mate rial are pathological changes which can lead to either transient or constant pressure upon the nerve root.981 Local instability may produce furthe r compression, by retrolisthesis, when the lower poste rior e dge of a vertebral body approaches the superior articular facet of the verte
bra below, and conve rts the oval foraminal shape into a restricted S-shaped exit for the nerve root. The real extent ofthe encroachment is always gre ater than the radiologic
ally evident narrowing (Figs 6. 1 , 6.2, 6.3, 6.4). The perineural 'safety cushion', of fat around the nerve root in the foramina, may disappear. 565
Discs become progressively flatter with advancing degene rative change , as do the ve rtebral bodies, and this shortens the vertebral column. Re duction in length of the vertebral column with age ing will also produce sinuosity of the vertebral artery and a tendency to constriction of the lumen, accentuated during move ments, even in the absence of atheromatous changes in the vessel wall.
Loss of disc space, radiologically evident by vertebrae appearing as dishes piled one upon another, angulates the lower ce rvical roots at the foraminal portal, producing a furthe r source of irritation and inflammatory reactions in this situation (Fig. 2. 14) and the first thoracic and eighth ce rvical roots are particularly liable to deformation in this way. 1I7 Localised irritation by angulation, or small haemorrhages produced by exogenous ove rstretching and other trauma, wi1l initiate in the dural sleeve the familiar sequence of inflammation, granulation and fibrosis with adhesion formation, nerve root stricture and loss of e las
ticity and mobility, the root-sleeve fibrosis of Fryk
holm. )91, 392, fl2, 717
Ricard and Masson ( 1 9 5 1 )"" have suggested that the secondary formation of arachnoid cysts may be respon
sible for intradural root compression.
Among the space -occupying changes causing ce rvical mye lopathy, poste rior paravertebral ossification with cal
cification of the poste rior longitudinal ligament has been re ported,86 1. 954 and unilateral face t interlocking may also re duce the dimensions of the neural canal.lOb
Keuter656 has drawn attention to the varie ty of clinical fe atures which may arise by impairment of spinal cord vascularity, particularly in those cases whe re the spinal tract of the trigeminal nerve shares in the ischae mic changes (Figs. 1 . 16, 1 . 1 7). Signs and symptoms will appear above and below the lesion, e.g. one patient showed partial analgesia and diminished te mperature sense of left he micranial area, he adaches, vertigo and dysaesthesia in the C6-7-8 territory of the distal left upper limb. Radio
graphy showed spondylotic change of the lower neck and arthrosis of uncove rte bral joints in the same area. Angio
graphy showed irre gularities of the lumen of the ve rtebral and basilar arteries.
Other examples of bizarre and widespread clinical features are described, involving cranial and facial areas, trunk and all four limbs.
Following indirect trauma, an extraforaminai portion of protruded disc at C6 1evel displaced the vertebral artery on the right side, producing pain in the lower neck, he mi
cranial and hemifacial pain, with numbness of the right half of the face and depression of biceps and triceps jerk.
Sensation was disturbed in right thumb and index finger.
Radiography de monstrated disc degene ration, and angio
graphy showed the change in the lumen of the vertebral artery on right he ad rotation. Surgical re moval of the pro
trusion almost completely relieved the cranial sensory disorders.
The essemial and important feature underlying clinical expression of cervical degenerative change is the enormous van'obilicy of che vercebrobasilar vascular system (Fig. 1 . 1 2).
THE CERVICOTHORACIC REGION
(Arthrotic and spondylotic changes have been described above, pages 82, 88.)
This is an important junctional are a :
1 . I n the biomechanical sense , in that he re the mOSt mobile region of the vertebral column is physically inter
de pe ndent with a region of very limited movement. Also, a number of important connective tissue structures and muscles cross the C7-T I segment, e.g.
a. The prevertebral lamina of deep cervical fascia, covering the prevertebral muscles and continuous laterally with investments of the scalene muscles and levator scapulae ; below it extends into the thorax on the front ofthe longus colli muscle, to blend with the anterior longitudinal ligament in the mediastinum.
b. The trape zius, scaleni, sternomastoid and longus
1 30 COMMON VERTEBRAL JOINT PROBLEMS
Fig. 6.2 Pati�nt D.C.H.
