Cervical Disorders

Cervical disorders
Dr.Atef A. Nadier, PhD

Lecture Of Orthopedic Physical Therapy, PUA
Spring 2022
Content
• Anatomy
• Biomechanics
• Cervical pain classification
• Disc surgery and post operative mangement
Local anatomy
1) Cervical aspect: There are seven cervical vertebrae-- the atlas(C1), the
axis(C2), and typical cervical vertebrae
From three through seven. (C3-C7).
1- There is no disc between the atlas and the axis.

2-The 7th spinous process is the longest.
3-Cervical vertebrae have transverse foramina that differ from other
vertebrae.
Local anatomy
Local anatomy
2. Ligaments:
1- Supraspinous ligament.
2- Interspinous ligament.
3- Ligamentum Flavum
4- Posterior longitudinal ligament.
5- Anterior longitudinal ligament.
6- Transverse ligament of the atlas
(intertransverse ligament.)
Local anatomy
3. Discs:
1)*Hyaline Cartilage: is the cartilage of the superior and inferior surfaces of the
vertebral body. It also forms the top and bottom border of nucleus pulposus. It
bears the weight and protects the nucleus pulposus.
2) *Annulus Fibrosus:It is a fibrous ring. It is elastic and holding the nucleus

pulposus, preventing herniation.
3) *Nucleus Pulposus: Is a kind of gelatinous, flexible, semifluid material, located in

the center of the annulus fibrosus. Both top and bottom surface are sealed by
hyaline cartilage.
Local anatomy
4. Cervical plexus:
The cervical plexus is formed by the ventral rami of the C1-C4 spinal
nerves. These nerves supply the muscles and skin of the head, neck,
shoulder, and chest.
Local anatomy
5. Brachial plexus:
The brachial plexus is composed C5, C6, C7,
C8 and T1 spinal nerves.
Those include a radial nerve, a median
nerve, a ulnar nerve.
The radial nerve: C5-C8,T1 of spinal
nerves.
The Ulnar nerve: C8 and T1 of spinal
nerves.
The median nerve: C5-C8,T1 of spinal
nerves
Local anatomy
6. Main muscles of neck :
1) Scalene muscles: ① Middle scalene;
② Anterior scalene; ③Posterior
scalene.
2) Sternocleidomastoid:
① Sternal head; ②Clavicular head.
3) Semispinalis capitis
4) Splenius capitis
5) Levator scapula
6) Trapezius
Local anatomy
• Anterior muscles
Biomechanics
1) Cervical spine has numerous articulations
2) Cervical spine – lordotic curve
3) Cervical spine provides different motion characteristics
4) Occipitoatlantal complex (C0-C1)
5) Atlantoaxial complex (C1-C2)

Biomechanics
• Greatest ROM occurs the middle of the cervical at the
level of C5-C6 during flexion and extension .
• Normal flexion to hyperextension at the atlanto-occipital joint range
is 15 to 20 degrees. Rest is contributed by lower vertebrae.
• Rotation and lateral flexion. These movements occur on atlantoaxial
joint [C1-C2].
• The C1-C2 motion segment accounts for 50% of the rotation in the
cervical spine.
• Rotation of the atlas on the axis does not occur without a small
degree of extension and lateral flexion and sometimes flexion.
Biomechanics
• The orientation of the cervical
vertebral bodies of the mid to
lower cervical column allows for
rotation and flexion movements
but is resistant to lateral flexion.
Biomechanics
• Lateral flexion is possible in the
cervical column but only due to
coupled rotational movement in
each segment to that side.
Neck pain classification
Neck Pain With

Mobility
Deficits:
Neck pain with

movement Neck Neck Pain With
Radiating Pain
coordination
impairments pain (Radicular))
Neck Pain With

