Altered spinal kinematics and muscle recruitment pattern of the cervical and thoracic spine in people with chronic neck pain during functional task

Knowledge on the spinal kinematics and muscle activation of the cervical and thoracic spine during functional task would add to our understanding of the performance and interplay of these spinal regions during dynamic condition. The purpose of this study was to examine the influence of chronic neck pain on the three-dimensional kinematics and muscle recruitment pattern of the cervical and thoracic spine during an overhead reaching task involving a light weight transfer by the upper limb. Synchronized measurements of the three-dimensional spinal kinematics and electromyographic activities of cervical and thoracic spine were acquired in thirty individuals with chronic neck pain and thirty age- and gender-matched asymptomatic controls. Neck pain group showed a significantly decreased cervical velocity and acceleration while performing the task. They also displayed with a predominantly prolonged coactivation of cervical and thoracic muscles throughout the task cycle. The current findings highlighted the importance to examine differential kinematic variables of the spine which are associated with changes in the muscle recruitment in people with chronic neck pain. The results also provide an insight to the appropriate clinical intervention to promote the recovery of the functional disability commonly reported in patients with neck pain disorders.     

Carpal tunnel syndrome,humeral epicondylitis,and the cervical spine: a study of clinical and dimensional relations.

Forty-three patients with idiopathic carpal tunnel syndrome, confirmed by nerve conduction studies and treated by surgery, were compared clinically and radiologically with 43 age- and sex-matched control patients. Patients with carpal tunnel syndrome had a significantly greater prevalence of lateral humeral epicondylitis (tennis elbow) (33%) than controls (7%). Randomised reading of the cervical spine radiographs in ignorance of the groups to which they belonged showed no significant difference in the prevalence of either intervertebral disc degeneration or intraforaminal osteophyte protruion using conventional grading methods. Measurement of the minimum anteroposterior diameter of the cervical spinal canal, the anteroposterior diameters of the cervical vertebral bodies, and the ratio of intervertebral disc height to adjacent vertebral body height in the cervical spine, however, showed a consistent trend to smaller measurements in the carpal tunnel group. Differences were significant at several vertebral levels in each of these dimensions. The narrowing of the intervertebral discs relative to the vertebral bodies in patients with carpal tunnel syndrome may indicate connective tissue changes, which might also occur in the common extensor origin at the elbow or in the contents of the carpal tunnel.     

Whiplash injuries; diagnosis and treatment

Whiplash injury may extend far beyond the neck, and may involve even the soft tissues of the pelvis. For permanent recovery, all the injuries must be evaluated and treated together. When impact from the rear snaps the head back and then forward, posterior subluxations in the cervical spine cause anterior-posterior narrowing of the intervertebral foramina, which may result in injury to the cervical nerve roots. Impact at the front, causing hyperflexion followed by hyperextension, has a similar effect although usually not as severe. Resulting symptoms may not appear until two or three weeks later, when irritative lesions have developed because of hemorrhage or swelling. Mild or progressive degenerative changes may cause no symptoms but may predispose the affected area to injury following some slight trauma. Capsular ligaments of the lateral intervertebral joints are especially liable to whiplash injury which may give rise to scars and adhesions that compress spinal nerves. Sympathetic system involvement may cause reflex and referred pain. Detailed neurologic, roentgen and electromyographic studies may be necessary for proper evaluation of injuries. Seemingly psychosomatic pain or disability is likely to have some physical basis in whiplash injuries. In 33 patients with whiplash injury, some recently injured and some chronically disabled with persistent symptoms, good results were observed following hydromassage, hot packs, joint mobilization exercises and, in a few, cervical or pelvic traction.     