(A.) Static films of advanced cervical spondylosis and arthrosis in a 79-year-old man. There is arthrosis of upper cervical joints, which is marked at C2-C3-C4, ankylosis of C4-C5-C6 and C7 with erosion of the body of C4. The patient was much more concerned about the pains of an arthrotic hip joint than the minimal symptoms in head, neck and upper limbs.
colli muscles, for example. The splenius capitis, splenius cervicis, semispinalis capitis, semispinalis cervicis, longissimus capitis, longissimus cervicis musdes all take attachment from bony apophyses of both the upper thoracic and the cervical vertebrae ; the iliocostocervicalis attaches below to angles of the 3rd to 6th ribs, and above to the transverse processes of C4, C5 and C6. In descriptions of pathology underlying those clinical conditions grouped as the thoracic outlet syndrome, the possible 'guy-rope' and asymmetrical tethering effect of these structures, tightened by the consequences of chronic spasm and fibrotic change, seem not to receive the attention they might merit.
2. The region is a site of major vascular, neurological and other traffic. Many varieties of tissue with widely differ
ing functions, and the potential for producing a variety of clinical effects remote from the site of interference, are closely packed together.
(8) There are marked arthrotic and osteophytic changes at C2-C3-C4, chronic spondylotic charges and bilateral cervical ribs (outlined).
3. J unctional regions are developmentally restless and anomalies ofskeletai and soft tissues are relatively common
in the cervicothoracic area (Figs 6.2, 6.50).
While signs and symptoms due to surgically proven pressure on the neurovascular bundle, as it emerges from the thoracic inlet to the arm, are well known, i n non
surgical cases there is no general agreement on either the site or the mechanics of the compression, 1209, 1210 or suf
ficient evidence in many cases that the clinical features are due to compression at all. The poorly recognised part played by minor unilateral joint abnormalities of the upper t hree or four ribs, possibly often by tension of soft tissue attachments as a consequence of cervical joint irrit
ability at higher segments, or due to the chronic sequelae of trauma, adds considerably to the confusion, because tingling in the upper limb is a very frequent symptom, and what patients are acrually trying to convey by the expressions tingling, fizzling in the fingers, pins and needles, heaviness, numb feelings, etc. may not have anything to do with physical trespass upon nerve fibres or vessels, and may well be expressions of abnormal impulse traffic in autonomic as well as somatic neurones, because of facilitated cervicothoracic segments.
There can be no doubt about the dinical effects of a P ancoast tumourin the lung apex, but a causal relationship between the presence of anomalies of ri b, muscle
PATHOLOGICAL CHANGES--COMBINED REGIONAL DEGENERATIVE 1 31
(c) NOI one inttrvtrttbral foramtn has escaped marked trespass by the changes of degenerative joint disease, apparent on lhe oblique film.
anachment, plexus formation, vascular arrangement and clinical manifestations does not always exist.
Many patients complain oftingling, few ( 1 .2 per cent)'·' have cervical ribs. Those who do seldom complain of para
esthesiae. Some have bilateral cervical ribs and paraes
thesiae on one side only (Fig. 6.S), others have unilateral cervical ribs and tingling on the radiographically normal side.
True cervical ribs relate with their proximal part, head, neck and anicular connections as a normal rib to the trans
verse process and vertebral body; fa lse cervical ribs do not have a well-formed head but only a ligamentous con
nection.I(I9} Occasionally, paired cervical ribs may be quite long, and be symmetrical ; a single short extra rib may have a cartilaginous cap, and sometimes the anoma
lous rib is attached to the first rib by a synostosis or by cartilage, or by a tight fibromuscular band.
Anomalous ribs may occur as high as C4. With the extra rib at the cervicothoracic junction there may be simul
taneous anomalies of the neurovascular bundle. The ribs and/or fascial bands must surely have a space-occupying effect in some of the subjects, but not all come to clinical notice because of symptoms reponed. When they do, determining whether the rib is causing the patient'S diffi
culties is not easy, as the anomalous structures vary in size, shape and relationship to the neurovascular bundle.
(D) The right oblique film shows similar changes. with one of the ccn·ical ribs well shown.
