neck exercises restore the integrity of the muscles by strengthening the muscles, relieving pain and stiffness and restoring the neck range of muscle. It also improves circulation to the neck muscles (Miller, 2011).

Exercises designed for cervical pain include Isometric neck strengthening routines, neck and shoulder stretching and flexibility exercise, back strengthening exercises such as McKenzie Exercises and aerobic exercises (Grubb and Kelly, 2000).

Isometric Neck Strengthening Exercises - Isometric neck exercises are head exercises that only require your hands for strengthening your neck muscles. Isometric exercises are the very basic strengthening exercises to help build endurance to the muscle. The isometric neck exercises will help protect the vital throat and surrounding structures. Isometric exercises will recruit muscles in order to strengthen without pain or movement. The patient can be sitting or standing position but sitting is more comfortable and hence preferred by most patients (Anne, 2009).

The procedure for isometric exercises for the various neck muscle groups are as given below.

To do these exercises, the head should be in the “neutral” position. Neutral position meaning the head is aligned with the shoulders, looking straight ahead with no tilt in any directions. In other words, perform a sitting chin tuck. A neutral position trains the neck muscles while in good posture (Miller, 2011).

Here the patient starts by sitting in a supportive chair and sit straight up. The feet are kept flat on the floor, shoulders well relaxed, and looking straight ahead and perform a chin tuck. This position is the starting positions for all of the isometric neck exercises described here.

There are four basic isometric neck exercises and they include: forward, backwards, sideways and rotation.

Isometric Neck Exercise: Front neck muscles (Neck Flexors) 

This is begun with the starting position. Place the palm of non-dominant hand on the top of your forehead. Take a deep breath in through the nose. Have the forehead match the resistance of your palm. Breathe out slowly through your mouth to the count of 10. Repeat 10 times (Anne, 2003).

Isometric Neck Exercise: (Neck Extensors) 

Repeat the starting position. Both hands are placed behind the top of the head. Take a breath in. Be sure to press the back of the head against your hands and breathe out. Hold this position for 10 seconds and repeat 10 times.

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Isometric Neck Exercise: (Neck Lateral Flexors) 

Start with the palm up against the top of your right side of your head. This is also known as the temple area. Take a breath. Have the head match the resistance on the right side without bringing the ear towards the shoulder. Breathe out to 10 seconds. Repeat 10 times. Switch sides to work the left side.

Isometric Neck Exercise: Rotation (Neck Rotators) 

Same as the side bending neck exercises but avoid the right side of your head to turn right. The left hand on can be placed on the top of the right head to avoid turning. Hold for 10 seconds and repeat 10 times.

Below are plates showing how the isometric neck strengthening exercises are done in the various neck movements.

Neck Stretching Exercises:

There are about twelve (12) upper extremity and neck stretching exercises that the physiotherapist uses to improve range of motion in stiff neck due to cervical spondylosis. These are described below:

Fig.8a. Isometric Exercise for neck flexors Fig.8b. Isometric exercise for neck extensors

Fig.8c. Isometric Neck Exercise for right and left flexion

Fig.8d. Isometric Neck Exercise for rotation

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(1) Scaleni Stretch:

The patient is instructed to sit straight up in a chair with the shoulders relaxed. The ahead is kept at eye level and the chin pointed down slightly. The head is then slowly bent to the right side. This stretch is held for 20 seconds. The patient is asked to rest for 15 seconds and repeat the exercise two more times. After, the procedure is repeated on the left side.

(2) Upper Trapezius Stretch: Sit straight up in a chair with your shoulders relaxed. Bring your chin down toward your right collar bone as far as you can without rounding your upper back. Then turn your head slightly to the left. You should feel a pulling sensation in the left side of the neck. Hold this position for 20 seconds. Rest 15 seconds and repeat again twice on that side. Then perform the stretch on the opposite side three times

Fig 9b(3) Sternocleidomastoid Stretch:

Sit straight up in a chair with your shoulders relaxed. Turn your head to look behind you over your right shoulder. Keeping your head turned to the right, slowly tilt your head to look up at the ceiling. Hold this position for 20 seconds. Rest 15 seconds and try it again twice more. Then try the stretch three times on the opposite side.

Fig 9c(4) Axial Extension:

Supine.Lying flat on your back with both your knees bent to a comfortable position, tuck your chin down toward your chest and flatten the back of your neck down to the floor. Hold this position for 20 seconds. Relax for 15 seconds and try the exercise twice more. Standing.Purchase a 4 foot long, 1/2 inch diameter dowel rod (or use a broomstick) and grasp it at either end with both hands. The rod should be at the base of your neck on your shoulders. Pull forward very gently on the rod with your hands as you push your head straight back so as to try to make a double chin. Do not let the level of your chin change. Watch yourself in a mirror to verify that your head is going straight backward. Hold this position for 5 seconds. Rest for 5 seconds and repeat nine more times. Below are diagrams to show these movements.

Fig 9a

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(5) Shoulder Shrugs:Standing in front of a mirror, slowly lift both shoulders up toward your ears. Try to lift them as high as they will go. Repeat this exercise 10 times.