WHIPLASH INJURIES—Diagnosis and Treatment

Whiplash injury may extend far beyond the neck, and may involve even the soft tissues of the pelvis. For permanent recovery, all the injuries must be evaluated and treated together.When impact from the rear snaps the head back and then forward, posterior subluxations in the cervical spine cause anterior-posterior narrowing of the intervertebral foramina, which may result in injury to the cervical nerve roots. Impact at the front, causing hyperflexion followed by hyperextension, has a similar effect although usually not as severe. Resulting symptoms may not appear until two or three weeks later, when irritative lesions have developed because of hemorrhage or swelling. Mild or progressive degenerative changes may cause no symptoms but may predispose the affected area to injury following some slight trauma. Capsular ligaments of the lateral intervertebral joints are especially liable to whiplash injury which may give rise to scars and adhesions that compress spinal nerves. Sympathetic system involvement may cause reflex and referred pain.Detailed neurologic, roentgen and electromyographic studies may be necessary for proper evaluation of injuries. Seemingly psychosomatic pain or disability is likely to have some physical basis in whiplash injuries.In 33 patients with whiplash injury, some recently injured and some chronically disabled with persistent symptoms, good results were observed following hydromassage, hot packs, joint mobilization exercises and, in a few, cervical or pelvic traction.     

Effect of cervical spine position on upper limb myoelectric activity during pre-manipulative stretch for Mills manipulation: a new model, relations to peripheral nerve biomechanics and specificity of Mills manipulation

Objectives(A) Describe a new method of investigation of the possible muscular effects of the commonly practiced Mills manipulation for lateral elbow pain (epicondylalgia), (B) ascertain if myoelectric activity is influenced during the pre-manipulative stretch for Mills manipulation, (C) establish whether muscle responses are influenced by ipsilateral lateral flexion of the cervical spine which reduces mechanical tension in the peripheral nerves of the upper limb.SampleEight asymptomatic subjects were tested bilaterally (N = 16).MethodsMyoelectric measurements – EMG signals were recorded with a 16 channel pocket EMG patient unit and processed off-line. Measurement of joint positions-three CCD adjustable cameras sensitive to 10 mm reflective passive markers applied at specific locations on the subjects’ bodies were used to reconstruct and verify accuracy of body movements and were correlated with EMG recordings.ResultsCompared with the standard (anatomical) position of the cervical spine in which Mills manipulation is typically performed, cervical spine ipsilateral lateral flexion produced significantly reduced activity in muscles that restrain the manipulation movement (elbow extension), namely biceps brachii (P = 0.018) and brachioradialis (P = 0.000). The affected muscles may therefore produce protective effects during the manipulation.ConclusionsChanges in myoelectric activity were in a pattern that suggests that muscle and neural mechanisms may be an integral part of the Mills manipulation. Cervical spine ipsilateral lateral flexion may be used to reduce mechanical stresses in the peripheral nerves and extraneous muscle activity, making Mills’ manipulation potentially safer and more specific.     

Value of x ray examinations of the cervical spine.

The value of x ray examination of the cervical spine was studied. In one district general hospital it has been estimated that such examinations occupy one radiographer and one room for four hours a week. Eighty-five per cent of patients aged 60 or more who had been referred for an x ray examination of the neck in one year were reported as having cervical spondylosis, and there were no unexpected findings of infection or malignancy at any age. The reports of patients referred for x ray examination of the cervical spine were compared with those of control patients who had originally attended for barium studies. There was no significant difference in the prevalence of cervical spondylosis between the two groups, although the severity of the disc changes was greater among cases than controls. There were no consistent relations between symptoms and changes seen on x ray films. It is suggested that x ray examinations should be performed only when there is a clinical suspicion of malignancy or infection, after trauma, or when surgery may be indicated. There is little point in taking x ray films of the neck to diagnose cervical spondylosis.     

Variation in emergency department use of cervical spine radiography for alert,stable trauma patients