Causes of the thoracic oUllet syndrome, same of them inter
related, have bee'l named as:
Trauma to the head, neck and shoulder region, with haematoma formation and resultant fibrosis in the supra
clavicular region.
Excessive callus after fractures of the clavicle.
Abnormality of the first thoracic rib, usually one that is unusually large or crooked, or with excess callus formation after fracture.
Abnormal size and shape of the clavicle, e.g. bifid c1avicle.7M
Inflammatory or malignant disorders in the cervical spine or shoulder girdle region.''''
Pancoast's tumour of the lung apex.
The scalenus anticus syndrome, 'almost always changes in the arrangement and in the course of scalenus anticus and medius are observed' ;1093 connective tissue encroachments beyond the normal area of the first rib attachment are seen, being carried further forward than normal ;1209 thus the lowest plexus trunk and the artery lie nOt on the rib but raised by the lower apex of a V
formation of the tendinous edges of scalenus anticus and medius.
Extensive arterial thrombosis (almost 9 per cent of 120 surgical cases) ;1209,1210 in all cases a well-developed cervi
cal rib was present, but in no case was any arterial change
l32 COMMON VERTEBRAL JOINT PROBLEMS
Fig. 6.3 Loss of C5-6 disc space and anterior lipping of the C5 and C6 vertebral bodies. The posterior lipping (osseus part of the 'osseocartilaginous bar') can also be seen.
observable where the artery lay on the rib. In 1 5 cases of arterial thrombi,764 4 had recanalised, 6 developed excellent collateral circulation but with a weak pulse and in 5 the pulse was still absent, suggesting only slight to moderate development of collateral vessels. In the absence of adequate revascularisation of distal tissues, mild trauma to the hand may result in ulceration which progressively worsens.
Aneurysmal dilatation of the third part of the subclavian artery, 1 cm distal to a cervical rib. This was present in 5 cases of a group of 120 surgical cases. Halstead (1916)490 reported 25 cases of dilatation in a series of 525 patients.
Thrombosis of the subclavian vein.764 Swelling of the arm, heaviness and bluish discoloration of the limb may occur.
While circulatory improvement from collateral vessels may sustain function and relieve symptoms, the arm rarely, if ever, returns to normal.
In 12 of 104 uncomplicated surgical cases,I210 pressure on the lower trunk was due to a strong, taut band springing from the tip of a small cervical rib, and passing downwards and forwards in the anterior border of scalenus medius.
In two young girls of 14, a large cancellous boss was situ
ated where a well-developed cervical rib reached the first thoracic rib.
Fig. 6.4 Oblique film clearly shows loss of disc space, lipping at C5-6 vertebral margins, with foraminal encroachment at the same level. The degree of trespass upon related structures is greater than is
radiologically evident, because of presence of radiotranslucent tissue.
Ofthe above group of 104 patients 69 showed cervical ribs in various stages of development, and in almost all of them there was no naked-eye evidence that either plexus or artery had been damaged by clavicular pressure. Com
pression of the axillary artery by the two heads of the median nerve ; experimental traction during open surgery revealed that all arterial pulsation ceased below the 'vice', but the subclavian anery was unaffected.
Sustained abduction or hyperabduction of the upper limb.
To these various causes there might be added:
Early spondylotic and arthrotic change in the upper thoracic spine and upper costas pinal joints, especially when the symptoms described include heaviness of the arm, subjective numbness and paraesthesiae which tend to have a glove or extrasegmental distribution, in the absence of objective neurological signs--often only the tips of all digits are affected in this way.
Palpable and persistent elevation of the first, and often the second, ribs, due either to mild fixation following moder
ate trauma to the region itself, or as the consequence of increased tension in the scalene muscles. This may be an acute condition because of irritability at upper cervical segments, or the established contracture of
connectivc-PATHOLOGICAL CHANGES---COMBINED REGIONAL DEGENERATIVE 133
Fig. 6.S Bilateral cervical ribs (outlined). The patient reported paraesthesiae on the right side only.
tissue elements. The unilateral combination of joint prob
lems at the C2 and T2 segments together is well known to clinically experienced therapists.
