Common Vertebral Joint Problems

COMMON VERTEBRAL

JOINT PROBLEMS

Gregory P. Grieve

FCS!' Dip T!' Honorary Fellow of the Chartered Society of Physiotherapy Post-Registration Tutor, Department of Rheumatology and Rehabilitation, Norfolk and Norwich Hospital

Former Supervisor and Clinical Tutor, Spinal Treatment Unit, Royal National Orthopaedic Hospital, London

Fo,.ewo,.d by

PHILIP H. NEWMAN CBE DSO MC FRCS Latcly Consultant Orthopaedic Surgeon to the Middlesex

Hospital, and Consultant Surgeon 10 the Royal National Orthopaedic Hospital and Institute of Orthopaedics,

London

Past President of the British Orthopaedic Association and formerly Chairman of the British Council of Management of the Journal of Bone and Joint Surgery

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CHURCHILL LIVINGSTONE

CHURCHILL LIVINGSTONE

Medical Division of Longman Group Limited

DiSlributed in the United States of America by Churchill Livingstone Inc., 19 West 44th Street, New York, N.Y. 10036, and by associated companies, branches and represematives throughout the world.

© Longman Group Limited 1981

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers (Churchill Livingstone, Robert Stevenson House. 1-3 Baxter's Place, Leith Walk, Edinburgh, EHI 3AF),

Firsl published 1981

ISBN 0 443 02106 6

British Library Cataloguing in Publication Data

Grieve. Gregory P.

Common venebral joint problems. 1. Spine-Diseases

1. Title

617'375 RC400

LIbrary of Congreu Catalog Card Number 81-67465

Foreword

Modern advance in prevention and treatment has elimi­ nated or brought under control many of the severe illnesses which, a generation or so ago, afflicted man. The medical profession now has greater opportunity to pay attention to the challenge of chronic arthritis and the effects of trauma, stress and strain and wear and tcar of the musculoskeletal system,

The population of the Western world of today, its av­ erage age and demand for physical comfort gradually in­ creasing, presents an expanding and exacting problem. In hospital practice, to which the more difficult cases 3fC referred, it is the consultant who examines, investigates, attempts to diagnose and prescribes treatment and having excluded a serious cause or the need for inpatient treatment may refer the patient to the department of physical medi­ cine for supervision and care. The therapist who carries out these instructions spends much time with the patient and learning from experience develops an unparalleled understanding of the nature of skeletal pain.

Greg Grieve has dedicated his professional life to an extensive study of these physical problems and has devoted his attention in particular to the multiple syn­ dromes arising from the intervertebral and sacroiliac joints.

So impressed was he by the work of Mennell, Marlin, Cyriax, Stoddard and others that he energetically became involved, with other Chartered physiotherapists, in found­ ing a school of instruction in the basic sciences as applied to the spine and of the problems of derangement and to train physiotherapists in the art of treatment by manipu­ lation. Following the initial courses, with other teachers, between 1965 and 1967 he was the pioneer who carried the

torch of planning the curriculum and progressive develop­ ment of the annual courses during the eight especially formative years, 1968 to 1975.

During this time Grieve delved deeply into the vast literature that has accumulated on this subject. The variety and extent of this field is aptly expressed in this book: 'The mountain of literature on spinal pathology is massive enough to have become all things to all men.' This book lists no less than 1400 references and its text is astoundingly reverent to the galaxy of opinions and conclusions and the conflicting hypotheses that they contain.

Derangement of the vertebral column is covered in all its aspects and it soon becomes obvious that the value of this monograph is unique. It unfolds the nature of the problem as seen by a person who has spent much time communicating with and actively treating patients. There is much to learn both from a diagnostic and therapeutic angle which is not found in the many textbooks written by the medical profession.

This is a comprehensive aggregation of the whole subject but there is nothing pedestrian in its teaching. It is prov­ ocative and doubtless the more conservative reader would now and again catch his breath.

Above all it provides stimulation for thought on a subject which is apt to be bogged down by tradition and hampered by interdisciplinary contention.

It is a brave and brilliant endeavour to translate the jargon of the various schools into a language with a scien­ tific basis. It cannot fail to appeal to all those interested in the vencbral column whatever their clinical status.