OBJECTIVE: To, assess the emergency department use of cervical spine radiography for alert, stable adult trauma patients in terms of utilization, yield for injury and variation in practices among hospitals and physicians. DESIGN: Retrospective survey of health records. SETTING: Emergency departments of 6 teaching and 2 community hospitals in Ontario and British Columbia. PATIENTS: Consecutive alert, stable adult trauma patients seen with potential cervical spine injury between July 1, 1994, and June 30, 1995. MAIN OUTCOME MEASURES: Total number of eligible patients, referral for cervical spine radiography (overall, by hospital and by physician), presence of cervical spine injury, patient characteristics and hospitals associated with use of radiography. RESULTS: Of 6855 eligible patients, cervical spine radiography was ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to have an acute cervical spine injury (fracture, dislocation or ligamentous instability); 98.5% of the radiographic films were negative for any significant abnormality. The demographic and clinical characteristics of the patients were similar across the 8 hospitals, and no cervical spine injuries were missed. Significant variation was found among the 8 hospitals in the rate of ordering radiography (p < 0.0001), from a low of 37.0% to a high of 72.5%. After possible differences in case severity and patient characteristics at each hospital were controlled for, logistic regression analysis revealed that 6 of the hospitals were significantly associated with the use of radiography. At 7 hospitals, there was significant variation in the rate of ordering radiography among the attending emergency physicians (p < 0.05), from a low of 15.6% to a high of 91.5%. CONCLUSIONS: Despite considerable variation among institutions and individual physicians in the ordering of cervical spine radiography for alert, stable trauma patients with similar characteristics, no cervical spine injuries were missed. The number of radiographic films showing signs of abnormality was extremely low at all hospitals. The findings suggest that cervical spine radiography could be used more efficiently, possibly with the help of a clinical decision rule.     

Altered alignment of the shoulder girdle and cervical spine in patients with insidious onset neck pain and whiplash-associated disorder

Clinical theory suggests that altered alignment of the shoulder girdle has the potential to create or sustain symptomatic mechanical dysfunction in the cervical and thoracic spine. The alignment of the shoulder girdle is described by two clavicle rotations, i.e, elevation and retraction, and by three scapular rotations, i.e., upward rotation, internal rotation, and anterior tilt. Elevation and retraction have until now been assessed only in patients with neck pain. The aim of the study was to determine whether there is a pattern of altered alignment of the shoulder girdle and the cervical and thoracic spine in patients with neck pain. A three-dimensional device measured clavicle and scapular orientation, and cervical and thoracic alignment in patients with insidious onset neck pain (IONP) and whiplash-associated disorder (WAD). An asymptomatic control group was selected for baseline measurements. The symptomatic groups revealed a significantly reduced clavicle retraction and scapular upward rotation as well as decreased cranial angle. A difference was found between the symptomatic groups on the left side, whereas the WAD group revealed an increased scapular anterior tilt and the IONP group a decreased clavicle elevation. These changes may be an important mechanism for maintenance and recurrence or exacerbation of symptoms in patients with neck pain.     

Cervical helical axis characteristics and its center of rotation during active head and upper arm movements-comparisons of whiplash-associated disorders, non-specific neck pain and asymptomatic individuals

The helical axis model can be used to describe translation and rotation of spine segments. The aim of this study was to investigate the cervical helical axis and its center of rotation during fast head movements (side rotation and flexion/extension) and ball catching in patients with non-specific neck pain or pain due to whiplash injury as compared with matched controls. The aim was also to investigate correlations with neck pain intensity. A finite helical axis model with a time-varying window was used. The intersection point of the axis during different movement conditions was calculated. A repeated-measures ANOVA model was used to investigate the cervical helical axis and its rotation center for consecutive levels of 15 degrees during head movement. Irregularities in axis movement were derived using a zero-crossing approach. In addition, head, arm and upper body range of motion and velocity were observed. A general increase of axis irregularity that correlated to pain intensity was observed in the whiplash group. The rotation center was superiorly displaced in the non-specific neck pain group during side rotation, with the same tendency for the whiplash group. During ball catching, an anterior displacement (and a tendency to an inferior displacement) of the center of rotation and slower and more restricted upper body movements implied a changed movement strategy in neck pain patients, possibly as an attempt to stabilize the cervical spine during head movement.     

Comparison of Modic Changes in the Lumbar and Cervical Spine,in 3167 Patients with and without Spinal Pain

Background Context

There are few comparisons of Modic changes (MCs) in the lumbar and cervical spine.

Purpose

Compare the prevalence of MCs in the lumbar and cervical spine, and determine how MC prevalence depends on spinal pain, age, disc degeneration, spinal level, and the presence or absence of kyphosis.

Study Design

Retrospective clinical survey.

Materials and Methods

Magnetic resonance images (MRIs) were compared from five patient groups: 1. 1223 patients with low-back pain/radiculopathy only; 2. 1023 patients with neck pain/radiculopathy only; 3. 497 patients with concurrent low-back and neck symptoms; 4. 304 asymptomatic subjects with lumbar MRIs; and 5. 120 asymptomatic subjects with cervical MRIs.