Telford and Mottershead ( 1 947)1210 examined the effects, in 70 men and 50 women (240 ar ms), of different postures of the arms in the erect position, and among the postures were abduction, at 90° and 180°, and adduction against resistance. The results of these particular tests were as follows :
Tabl£ 6.1
Adduction Abduction against
180 resistance 70 males (140 arms)
No effect on radial pulse 131 75 18
Radial pulse diminished 6 42 38
Radial pulse absent 3 23 84
SO females (100 arms)
No effect on radial pulse 91 35 9
Radial pulse diminished 6 35 16
Radial pulse absent 3 30 75
In passive abduction t090 the alteration is 7.5 per cent, when the arm is adducted there is a sharp rise to 90 per
cent, and plainly muscular action is now a factor; the authors offer the suggestion that pectoralis minor and sub
scapularis are taughtened to a degree sufficient to trespass upon the axillary artery. When describing the excellent results following surgical excision of an anomalous joint in the central portion of the first thoracic rib, Ross and Vyas ( 1972) 1060 include, as the mOst important contribu
tory cause of the thoracic outlet syndrome, reduced tone in the muscles of the shoulder girdle, with consequent de
pression of the clavicle narrowing the thoracic outlet further and compressing the neurovascular bundle.
Telford and Mottershead mention that, 'it is an old observation that in certain positions of the shoulder the radial pulse is diminished or completely arrested . . . it is taken for granted that the cause of this interference is costo
clavicular pressure.' The authors applied downward trac
tion to the arm in 25 bodies postmortem and report that when the shoulder girdle is depressed, the clavicle moves downwards and forwards; the further the clavicle is depressed the further forward it moves, widening the interval between clavicle and rib. At no point could the clavicle be made to impinge upon the subclavian artery.
In order to press the clavicle directly backwards on to the first rib it was necessary to open and disorganise the ster
noclavicular joint.
With regard to the brachial plexus, depression of the shoulder caused the upper and middle trunks, together with the C7 contribution to serratus anterior, to be stretched tightly over the tendinous edge of scalenus medius; the lower trunk is pulled down hard into the angle formed by the scalenus medius tendon and first rib. It was not possible by arm traction to compress the subclavian artery against either of the scaleni.
When the shoulders were retracted, the tendon of the sub
clavius muscle compressed the subclavian vein against the first rib, but the clavicle itself does not impinge upon it;
the middle third of the clavicle pushes the neurovascular bundle backwards against the anterior border of scalenus medius, and in the presence of space-occupying resistance (extrafascial band, cervical rib, abnormal first thoracic rib) could compress the bundle. Sympathetic nerve fibres are present in the lower trunk. 122), 1209 Movement of the clavicle in abduction showed no essential difference from the effects of clavicular retraction.
The authors suggest that the concept of costoclavicular compression is supposition, unsupported by anatomical evidence, and that symptoms referrable to the plexus on shoulder depression are caused by drag on the nerve cords.
The plexus is stretched taut over the edge of scalenus medius, and this effect is accentuated if the attachment is carried somewhat forward on the rib. In retraction and abduction, the clavicle does impinge the plexus and vessel against scalenus medius, and this possibly explains tem
porary hand tingling during prolonged abduction when dressing the hair, for example, or decorating a ceiling.
1 34 COMMON VERTEBRAL JOINT PROBLEMS
In a group of 37 patients, who were treated surgically by anterior scalenotomy, after an injection of local anaes
thetic into scalenus anterior had given relief of symptoms, Silvers ten and Christensen ( I 977)"" described the clinical features. In 2 1 patients no radiographic abnormality was observed ; 8 had cervical ribs, 6 had a large transverse process of C7 and 3 had spondylotic changes. Neurologi
cal signs were detected in 1 6 patients and several patients presented with muscle atrophy, variously of the thenar, hypothenar, interosseous or upper arm muscle groups.
The purpose of injection was to relax the muscle and note if symptoms were relieved. While the technique of muscle section was nOt described, it follows that release of the muscle and/or attachments was responsible for relief of symptoms (see Patterns of clinical presentation, p. 205). It would be of interest to have had comparisons of [he degree of tcnsion in both scalenous anterior muscles, since although expansion of the first rib attachment area is well recognised, hyperronus of the muscle itself, with its consequences on the posture of the rib, is rarely mentioned,l'80b No onc mechanical cause can explain all cases. 1210