Headache
(Cervicogenic))
A)Neck Pain With Mobility Deficits:
• Examination:
• Cervical active range of motion (ROM),
• Cervical and thoracic segmental mobility tests.
Neck Pain With Mobility Deficits:
• A movement restriction is a loss of movement in a specific direction.
• When the cervical range of motion (CROM) is painful or restricted,
muscle pathology is suggested if the restricted motion exists in the
direction opposite to the action of the involved muscles.
Normal ranges of motion:
• Flexion .................. 80 ± 10°
• Extension................. 80 ± 10°
• Rotation ................. 80 ± 10°
• Side flexion ................. 35° ± 1 0°
Common symptoms:
Central and/or unilateral neck pain.
 Limitation in neck motion that consistently reproduces symptoms.
 Associated (referred) shoulder girdle or upper extremity pain may be
present.
Expected exam findings:
Limited cervical ROM.
 Neck pain reproduced at end ranges of active and passive motions
Restricted cervical and thoracic segmental mobility.
Neck and referred pain reproduced with provocation of the involved
cervical or upper thoracic segments or cervical musculature.
Deficits in cervicoscapulothoracic strength and motor control may be
present in individuals with subacute or chronic neck pain.
Neck pain With Mobility Deficits:
Treatment:
A) Acute:
• Thoracic manipulation.
• Cervical mobilization or manipulation.
• Cervical ROM, stretching, and isometric strengthening exercise.
• Advice to stay active plus home cervical ROM and isometric exercise.
• Self strech upper trapezious
• For levator scapule
Strech upper trapezious

• Manipulation thervicothoracic & Isometric exercises .
• Mobilization for cervical spine
Supervised exercise:
• Cervicoscapulothoracic and upper extremity stretching,
• Strengthening, and endurance training.
• General fitness training (stay active).
B) Subacute:
• Cervical mobilization or manipulation.
• Cervicoscapulothoracic endurance exercise.
C) Chronic:
• Cervical mobilization .
• Mixed exercise for cervicoscapulothoracic regions.
• Neuromuscular exercise: Coordination, proprioception, and
• Postural training.
C) Chronic:
• Supervised individualized exercises .
• Dry needling.
• low-level laser.
• Pulsed or high-power ultrasound.
• Intermittent mechanical traction.
• TENS, electrical muscle stimulation.
B) Neck Pain With Radiating Pain
(Radicular)
Common symptoms :
• Neck pain with radiating ( lancinating) pain in the involved extremity .
• Upper extremity dermatomal paresthesia or numbness, and
myotomal muscle weakness .
Neck Pain With Radiating Pain (Radicular)
• Neck and neck-related radiating pain reproduced or relieved with
radiculopathy testing:
 Positive upper-limb nerve mobility test,
Spurling’s test,
Cervical distraction,
Cervical ROM tests ,
May have upper extremity sensory, strength, or reflex deficits
associated with the involved nerve roots.
Neck Pain With Radiating Pain (Radicular)
Cervical spondylosis:
 A chronic degenerative condition affecting the contents of the spinal
canal (nerve roots and/or spinal cord) and the cervical vertebral
bodies and IVDs, and
It is the most common cause of progressive spinal cord and nerve
root compression.
The discs degenerate, flatten and become less elastic.
The facet joints and the intervertebral joints are slightly displaced
and become arthritic, giving rise to pain and stiffness in the neck.
Cervical Spondylosis
• Bony spurs, ridges or bars
appear at the anterior and
posterior margins of the
vertebral bodies; those that
develop posteriorly may
encroach upon the spinal canal
or the intervertebral foramina,
causing pressure on the neural
structures.
Clinical Features:
The patient, usually aged over 40, complains of neck pain and
stiffness.
 The symptoms come on gradually.