Results

The prevalence of MCs was higher in those with spinal pain than in those without, both in the lumbar spine (21.0% vs 10.5%) and cervical spine (8.8% vs 3.3%). Type II MCs were most common and Type III were least common in all groups. The prevalence of lumbar MCs in people with back pain was little affected by the presence of concurrent neck pain, and the same was true for the prevalence of cervical MCs in people with neck pain with or without concurrent back pain. When symptomatic patients were reclassified into two groups (back pain, neck pain), the prevalence of lumbar MCs in people with back pain was greater than that of cervical MCs in people with neck pain. The prevalence of lumbar and cervical MCs increased with age, disc degeneration, (descending) spinal level, and increased kyphosis.

Conclusions

There is a significantly higher prevalence of MCs in patients with back and neck pain. The reported association with increased kyphosis (flat back) is novel.     

Severe neurologic manifestations from cervical spine instability in spondylo-megaepiphyseal-metaphyseal dysplasia

Spondylo-megaepiphyseal-metaphyseal dysplasia (SMMD; OMIM 613330) is a dysostosis/dysplasia caused by recessive mutations in the homeobox-containing gene, NKX3-2 (formerly known as BAPX1). Because of the rarity of the condition, its diagnostic features and natural course are not well known. We describe clinical and radiographic findings in six patients (five of which with homozygous mutations in the NKX3-2 gene) and highlight the unusual and severe changes in the cervical spine and the neurologic complications. In individuals with SMMD, the trunk and the neck are short, while the limbs, fingers and toes are disproportionately long. Radiographs show a severe ossification delay of the vertebral bodies with sagittal and coronal clefts, missing ossification of the pubic bones, large round "balloon-like" epiphyses of the long bones, and presence of multiple pseudoepiphyses at all metacarpals and phalanges. Reduced or absent ossification of the cervical vertebrae leads to cervical instability with anterior or posterior kinking of the cervical spine (swan neck-like deformity, kyknodysostosis). As a result of the cervical spine instability or deformation, five of six patients in our series suffered cervical cord injury that manifested clinically as limb spasticity. Although the number of individuals observed is small, the high incidence of cervical spine deformation in SMMD is unique among skeletal dysplasias. Early diagnosis of SMMD by recognition of the radiographic pattern might prevent of the neurologic complications via prophylactic cervical spine stabilization.     

Position accuracy and electromyographic responses during head reposition in young adults with chronic neck pain

The head reposition test is traditionally used to examine the proprioceptive sensitivity of the neck. The aim of this study was to investigate the position accuracy and corresponding cervical electromyographic (EMG) responses of the neck pain subjects during sagittal head-to-neutral tasks. Twelve young subjects with chronic neck pain and twelve young healthy subjects were recruited. The position accuracy was measured by the constant error, variable error, and root mean square error of joint angles during head-to-neutral tasks in flexion and extension directions. Surface EMG of neck flexors and extensors were analyzed by the voluntary response index, including the similarity index (SI) and electromyographic magnitude (MAG) of muscle groups. The normalized average integration of EMG activity (NAIEMG) of individual muscle was also calculated. The results showed: (1) significantly larger constant error and root mean square error but similar variable error in patients compared with controls, (2) smaller SI but similar MAG in patients compared with controls, (3) greater synergistic/antagonistic NAIEMG in patients than controls. The findings suggested that young adults with chronic neck pain exhibit proprioceptive dysfunction and altered EMG pattern during voluntary sagittal neck motions. This study provides guidelines which could lead to the development of therapeutic exercise programs.     

Interspinous bursitis is common in polymyalgia rheumatica,but is not associated with spinal pain

Introduction

Polymyalgia rheumatica (PMR) is a common inflammatory disease in older people characterized by shoulder and/or pelvic girdle, and cervical and, occasionally, lumbar pain. Interspinous bursitis has been suggested as a potential cause of spinal symptoms. We evaluated, by 18 F-fluorodeoxyglucose (FDG) positron emission tomography integrated with computed tomography (PET/CT), the vertebral structures involved in PMR in a cohort of consecutive, untreated patients.