Fig 9e(6) Shoulder Circling:

Stand in front of a mirror and watch yourself slowly roll your shoulders forward as far as they can go. From that forward position, then take the shoulders up toward your ears as far as they will go and then back as far as they will go so that you define half circles from front to rear. Do this 10 times. Repeat the shoulder rolls starting from the rear and going to the front.

Fig 9d (i) Supine Fig 9d (ii) Standing

Fig 9f

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(7) Protraction/Retraction:Stand up straight and slowly bring both shoulders forward as far as you can. Try to have the shoulders touch each other in front. Then take the shoulders back as far as you can, trying to squeeze the shoulder blades together in back of you. Repeat this 1 0 times.

(8) Neck Half – Circles:Stand up straight and slowly roll in a circle by taking your right ear to your right shoulder, dropping the chin to the chest, taking the left ear to the left shoulder and returning the head to center. Try to go as far as you can in each direction without pain. Do not let the shoulders creep up toward the ears. Keep them depressed throughout this exercise. Roll the head to the right 1 0 times and then to the left 1 0 times. Do not roll the head to the back.

(9) Scapular Stretches: Overhead.Stand up straight and take your left hand over your head. Bend it at the elbow so that your left hand is over your head near your right ear. Then take the right hand and push the left elbow with it more toward the right. Hold this stretch 20 seconds. Rest 15 seconds and repeat the stretch twice more on this side. Then repeat the exercise on the other side. Cross-chest.Stand up straight in front of a mirror and make sure both shoulders are pointed straight ahead. Take the left arm across your chest so that your left hand is near your right shoulder. Use your right hand to then push your left elbow in close to your chest and your left hand more toward the rear of the room. Hold this stretch 20 seconds. Rest 15 seconds and repeat the stretch twice on that side. Then repeat the whole exercise on the other side.

Fig 9g

Fig 9h

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Behind-the-back.Stand up straight and place your left hand in the small of your back. Then grab the left hand with the right and pull the left hand more in the direction of the right. The shoulders should stay squared off to the front during this stretch. Hold the stretched position for 20 seconds, rest for 15 seconds and repeat it twice more. Then repeat the entire stretch on the right side.

(10) Forearm Stretch:Sit or stand straight up and raise your left arm straight out in front of you. Flex your left wrist up so the fingers point toward the ceiling. Use your right hand to pull the left palm and fingers in toward your body more. Hold this stretch 20 seconds. Relax for 15 seconds and repeat this stretch twice more. Try it on the other side. Then again take the left hand out in front of you, but this time point the fingers down toward the floor. Again use the right hand to exacerbate the stretch of the left forearm. Again hold the stretch for 20 seconds, three times. Repeat on the right.

(NISMAT, 2007)

2.8.4c ELECTROTHERAPY AND OTHERS

Other commonly used modalities for cervical spondylosis intervention by the physiotherapist include ultrasound, short wave diathermy, microwave diathermy, electrical stimulations such as transcutaneous electrical nerve stimulation (TENS), Trabet 2 -5 current, interferential current, heat or hot packs, cold (ice packs) and massage.

Fig 9i(a) Over the Head method

Fig 9i(b) Cross – chest Method

Fig 9i(c) behind the back method

Fig 9j

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Ultrasound, Microwave and short wave diathermies, TENS, Trabet 2 -5 current and interferential have pain relieving effect on the nerves and hence its usage in the management of neck pain in patients suffering from cervical spondylosis. TENS is contraindicated in patients who may have impaired circulation to the neck (Arch4life, 2010)

Massage to the neck muscles such as gentle effleurage massage relaxes the muscles of the neck and also improves circulation to the neck which helps to relief pain in the neck (Rena, 2010).

2.9 SURGICAL MANAGEMNET

Cervical management is often not the first intervention of choice. Surgery is only indicated when other forms of management such as physiotherapy and pharmacological management have failed (Baskin, 2003).

Surgical care for cervical spondylosis involves anatomic correction of the degenerative pathologic entities that compress a nerve root or the spinal cord (Rena, 2010).

Indications for surgery include intractable pain, progressive neurologic deficits, and documented compression of nerve roots or of the spinal cord that leads to progressive symptoms. Surgery has not been proven to help neck pain and/or suboccipital pain. Several approaches to the cervical spine have been proposed. The approach selected is determined based on the type and location of pathology and the surgeon's preference (Kadanka et al, 2002).

Some of the surgical procedures include; removal of osteophytes, laminectomy - usually, a wide decompression, e.g. from C3 to C7, foraminectomy - decompression of nerve root at one or more levels after drilling away overlying bone, and anterior cervical discectomy and fusion (Lee et al, 2006).

2.3.0 PROGNOSIS

The prognosis of symptomatic cervical spondylosis depends on the stage of disease and the degree of neurologic injury and dysfunction, if any. The vast majority of patients has mild symptoms and no neurologic problems and responds well to nonoperative treatments. Other patients have chronic conditions requiring longer or ongoing treatment or surgery. The most serious development of spondylotic conditions is cervical spondylotic myelopathy, or compression of the neck spinal cord with cord damage. However, even in this condition surgical outcomes can be very successful with long-term improvement in symptoms and function achieved in up to 80% of cases (Devereaux, 2009)

By OPPONG KWADWO SAMUEL

UNIVERSITY OF GHANA

COLLEGE OF HEALTH SCIENCES