 Pain may radiate widely to the occipite, the back of the shoulders
and down one or both arms.
 The appearance of the neck and scapular muscles is normal but are
tender.
 Occipital headache and dizziness
Clinical Features:
Sometimes ,narrowing of the intervertebral foramina and
compression of the nerve roots (radiculopathy):
• Pain referred to the interscapular area and upper limb,
• Numbness and/or tingling in the upper limb,
• Muscle weakness.
• Depressed reflexes in the arm or hand.
• Weakness in the lower limbs suggests spinal cord pressure
(myelopathy) in advanced cases, where there is narrowing of
the spinal canal.
• Dermatomes of the upper limb:
• Myotomes of the upper limb:
• X RAY and imaging
MRI Cervical spondylosis:
• T2-weighted sagittal MRI of a 59-year-old
woman who presented with a spastic gait
and weakness in her upper extremities
showing cord compression from cervical
spondylosis, which caused central
spondylotic myelopathy. Note the signal
changes in the cord at C4-C5, the ventral
osteophytosis, buckling of the
ligamentum flavum at C3-C4, and the
prominent loss of disk height between C2
and C5.
• Compression distraction test:
Spurling test:
•Extending the neck
•Side bending the head
•Downward pressure
•Positive finding (reproduction
of radicular pain)
•72% sensitive & about 92%
specificity.
Neural Testing for the Upper
Quadrant:
• The test positions and maneuvers used to detect
nerve tension and mobility are the same as the
treatment positions and maneuvers.
• Tension signs are stretch pain or paresthesias
that occur when the neurological system is
stretched across multiple joints and is relieved
when one of the joints in the chain is moved out
of the stretch position.
Treatment of Neck Pain With Radiation
Acute :
• Mobilizing and stabilizing exercises.
• Low-level laser.
• Possible short-term collar use .
Chronic:
• Combined exercise: Stretching and strengthening elements plus
manual therapy for cervical and thoracic region: Mobilization or
manipulation .
• Education counseling to encourage participation in occupational and
exercise activity.
• Intermittent traction.
Manual cervical traction:
• (A) With the fingers of both hands under the occiput;
• (B) With one hand over the frontal region and the other hand under
the occiput; and (C) using a belt to reinforce the hands for the
traction force
Manual cervical traction:
• Gentle intermittent joint distraction and gliding techniques may inhibit painful
muscle responses and provide synovial fluid movement in the joint for healing.
• With spondylosis or stenosis:
 If a patient have signs of nerve root irritation and does not have signs of acute
joint inflammation stronger traction forces may be beneficial to cause opening of
the intervertebral foramina, which helps relieve the pressure.
Remember:
If a patient has RA, traction and joint mobilizations/manipulations in
the spine are potentially dangerous because of ligamentous necrosis
and vertebral instability; therefore, they should not be
performed(Contraindicated).
C) Neck Pain With Headache (Cervicogenic)
Cervicogenic headache (CGH) is a chronic, hemicranial pain syndrome
in which the sensation of pain originates in the cervical spine or soft
tissues of the neck and is referred to the head.
Common symptoms:
• Noncontinuous, unilateral neck pain and associated (referred)
headache .
• Headache is precipitated or aggravated by neck movements or
sustained positions/postures.
Cervicogenic headche
Expected exam findings :
 Positive cervical flexion rotation test .
Headache reproduced with provocation of
the involved upper cervical segments.
 Limited cervical ROM .
 Restricted upper cervical segmental
mobility .
Strength, endurance, and coordination
deficits of the neck muscles.
• Craniocervical flexion test:
Cervical Flexion-Rotation(CFR) Test:

•The cervical spine is fully flexed and rotated to
right and left while noting range of motion and
pain.
• A firm end-feel with limited ROM presumes
limited rotation of the atlas on the axis. (Limited
to about 45° rotation in patients with CGH )
Factors to differentiate CGHs:
 Unilateral non throbbing and non-shift
pain with a facet ‘locks’ irradiating from
the back of the head.
 Evidence of cervical dysfunction
presenting during manual examination.
 May occur with trigger point palpation
in the head or neck.
 Aggravated by sustained neck positions.
 Normal imaging.
Common proplemes associated with SGH
1-Weakness of deep
cervical muscles.
2- Overactivity of
3- Restricted cervical musles
upper cervical as upper
segmental trap.,SGM and
mobility. suboccipital
muscles.
Treatment of Cervicogenic headche
Acute:
• Exercise: C1-2 self-SNAG
Subacute:
• Cervical manipulation and mobilization
• Exercise: C1-2 self-SNAG
Chronic :
• Cervical mobilization
• Cervical and thoracic manipulation
• Exercise for cervical and scapulothoracic region.
• C1-C2 self-sustained natural apophyseal glide (SNAG) for
cervical right rotation.
• Force is applied to the C1 level via horizontal pressure from the
strap. At the same time, the subject actively turns his/her head
to the right.
• the thin, rubber-covered strap was positioned on the posterior
arch of C1 and drawn horizontally forward across the face.( to
facilitate rotation at C1- C2 in the same direction) .
• The subject applied forward pressure on the strap and turned
the head toward the restricted side of rotation, sustaining end
range for 3 seconds.
• Forearm traction for upper cervical spine.
Exercise for cervical and scapulothoracic
region:
strengthening and endurance exercise with
neuromuscular training, including motor
control and biofeedback elements.
• Combined manual therapy
(mobilization or manipulation) plus
exercise (stretching, strengthening, and
endurance training elements).
Patients with cervical pain often exhibit forward head posture and
rounded shoulders associated with muscle imbalance.
Patients should be instructed in proper diaphragmatic breathing to
reduce activation of accessory respiratory muscles .
The craniocervical flexion (CCF) exercise for activating the deep neck
flexors.
(CCF) exercise:
• An inflatable pressure cuff is placed behind the neck as
the patient lies supine as described previously for the CCF
Test .
• The cuff is inflated to 20 mm Hg and the patient is
instructed to very slowly flex the upper cervical spine with
a gentle nodding motion and hold steady for 10 seconds
without activating the SCM.
• The exercise is progressed by increasing the cuff inflation
by 10 mm Hg toward a goal of 40 mm Hg.
• Craniocervical flexion against elastic band loop. Begin with cervical
spine in protraction (a). Maintain hand position while retracting
against the tension in the band (b).
Positional release for suboccipital muscle:
• graspe the patient's head and extende it (Passivelly) moderately and
laterally flexed and rotate it away from the tender point side. (for90
sec/3times)
D) Neck pain with movement coordination
impairments
This syndrome is characterized by complaints in both the neck and the
head and includes symptoms such as dizziness, tinnitus, and
headache.
• Causes of dizziness:
Vertebrobasilar insufficiency(VIB)
Altered proprioceptive afferent signals from upper cervical spine as
whiplash-associated disorder (WAD)
Irritation of sympathetic vertebral plexus.
Neck pain with movement coordination
impairments
Remember:
• The cervical spine has a very delicate proprioceptive system, which
signals the position of the head relative to the trunk, coordinates the
vestibular and visual systems and plays a crucial role in controlling
posture and balance.
impairments
Common symptoms:
Mechanism of onset linked to trauma or whiplash .
Associated (referred) shoulder girdle or upper extremity pain .
 Associated varied nonspecific concussive signs and symptoms.
impairments
Positive cranial cervical flexion test.
 Positive neck flexor muscle endurance test.
 Positive pressure algometry.
Strength and endurance deficits of the neck muscles .
 Neck pain with mid-range motion that worsens with end-range
positions.
impairments
Remember:
• Pressure pain threshold (PPT) is defined as the minimal amount of
pressure that produces pain.
• Algometers are devices that can be used to identify the pressure
and/or force eliciting a pressure-pain threshold.
• A quantitative indicator of the degree of hyperalgesia.
impairments
Neck flexor muscle endurance test:
• Tuck patients chin in and lift off table 1 inch. The examiner looks for
substitution of the platysma or SCM muscle.
• Normal Values: Men: 38.9 seconds, Women: 29.4 seconds
impairments
• A.Dizzness,
• B.dizzness with cervical
• C.+With vestibular
impairments
Treatment:
Acute:
If prognosis is for a quick and early recovery:
• Education: advice to remain active, act as usual
• Home exercise:
• pain-free cervical ROM and postural element .