Preface

Is there anything whcrcofit may be said, 'Sec, this is new? It hath been already of old times, which was before us.' (Ecclesiastes i, 10)

There is )jute new in this book, only a different voice saying the old things, yet gathered together in a form which I hope will be useful to my colleagues.

A commonly expressed regrct of therapists who strive to improve their handling of common joint problems is that some of those whose prerogative it is to diagnose and pres­ cribe at times appear to have only a limited conception of the capabilities of modern therapists. Such is the speed with which the technology and capabilities of all disciplines has riscn, this circumstance probably now applies to all interdisciplinary relationships.

Since it is incumbent upon us to keep our own house in order, therapists must do something about their own situation. We must provide opportunities for our peers and colleagues to know about our work, aspirations and capabilities.

In any case, it is really no more than enlightened self­ interest to comprehend as much as we can about the context

of our work because if we do not, its value and our worth will fall away. Wright and Hopkins (1978) "" have em­ phasised that some 30 per cent of physiotherapists' time is devoted to rheumatic and orthopaedic conditions.

I have attempted to formulate a guide, a vocabulary of basic information for those spending much of the day handling vertebral joint conditions. As a foundation for improving our knowledge we must know something of this if we aspire to become competent in the conservative treat­ ment of common vertebral joint problems, and to know in which direction our knowledge must be expanded.

The easily portable knapsack-and-bedroll information and rule-of-thumb clinical methods of times past are no longer enough. Today's workers must gather knowledge from many fields, and train themselves to apply it quickly and accurately when assessing the multitude of facts ob­ tained by a good clinical examination.

As the more successful treatment of respiratory, nervous and metabolic disease, for example, has naturally evolved

from a deeper understanding of the nature of the functional abnormality concerned, it is surely axiomatic that abnor­ malities of the musculoskeletal system arc more effectively treated when the nature of the abnormal movement is understood, since bodily movement is the function con­ cerned. There is nothing incongruous or unacceptable in applying this basic law of progression in therapeutics equally to the treatment of diseases of the blood, for in­ stance, and degenerative joint disease of the vertebral column.

To treat musculoskeletal pain, whether by manipulation, acupuncture, hydrocortisone injection, transcutaneous nerve stimulation, the 'back school', relaxation techniques, exercises, ultrasound or whatever, without first making a comprehensive attempt to understand the clinical nature of the musculoskeletal abnormality as it affects each patient, is the road to Erewhon.

The basic physical examination of common vertebral and peripheral joint conditions has now been developed to the stage of a modern technology, and given this as increas­ ingly standard practice, the steady accumulation of further knowledge is certain. Without this basis, low back pain, fibrositis, muscular pains, sciatica and tension headache, etc., will remain classically associated with patent medicine advertisements, rubifacient unctions, generalised exer­ cises, other 'shot-gun' regimes like generalised relaxation or whatever piece of gleaming chromium-plated machinery happens currently to be in vogue. There is nothing sadder than yesterday'S machine.

While we make no real effort to understand the myriad clinical presentations of joint abnormality, troublesome joint pains will thunder on unabated.

Since the level of useful knowledge in the world increases horrendously, individuals have great difficulty in keeping up with advances in their own small sphere; there are the problems of assimilation and especially organisation of the available information. I have had in mind the need for a new structural framework, perhaps serving as a skeleton around which increasingly better-informed successors will build yet more meat, the whole remaining organised in the

viii PREFACE

sense that the skeletal framework is never lost from sight.

The volume of information requires that many contri­ butors are needed, and this implies my hope that others will share in formulating succeeding and bener forms of this text. Unless they be monsters of omniscience, indivi­ duals who singlehandedly attempt to write on the many and diverse aspects of vertebral joint conditions must deal with some aspects about which they have little or no first­ hand knowledge.

Without divine dispensation one's own view of what is important cannOt be acceptable to more than a handful, and for this reason alone, I would be very grateful for information about omissions, contradictions and ambi­ guities; suggestions from like-minded colleages would help to make a more suitable bony framework for the new meat and help to eradicate the inevitable defects of a first attempt.