Methods

Sixty-five consecutive patients with PMR were studied. After a standardized physical examination, which included evaluation of pain and tenderness in the vertebral column, they underwent FDG-PET/CT. Sites of increased uptake and their correlation with spontaneous and provoked pain were recorded. For comparison, FDG-PET/CT was performed also in 65 age- and sex-matched controls and in 10 rheumatoid arthritis (RA) patients.

Results

The most frequent site of spontaneous and provoked pain was the cervical portion. FDG uptake was more frequent in the lumbar portion than at any other location, and in the cervical rather than in the thoracic portion (P <0.0001). No correlation was found between uptake and spontaneous or provoked pain. There was an association between presence of cervical and lumbar bursitis (r = 0.34, P = 0.007). None of the control patients and one out of ten RA patients showed interspinous bursitis.

Conclusions

Interspinous bursitis is a frequent finding in the lumbar spine of patients with PMR. However, it is not associated with clinical symptoms and can hardly explain the spinal pain reported by the patients. Cervical pain is more frequent than lumbar pain in PMR patients and may be caused by shoulder girdle involvement.     

Pulled elbow: a study of 100 patients.

Pulled elbow is a common condition but may not be recognized by practitioners unaware of its existence. Most of a series of 100 children with this condition were aged 1 or 2 years, and none were over 6 years. An important precipitating factor was the normal recalcitrance of the 1-3 age group. The three children who were over 5 years had all had earlier episodes which may have stretched the annular ligament. The wrist was the most common site of pain after the elbow. A single manipulation was successful in 96 cases but multiple manipulations may be needed.     

The neutral posture of the cervical spine is not unique in human subjects

Cervical spine injuries often happen in dynamic environments (e.g., sports and motor vehicle crashes) where individuals may be moving their head and neck immediately prior to impact. This motion may reposition the cervical vertebrae in a way that is dissimilar to the upright resting posture that is often used as the initial position in cadaveric studies of catastrophic neck injury. Therefore our aim was to compare the “neutral” cervical alignment measured using fluoroscopy of 11 human subjects while resting in a neutral posture and as their neck passed through neutral during the four combinations of active flexion and extension movements in both an upright and inverted posture. Muscle activation patterns were also measured unilaterally using surface and indwelling electromyography in 8 muscles and then compared between the different conditions. Overall, the head posture, cervical spine alignment and muscle activation levels were significantly different while moving compared to resting upright. Compared to the resting upright condition, average head postures were 6–13° more extended, average vertebral angles varied from 11° more extended to 10° more flexed, and average muscle activation levels varied from unchanged to 10% MVC more active, although the exact differences varied with both direction of motion and orientation. These findings are important for ex vivo testing where the head and neck are statically positioned prior to impact – often in an upright neutral posture with negligible muscle forces – and suggest that current cadaveric head-first impact tests may not reflect many dynamic injury environments.     

Cryptococcal osteomyelitis. Report of a case with aspiration biopsy of a humeral lesion with radiologic features of malignancy

BACKGROUND: Osteomyelitis due to Cryptococcus neoformans typically exhibits lytic lesions on radiographs. Extensive periosteal reaction is an uncommon feature. CASE: A 68-year-old man presented with pain and swelling in the left elbow. Radiologic studies exhibited a lytic humeral lesion with extensive periosteal reaction, interpreted as a malignant neoplasm. Fine needle aspiration biopsy (FNA) revealed abundant cryptococcal organisms. CONCLUSION: Cryptococcus is an uncommon cause of lytic osseous lesions that may mimic malignant neoplasms. Extensive periosteal reaction may support a radiologic diagnosis of primary osseous malignancy in rare cases. FNA with examination of Diff-Quik-stained slides may be employed for distinguishing cryptococcal osteomyelitis from malignant tumors and for prompt identification of the organisms.     

