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Abstract Recent studies have elucidated which tissues within cervical spine when irritated or inflamed are capable of eliciting pain. Nerve fiber endings have been identified within the outer annular layers of the intervertebral disc capable of transmitting painful sensations. They are considered to be a neurologic basis of diskogenic pain. The anterior longitudinal ligament is considered to be the nociceptive site and is innervated by the sinu vertebral nerve. The posterior longitudinal ligament is innervated by the recurrent sinu vertebral nerve and is considered to be a site of noceception. Irritation of the cervical nerve roots within the region of intervertebral foraminae results in radicular pain. The dura is innervated by the sinu vertebral nerve and considered to be the site of pain. The zygapophyseal joints are innervated by somato sympathetic fibers of the posterior primary division of the nerve root and are defined as a source of pain. The neck muscles are also a . site of nociperception. 171 The causes of neck pain include cervical spondylosis, subluxations of cervical spme (The Whiplash syndrome), inflammation (rheumatoid arthritis), muscle disorder (muscle hyperactivity), neoplastic conditions, infections and Pancoast tumors. Cervical spondylosis is the term used to describe degeneration of the cervical spine. Primarily it is a process that involves the intervertebral disc. It progresses with age and often develops at multiple interspaces. The pathophysiolgy of cervical spondylosis is multifactorial including anatomic, biomechanical and electrophysiological factors . Cervical spondylosis can be divided into three primary groups of clinical manifestations. The first group of patients includes those that have radicular complaints. The second group presents with myelopathy secondary to cervical spondylosis. The third group presents primarily with neck pain without a true radicular or myelopathic component. Cervical spondylotic myelopathy is the most senous consequency of cervical intervertebral disc degeneration. Imaging modalities play a major role in the diagnosis and management of patients with cervical spondylotic myelopathy. Electrodiagnostic studies play a limited role in the evaluation of cervical spondylotic myelopathy. 172 Clinical conditions that should be considered in the differential diagnosis of cervical spondylosis are divided into two major subheadings: intrinsic and extrinsic condition. Intrinsic cervical conditions include, inflammation (Rheumatoid arthritis), neoplastic conditions, infections, multiple hyperextension / hyperflexion injuries of the cervical spine (whiplash syndrome), Pancoast tumors and syringomyelia. Extrinsic conditions include tendinitis in the shoulder (frozen shoulder), rotator cuff tendinitis, brachial plexitis, compressive neuropathies (thoracic outlet syndrome, median, nerve compression) and shoulder hand syndrome. Treatments of cervical spondylosis include non- surgical and surgical treatments. The non- surgical treatments include medication with non steroidal anti-inflammatory drags, physical therapy (transcutaneous electrical nerve stimulation, ultrasound, neuroprobe, aryl cervical traction) & cervical epidural steroid injections. Chemonucleolysis IS extremely controversial and certainly the experience in the lumber spine has been associated with significant neurological risk. Surgical treatments include the posterior. and anterior approaches. The posterior approaches include hemilaminectomy and foraminotomy for the management of cervical radiculopathy, and Laminectomy with flavectomy and laminoplasty for the 173 management of cervical myelopathy. The anterior approaches include anterior diskectomy with or without bone graft. The anterior approach to the surgical management of a central cervical soft disc herniation has been shown to be superior to that of the posterior laminectomy approach. The Whiplash syndrome is considered to be an injury of soft tissue from acceleration - deceleation, essentially a strain - sprain type of injury. A wide variety of clinical problems occurring following acceleration injury have been reported. These include spinal symptoms, central nervous system symptoms and psychiatric symptoms. The spinal symptoms include diffuse neck pain with or without radicular, radiation, cervical radiculopathy, cervical myelopathy and symptoms of lumber pain syndromes including herniated nucleus pulposus. The central nervous system symptoms are those of cerebral concussion, the Barre syndrome (sympathetic dysfunction), multiple cranial nerve dysfunction & chronic headache. 174 The psychiatric symptoms are mood and personality change, sleep disturbance, psychoneurotic reaction, depression and litigation neurosis. In treatment, conservative measures of orthopedics and neurosurgery are indicated, and include the use of cervical collars, physical therapy modalities, and the use of anti - inflammatory, and muscles relaxant. Surgery is reserved to the more severe and intractable cases. |