One could have written entirely on 'Manipulation', yet this presupposes that manipulation is the primary interest. This is not so-the more we understand about the genesis of these conditions, the temperament and life-habits of the patients in whom they are occurring and more especially the infinite variety of presentation from patient to patient, the better we help them; 'manipulation' is but one of our treatments, albeit a subject in itself.

The text is addressed to the members of no particular discipline other than like-minded professional colleagues, by whatever academic route they may have developed an interest in the conservative treatment of the ubiquitous, frustrating and depressing spinal joint problems suffered by such multitudes of people.

I have not attempted to categorise, or elaborate on, the pathology and syndromes of common musculoskeletal ab­ normalities other than in a general way, for these excellent reasons:

1. I already know of at least three different solutions to the problem of syndrome classification, which is a highly artificial business, anyway.

2. There is not space for such a full dissertation, should I be competent to provide it, if there is also to be some general attention to treatment techniques.

3. Knowledge of the subject is expanding and changing with such speed that a text purporting to be up-to-date and written by even the best authorities has little chance of meeting such a claim.

Hence, principles only arc important, and do not change with the years. In The History of ImpressionismlO29 Renoir is quoted as observing, ' . . . though one should take care not to remain imprisoned in the forms we have inherited, one should neither, through love of progress, imagine that one can detach oneself completely from past centuries.'

Further, if we look to our experience we find that it is by thoroughly familiarising ourselves with the inventions of

others that we learn to make inventions of our own, par­ ticularly in regard to clinical examination procedures and treatment techniques.

While physiotherapists should not anempt [Q write com­ prehensively on problems of diagnosis, or the disciplines of pathology, medicine, surgery, neurology, radiology and epidemiology, etc., perhaps in the devotion of a profes­ sional lifetime to this field of minor orthopaedics one may have acquired the competence to touch upon these discip­ lines as they concern the group of conditions under dis­ cussion here.

When students approach their training in 'clinical con­ ditions' as diseases of the various systems, the conditions tend to assume a sort of social pecking order in their minds. Regrettably, the largely benign and humble rheumatic dis­ orders have a habit of being relegated to the lower orders and boring peasants of this hierarchy. I believe this to be a profound mistake, since by meticulous examination and enlightened assessment each one of the 'old (and young) necks and backs' becomes an exciting detective stOry of absorbing interest and amply repays informed and accurate treatment, which need not be vigorous or aggressive. The ample repayment lies in the pure pleasure of relieving chronic and often disabling pain and other symptoms and in one's slowly increasing awareness of the infinite variety of ways in which movement-abnormalities of the vertebral column can present.

Degenerative joint disease of the spine is perhaps best regarded as a family of physiological ageing processes, with pathological changes intervening sooner or later as a con­ sequence, the process being influenced by direct and indi­ rect trauma or stress, and coexistent disease. Patients rarely attend because their spines are undergoing gradual and silent degeneration with gradual diminution of movement, but because they have pain and other troublesome symp­ toms in a specified area, and sometimes two or three.

'There is in medicine a natural law that any single man­ ifestation, subjective or objective, may have behind it a multiplicity of organic causes, just as any single patho­ logical event is bound to project itself into a number of different clinical manifestations' (Steindler, 1962).1171 It is convenient to use generalised treatment procedures for 'the arthrosis' or 'the spondylosis' as the basic reason for the patient's attendance, yet always more rewarding to broaden an understanding of the infinite variety of ways in which patients can be troubled and try to perceive the nature of the causes and to adapt treatment for the unique form in which the disease affects each one.

With regard to affections of the cranial nerves, for ex­ ample, Brodal (1965) has pointed out that it is somewhat unreliable to attempt fitting a given series of symptoms to one of the many syndromes described, since these syn­ dromes rarely occur in typical form. The same applies to migraine, of course (p. 218), and especially so to all clinical presentation of musculoskeletal joint problems.

Attempts to eradicate this annoying untidiness, by seek­ ing to impose artificial order and regularity, where none can yet exist, are foolish. Plato observed that man never legislates, but destinies and accidents happening in all Sorts of ways, legislate in all sorts of ways (see p. 205). There are too many factors involved; very many of the so-called typ­ ical syndromes arc surprisingly uncommon. This becomes more apparent in direct relationship to the comprehen­ siveness of history-taking, initial examination and careful palpation.