Haemodynamic changes in patients with whiplash injury measured by transcranial Doppler sonography (TCD)

The daily increasing number of cervical whiplash injuries presents ever-greater requirement for vertebrobasilar diagnostics. A cervical spine injury, which is quite frequent injury, may occur during a fall, or industrial, traffic, sport or war injury. Transcranial Doppler (TCD) sonography with Transcan 3-D EME device and 2 MHz probe was used for the assessment of vertebrobasilar circulation in patients with a whiplash injury of the cervical spine, that occurred mostly in car accident. This study includes 47 patients with clinically verified cervical spine trauma with x-ray evidence of no bone lesion. The patients were examined by TCD within a month, and then six months following the accident. The obtained values were compared to normal blood flow velocities and correlated with the severity of clinical picture. During the first month after the injury, statistically significant disturbances in the vertebrobasilar circulation were recorded, such as the increase in mean blood flow velocities in AVL (68%), AVR (62%) and BA (51%) (mostly as spasam). Six months later, normal findings were obtained in about 50% of the vessels, whereas in rest of the patients vasospasam persisted in one, two or all examined blood vessels. TCD of the vertebrobasilar circulation was found to be a very useful method in the diagnostics and follow-up of patients with a whiplash injury.     

Cervical spine posteroanterior stiffness differs with neck position

PurposeSpinal stiffness is commonly considered when treating patients with neck pain, but there are few studies reporting the objective measurement of cervical spine stiffness or the possible kinesiological factors that may affect its quantification. The aim of this study was to determine if the position of the neck affects cervical spine stiffness.MethodsAn instrumented stiffness assessment device measured posteroanterior cervical spine stiffness at C4 of 25 prone-lying asymptomatic subjects in three neck positions in randomised order: maximal flexion, maximal extension, and neutral. The device applied five standardised mechanical oscillatory pressures while measuring the applied force and concurrent displacement, defining stiffness as the slope of the linear portion of the force–displacement curve. Repeated measures analysis of variance with Bonferroni-adjusted post hoc comparisons determined whether stiffness differed between neck positions.ResultsThere was a significant difference in cervical spine stiffness between different neck positions (F_(1.6,38.0) = 16.6, P < 0.001). Stiffness was least in extension with a mean of 3.09 N/mm (95% CI 2.59, 3.58) followed by neutral (3.94, 95% CI 3.49, 4.39), and then flexion (4.32, 95% CI 3.96, 4.69).ConclusionWhen assessing cervical spine stiffness, neck position should be standardised to ensure maximal reliability and utility of stiffness judgments.     

Factors influencing recovery from headache after common whiplash.

OBJECTIVE--To assess the relation between pretraumatic and trauma related headache in patients suffering from whiplash. DESIGN--Follow up study of patients examined a mean (SD) of 7.4 (4.2) days after trauma and again at three and six months. SETTING--Patients referred from primary care. SUBJECTS--117 patients (mean age 30.8 (9.5) years. MAIN OUTCOME MEASURES--Prevalence of trauma related headache and the predictive relation by multiple logistic regression between different somatic and psychological variables and trauma related headache at each examination. RESULTS--Prevalence of trauma related headache decreased from 57% to 27%. History of pretraumatic headache proved a significant risk factor for presenting with trauma related headache. A significant relation between trauma related headache and the following variables was found: at seven days the initial wellbeing score, early onset of neck pain, depression scale from the personality inventory, and the initial intensity of neck pain; at three months, intensity of neck pain, and history of pretraumatic headache; and at six months neck pain, pain intensity, and history of pretraumatic headache. CONCLUSIONS--History of pretraumatic headache significantly increases the likelihood of presenting with trauma related headache but only in combination with findings indicative of clinically important injury to the cervical spine.     

Fine needle aspiration cytology of late-stage callus in stress fracture. A case report

BACKGROUND: Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone lesions when combined with careful radiologic and clinical evaluation. The cytologic features of callus have not been described before in the English-language literature. CASE: An 18-year-old female presented with a pain in the right lower leg that had been present for two months. Clinical and radiologic findings suggested either stress fracture or periosteal osteosarcoma. The aspiration specimen showed individually scattered, oval cells with moderate amounts of pale pink cytoplasm. The cells contained a single eccentrically located nucleus with evenly distributed, fine chromatin. Osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of benign bone-forming lesion, compatible with callus in fracture, was made. The diagnosis of late-stage callus was confirmed by subsequent histologic examination. CONCLUSION: Typical cases of stress fracture do not need histologic examination, but some cases may be confused with benign and malignant bone tumors. The typical and unique cytologic features of late-stage callus combined with clinical and radiologic findings may prevent the use of more invasive diagnostic procedures and can be a choice for management.