• Monitor for acceptable progress.
• Minimize collar use.
impairments
Subacute:
If prognosis is for a prolonged recovery trajectory:
• Education: activation and counseling.
• Combined exercise:
• Active cervical ROM and
• Isometric low-load strengthening plus manual therapy (cervical
mobilization or manipulation) plus
• Physical agents:
• Ice, heat, TENS
impairments
Subacute:
• Supervised exercise:
• Active cervical ROM or
• Stretching, strengthening, endurance,
• Neuromuscular exercise including postural, coordination, and
stabilization elements.
impairments
Chronic:
• Education: prognosis, encouragement, reassurance, pain
management .
• Cervical mobilization .
• TENS.
impairments
Chronic:
• Individualized progressive exercise:
• low-load cervicoscapulothoracic strengthening,
• Endurance, flexibility, functional training using cognitive behavioral
therapy principles, vestibular rehabilitation,
• Eye-head-neck coordination, and neuromuscular coordination
elements
impairments
Surgery for disc lesions
Indications for Surgery:
• Patients with upper or lower extremity radiculopathy, caused by
nerve root irritation and
• who have failed conservative measures including physical therapy,
medications, and steroid injections.
Surgery for disc lesion
• Common Surgeries The two most common surgical procedures in the
spine are laminectomy and fusion of one of more vertebrae.
• A laminectomy :is the removal of the lamina.
• A partial or hemi-laminectomy is a removal of only part of the
lamina;
• A complete laminectomy is the excision of the entire lamina, the
spinous process, and the ligamentum flavum that attached to the
lamina.
Indications of fusions:
• When the patient presents with axial pain combined with instability,
• Severe arthritic degenerative changes,
• or peripheral pain that is not controlled.
The advantages :
• It reduces or eliminates segmental motion,
• Reduces mechanical stress at the degenerated disc area,
• Reduces the incidence of additional herniations at the affected disc.
Disadvantge:
• May expedite the degenerative processes, create a hypermobility at
adjacent spinal segments, and alter overall spinal mechanics.
N.P:
Anterior cervical disc fusion:
• Both the platysma and longus coli muscles are interrupted during this
procedure.
• Once the disc is excised, the adjacent vertebrae are then internally
fixated with a single unilateral plate and screws attaching directly to
the vertebral bodies.
Complications (rare):
• Sore throat, hoarseness, and difficulty swallowing.
• Neurological or more serious complications:
• Myelopathy, radiculomyelopathy, and
• Recurrent laryngeal nerve palsy, have been reported as ranging from
1% to 4% of the post-surgical population.
Postoperative Management:
Maximum Protection Phase:
• Wound management and pain control.
• Bed mobility.
• Bracing. To promote healing, patients are typically placed in a
Philadelphia collar then a soft collar.
• A-AROM or AROM heel slides,
• Short-arc quads, quad and gluteal isometrics, and ankle pumps.
Remember:
• Patients who have undergone a laminectomy are instructed to avoid
excessive extension due to the weakened boney neural arch.
Moderate and Minimum Protection Phases:
Scar tissue mobilization. After the incision site is healed
Progressive stretching and joint mobilization (grade I to II).
Initiate segmental and progress to global stabilization exercises to
patient tolerance.
Single plane exercises and progress complexity as patient tolerates.
Gait training: An assistive device is usually indicated to facilitate an
erect posture and unload some of the stress to the surgical area.
REFERENCES
Carolyn Kisner, Lynn Allen Colby Therapeutic Exercise Foundations and
Tec,2020.
David J ORTHOPEDIC PHYSICAL ASSESSMENT 5ThEdition, David et al.2011.
Dutton’s Orthopaedic Examination, Evaluation and Intervention, Fourth
Edition 4th Edition,2020.
Neck Pain: Clinical Practice Guidelines. J Orthop Sports Phys Ther.
2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302
Tension-Type and Cervicogenic Headache , Robert et al, 2010.
Baogan etal.CervicalProprioceptionImpairment .pain ther.2021
Positional release versus post isometric relaxation in treatment of CGH.
Nadier et al. Bioscience research. 2019.
Thank you

Cervical Disorders

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Cervical Disorders

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Cervical disorders

Dr.Atef A. Nadier, PhD

1- There is no disc between the atlas and the axis.

2) *Annulus Fibrosus:It is a fibrous ring. It is elastic and holding the nucleus

3) *Nucleus Pulposus: Is a kind of gelatinous, flexible, semifluid material, located in

2) Cervical spine – lordotic curve

3) Cervical spine provides different motion characteristics

4) Occipitoatlantal complex (C0-C1)

5) Atlantoaxial complex (C1-C2)

Neck Pain With

Neck pain with

Neck Pain With

Strech upper trapezious

Cervical Flexion-Rotation(CFR) Test:

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