Because there appears to be a gross imbalance among the weight of literature on degenerative change, in that the lumbar disc has cornered a fashionable and ridiculously large share of anemion, I have devoted more space than may be customary to arthrosis, and to seemingly less-vis­ ited districts of the vertebral column. The subjects of ver­ tebral traction and the sacroiliac joint have also been given rather more space, since they currently attract considerable interest.

The opposite end of the spine, in the form of therapy for headache, already suffers from an embarrasssment of riches-academic debates over migraine become more eru­ dite and the drugs more exotic with an increasing ball-and­ chain paraphernalia of side-effects.

A very great deal more is being learned about what appears to a clinical therapist to be, in many cases, of little shopfloor clinical value, and we wistfully hope that more time will be devoted to comprehensively examining and palpating the bit that holds the headache up-the cervical spine and the craniovertebral junction.

With regard to pathological changes, it has been neces­ sary to restrict discussion to those aspects which are of first importance in the field of musculoskeletal joint problems; where convenient to do so, reference as is necessary is made in the 'Clinical presentation' section rather than in the more detailed section on 'Pathological changes' (cf. anky­ losing spondylitis).

Where it has seemed to me appropriate I have not hesi­ tated to cross the somewhat 'watertight' descriptive boun­ daries of aetiology, pathology and clinical features, for the more effective presentation of important aspects in parti­ cular spinal regions, e.g. in the section on 'whiplash' in­ juries, the discussion of surgical problems in the section on biomechanics of the cervical cord and meninges, and the discussion of soft tissue changes.

Bourdillon (1973)'" expressed a salient feature of spinal musculoskeletal problems:

The paucity of clinical signs and the diversity of symptoms produced by spinal join( disorders confused the medical profes­ sion [Q such an extent that they were not always recognised as having their origin in spinal joints.

Occasionally, because the clinical therapist may only partially appreciate what the patient is complaining about, or fully appreciates it but docs not know what to do about

PREFACE ix it, or the facilities for help are not as adequate as desired, the patient is given a few generalised exercises and told to 'live with it'. There is the paradox that while musculo­ skeletal abnormalities are the most frequent cause of de­ pressing aches and pains, they tend to be regarded as the least rewarding to treat and thus may be the worst pro­ vided-for. The run-of-the-mill standard of clinical examin­ ation of these 'uninteresting' conditions is perhaps not always as painstaking as it might be, and the patience of patients is at times unbelievable. The amount of real need is calamitous, and the clinical wherewithal to cope with it ethically, knowledgeably, effectively and with a minimum of vigour, has been sadly thin on the ground.

For this reason, the energetic attack with limited means on the important lumbar spine problems by the Society for Back Pain Research will do much good; the cervical region of the vertebral column, and the ubiquitous problems of cervical spondylosis, have also received an increasing vol­ ume of expert attention 1 11 _{and, together with the advances} in the understanding of pain behaviour, today's clinical workers arc immeasurably better equipped than those of two decades ago. I t may be that the word 'manipulation' will conjure in the minds of many the 'rogue-elephant' manipulator, banging away in a vigorous manner at what­ ever joint condition may present itself; it may also be that (happily a small) minority of authors with a manipu­ lative bent, who have acquired authoritative voice and responsibility over the years, have tended to alienate the moderately minded by an habitual style of unbuttoned rhetoric and noisy self-aggrandisement.

I quote F. Dudley Hart''':

In medicine the authority in the past for some theory of ae­ tiology or drug action or pathological or physiological process was often some (often professorial) God-like figure and was sometimes based on precious little evidence, but it was accepted as true because (l) it seemed to explain things nicely and often relatively simply and (2) the gentleman who said or wrote it was a great authority .... The God-like physician, proven repeatedly right in the past and venerated and respected ac­ cordingly, can hold back for years afterwards medical progress by an ... utterance based on inadequate evidence .... It is so much easier for us all to believe in somebody reputable than to work it out for ourselves and see if he was right. ... Most of us perform our medical duties acting on working hypotheses rather than on fixed beliefs, but it is very easy for the one gradually and very insidiously [0 become the other, particularly

if one is teaching and lecturing. What I say three times is true, is true, is very true.

Having travelled the long road from cocksure ignorance to thoughtful uncertainty, I am mindful of the prime need for the younger clinical workers to develop their vocabu­ lary of anatomical information and their capacities for assessment, because superficial conclusions derived from casually observed phenomena are not always justified. The fact that most strip-clubs audiences are said to comprise

x PREFACE

baldheaded old men should not lead to a 'logical' conclu­ sion that looking at ladies without any clothes on makes the hair fall out.

The patient who presents as 'just another old disc lesion' may have a pain behaviour and more subtle clinical signs which only reveal themselves on careful examination.

Those who have the wit and the stamina to adopt the attitude of intellectual explorers, rather than opting for an easier and safer pathway as passive recipients of orthodox knowledge, will get more interest and fun out of the pro­ ceedings and will find the work more absorbing; the overall profit exceeds the pain by a handsome margin. For myself, one of the hardest things I had to learn was concentration on treating the signs and symptoms and nOt unwittingly trying to treat the X-ray appearance, the textbook, the dogma or mechanical concepts of what was believed to have occurred, important though three of these may be.

I plead that the medical and physiotherapy schools might devote much more attention to the teaching of ver­ tebral anatomy and the comprehensive management of benign articular pathology of the spinal column because, like the common cold, there's a lot of it about and its depredations interfere with our economic and social affairs to a sad extent. This is a pity, because a truly remarkable amount of the population's money syphons itself into re­ search of one kind and another and it is plain that a minor proportion of it might acquire considerable cost-effective­ ness by being channelled into teaching very many more clinicians and therapists how to recognise and treat by relatively simple means the early painful manifestations of vertebral degenerative joint disease.

A summary (Wood, 1980)"'" of the proceedings of a Workshop on undergraduate education in rheumatology, suggests that while the musculoskeletal system is one of the major systems of the body, its status is only infre­ quently recorded in patients' casenotes.

Although considerable progress has been evident since the 1971 survey) nevertheless there were still grounds for concern about the adequacy of rheumatological teaching in many undergraduate medical schoolsj the situation in regard to rehabilitation is less satisfactory.

Under the heading of 'Educational objectives' is suggested the fostering of an attitude of 'cooperation in regard to the con­ tributions that can be made by various health professionals and other members of the team'.

The summary also observes that:

... the persisting neglect of the musculoskeletal system is cause for serious concern, and tends to be encouraged by the fact that patients are usually aware of their problem, in contrast to

the occult nature of many visceral lesions; much effort is

required [0 encourage all medical colleagues to examine joints properly ...

It has been suggested that because the conundrum of rheumatoid arthritis will probably be solved within the decade, rheumatology must look to new fields and should turn its main energies to backache. Together with these logical and reasonable observations is included:

Sufferers who are sufficiently alarmed by their symptoms and

whose pains arc severe will seek help, some from family doctors and some from heterodox healers, the osteopaths, chiroprac­ tors, manipulating physiotherapists, unqualified bonesetters or others of the host described as 'fringe medicine'.

The writer of such phrases about ethical and competent paramedical workers in the health care team could nm have more plainly bared his deep anxieties. Those who profess to handle the vertebral column must be awake [Q all aspects at all times. Problems, a few of them highly disconcerting, have a habit of looming suddenly and the more so as one slides into an easy familiarity of handling after a 'routine' history-taking. The possibility of serious pathology, and some limes malignancy, hangs over all clinical presenta­ tions of vertebral pain. That which presents as a simple joint problem can be the seemingly innocent augury of something more sinister. Not often, but often enough. For this reason alone, the therapist must be soundly and com­ prehensively informed, always awake and always eco­ nomical in the use of vigour. There is no other way to avoid serious or catastrophic manipulation accidents.

Should there be a message in this book, it lies in the sections on assessmcnt. In its coordinated activity and usc of stored patterns the mind is like a group of prime movers and syncrgic muscles and its ability to grasp, sort and organise information can reach an artistry as perfect as an outfielder's leap for a back-hand catch. I n his essay on Sir Isaac Newton, J. M. Keynes describes the mind-muscle as much like a lens; the ability to gather unrelated bits of knowledge in a new pattern varies from person to person. This ability is an essential quality for the accurate and detailed assessment of joint problems. Anatomical infor­ mation, painstaking clinical method and basically simple things done carefully and well are more important than the facile acquisition of exotic manipulation techniques. Since we tend, at times, to take ourselves much toO seriously I hope the mild irreverence here and there in the text does not make my more sober colleagues too unhappy.

The late Sir Winston Churchill once said that short words were better than long ones and the old words were best of all. I hope there are not too many long words.

Acknowledgments

We climb on the shoulders of those who have gone before, and those who follow will climb on OUf own; we also lean

on the shoulders of colleagues and I express with pleasure a debt of gratitude to john Conway (from whom I learnt much about the value of treating patients in (he side-lying position) and joe jeans (whose friendly but incessant demands that I produce a book have now been met), also Freddie Preasrner, Brian Edwards, Peter Edgclow, Marjorie Bloor, Sue Adams, Freddy Kaltenborn, Beryl Graveling, Sue Barker, Shelia Philbrook, Chris Cox head, and jill Guymer.

I wish to acknowledge the fruitful working relationship between Geoffrey Maitland and myself, extending over eighteen years and dating from his visit to St Thomas' Hospital in London during 1961. We have both had the privilege of developing the usc of mobilisation and mani­ pulation techniques by physiotherapists in our respective countries, and the free exchange of information and ideas between us has afforded me pleasure as well as profit.

Figures 2.18, 2.19 and 2.20 arc reproduced from Verte­ bral MalliplIlalioll (4E) by kind permission of Geoffrey Maitland, AVA FCSP MAPA, and Messrs Butterworth, London.

There is an especial place in my regard for Mr P. H. Newman, in whose Tuesday clinics at the Royal National Orthopaedic Hospital I learnt so much about orthopaedic patients. He graciously lent his immense tcaching au­ thority to the 1973, 1974 and 1975 CSP Manipulation Courses, and has very kindly honoured me by writing the foreword to this book.

All therapists will join me in recording our considerable debt to Professor R. E. M. Bowden, Dr D. A. Brewerton, Mr R. Campbell Connolly, Dr j. Ebbetts, Mr A. W. F. Lettin, Dr R. O. Murray, Dr A. Stoddard, Dr j. D. G. Troup, Professor P. D. Wall and Dr B. D. Wyke. To our debt I add my warm personal thanks, also to Dr Basil Christie, Dr Ian Curwcn, Dr Desmond Newton and Mr Hugh Phillips; they have more than once guided my wan­ dering notions.

I am grateful to Professor D. L. Hamblen, Mr P. H.

Newman, Mr H. Phillips, Dr W. G. Wenley and Dr B. D. Wyke for kindly looking at sections of the text and advising mc; faults which remain are my own, of course.

Dr A. Burnell's enthusiasm has been a constant encour­ agement to physiotherapists and we owe much to Dr J. Cyriax, who brought some order to the examination of musculoskeletal problems and upon whose work further developments have been based. Also to Mr W. j. Guest, Principal of the West Middlesex Hospital School of Physiotherapy; his capacity for doing good unobtrusively has benefited physiotherapy more than it knows and I take pleasure in publicly recording my appreciation of his en­ couragement and support of the CSP Manipulation Courses in the early days, and of myself over 30 years of professional association.

Members of the Manipulation Association of Charlered Physiotherapists have been most fortunate to enjoy access to the great and important volume of continental medical literature in this specialist field, and for this are in major debt to the multilingual erudition of my classmate of years now sadly past, Mr H. j. C. Cooper, and to his unfailing willingness (Q burn the midnight oil on our behalf with French, German and if need be Russian translations.

It is a pleasure to record my debt (Q the technical skills of Dr john Graves of the Graves Audiovisual Medical Library, Miss Vta Boundy, Medical Photographer to the Institute of Orthopaedics, London, Mr john Tydeman of the Department of Medicallllustration, Norfolk and Nor­ wich Hospital, and to Anglia Photographics, Halesworth; they have devoted much care and technical skill to the illustrations.

To those who patiently modelled during the long and tedious photographic sessions, viz. the late Moira Pakenham-Walsh, Sarah Key, jenifer Horsfall, Kathleen \'\Iinter, Denise Poultney and Fiona Percival, J am very grateful.

To Mrs M. Moore, Librarian of the Norfolk and Norwich Institute of Medical Education, and to Mr C. Davenport and Mr P. Smith, respectively the previous

xii ACKNOWLEDGMENTS

and present Librarians of the Institute of Orthopaedics, London, I gratefully acknowledge the efficient help I have been given.

I thank Mr G. T. F. Braddock for generously providing photographic evidence of a unique experiment, which raised my interest when described, and for allowing me to publish it.

Professor Peter R. Davies has been especially generous with advice on expression of magnitudes in S-I units.

Mrs J. Whitehouse, The CSP Journal Editor, has kindly

allowed me to reproduce very many figures and passages from my writings in Physiotherapy. I thank Mr B. Holden of Carters Ltd, Mr N. Peters of The Tru-Eze Co. Inc. and Mr J. Maley of the Chattanooga Pharmacal Co. for promptly sending me the illustrations I had requested.

Every care has been taken to make the customary ac­ knowledgment to holders of copyright, but if any copyright material has inadvertently been used without due permis­ sion or acknowledgment, apologies are offered to those concerned.

Contents

1. Applied anatomy-regional 7. Clinical features 159

Cervical 3 Neurological changes 160

Thoracic 13 Pain and tenderness 161

Lumbar 17 The autonomic nervouS system in vertebral

Pelvic 29 pain syndromes 176

Surface anatomy 31 Referred pain 189

Abnormalities of feeling 196

2. Applied anatomy-general 36 Changes in muscle and soft tissue 196

Deformity 199

Articular cartilage 36 _{Functional disablement 200}

Lubrication of synovial joints 36 _{The psychological aspect of vertebral pain 202}

Vertebral movement 38

Inrcrvcrtcbral foramen 53

Biomechanics of spinal cord and meninges 56 8. Common patterns of clinical presentation 205

Venous drainage 62

Arthrosis and spondylosis 205

Autonomic nervous system 64

Patterns of somatic nerve root supply 69 Upper cervical region 206

Cervico-thoracic region 229

3. Aetiology in general terms 74 Thoracic region 232

Lumbar spine and pelvis 250

4. Incidence 77 The pelvic joints 279

Neoplasms 300

5. Pathological changes-general 82

Synovial joints 82 9. Examination 303

Symphyses (Intervertebral body joints) 88 Introduction 303

Nerve root involvement 94 Regional Examination procedures 322

Soft tissues 110 Cervical region 322

Neoplasms 121 Shoulder and clavicular joints 324

Thoracic region 326

6. Pathological changes-combined regional _{Lumbar region} 327

degenerative 125 Pelvic joints 328

Cervical spine 125 Hip 334

Passive physiological movement tests 336

Cervico-thoracic region 129 _{Recording examination 341}

Thoracic spine 134

Lumber spine 138

Sphincter disturbance ₁₅₀ 10. Assessment in examination-Prognosis 350

The pelvis ₁₅₁

Serious pathology simulating musculoskeletal

xiv CONTENTS

12. Principles of treatment 376 Localised manipulation 463

Aims of treatment 377· Regional manipulation _Exercise 464 ₄₆₄

Definition of passive movement techniques 378� _{Contraindications 465}

Manipulation in general terms 38

�

Grouping of techniques 38

Supports and appliances and adjunct

16.

13. Recording treatment and clinical method 435 physiotherapy treatments 468

Use of technique 441

Selection of technique 442 17. Medication and alternative methods of

Assessment during treatment 444 pain relief 483

14. Exercises 45 1 18. Prophylaxis 496

15. Indications for passive movement 19. Invasive procedures 51 4

techniques and exercise 460 _{Minor procedures 5 14}

General indications 460 Major surgery with indications for seeking

Soft�tissue techniques 460 surgical opinion 525

Localised mobilisation 46 1

Regional mobilisation 462 References 535

Stretching CA) 462

For

Barbara Grieve-the other half of the team

and lO our melltor, Ted Goldblatt, with affection alld regard

1. Applied anatomy-regional

A

shore general summary of vertebral structures and

their function may usefully precede descriptions of

degenerative change and irs consequences. Where indivi­

dual features require morc extended discussion, this has

been included in the appropriate sections throughout the

text.

Because structural variations have considerable impor­

tance in this clinical field, and their likelihood always

worth bearing in mind, some anomalies have been in­

cluded with regional descriptions; reference should

sooner or later be made to fuller and more detailed

accounts.

)15,881,1274,109)

Fig. 1.1 (A) Anterior aspect ofthe venc:bral column. Note the variations in length of transverse processes. (8) Lateral aspect. Note: the varying configuT8lions and size of spinous processes.

2 COMMON VERTEBRAL JOINT PROBLEMS

frequently, cardiac and renal abnormalities occur, and there may be congenital malformations of the gastro­ intestinal and respiratory system. lOGO

The

join" of

the vertebral column

(Figs

1 . 1 , 1 . 2

and 1.3)

at:!

of

three kinds:

I. Symphyses,

i.e. secondary cartilaginous JOints, between the vertebral bodies, with their interposed discs. The upper rwo synovial joint segments have no disc

-;;

d are therefore not symphyses, besides showing other atypi­ cal features.

2

.

.

$.JJ1lovial joints,

also called

zygapnphyseal

or facet joints, bctween the articular processes of the vertebral arches. The anterior symphysis together with the 2 pos­ terior facet joints typically form one of the 'mobile segments' of the spine, totalling 25 including the upper

2

atypical segments.

3. In the cervical spine only, a further group of small articulations rcquires consideration (Fig. 1.4): these are the Q!ired

j

oinlS of

Luschka,

1091

the uncovertebral or neuro­

central articulauoQs. situated in the uncovertebral region on each side between the outer posterior margins of the vertebral bodies, at the five segments berween the second �nd seventh yerrebrae.548 ArtICular facet on supenor aspect --____ -= of atlas Lateral top

---�1'·

of atlas Transverse

�

�

m

-�---�

,

�

C2

Fig. t.2 Lateral aspect of cervical spine. Note the large and prominent spinous process of C2. the distance between the posterior tubercle of the arch of atlas and the C2 spinous process. and the somewhat depressed spinous processes of C3, C4 and C5. Tip of lateral mass of atlas is palpable between mastoid process and mandibular angle.

�--�_Cl--{;2

facet joint

Bifid

spflnous

�ocess

ofC2 ofC2

Fig. 1.3 PoSterior aspect of the craniovertebral region. Note the lateral tip of atlas extending well beyond the transverse process of C2. The mastoid process of the temporal bone would lie laterally to the margins of the illustration.

CERVICAL SPINE

Because the consequences of arthrotic and spondylorjc changes in the neck arc usually more marked and wjde_

spread than degeneration of other spinal regioos, the salient facts of anatomy and articular function in this area

need careful consideration.'�'" 475,1)54,1)55.1)57,1364,967,1242 A. UPPER CERVICAL SPINE (Fig.

1 .5)

T niovertebral re ion is of importance, as some 0

the most essential atwrcor jmpulses or the static and

dynamic regulation of body posture arise from receptor s

Y

stems in the connective tissue strucrutes and mpscles

around the upper vertebral synovial joints. The impor­ tance of their func[tonal role is clearly demonstrated, for example, in consideration of the tonic neck reflexes.

�

posture governs body posture and limb control; abnor­ malities of afferent impulse traffic from joint receptors, because of degenerative changes, can be expected to reduce the efficiency of postural control and produce the alarming symptoms of defective equilibration.

Experimental cervical lesions jn monkeys jmm)ving

u ilatera! section of u per cervical dorsa r -duce bo y dysequilibrium; and positional n stagmus, in rabbits, IS cause y oc 109 the articular receptors in

the intervertebral joints and ligaments. 586,587,188, U8, 136.J

OccipitoatlantaJ joint

The convex occipital condyles, and reciprocally concave articular surfaces of the atlas, have their long axes

con-Fig. 1.4 Anterior aspect of cervicothoracic region. The uncovenebral region at C5-6 level shows the sclerosis of bony margins and flanening of the C6 uncus on the patient's right side. Compare with uncovertebral region of C6-7 space.

APPLIED ANATOMY-REGIONAL

3

F11r. 1.5 Anterior aspect of upper cervical region. There is chondro­ osteophytosis at C3-4 facet-joints on either side, and also at C4-5 on patient's left side.

verging anteriorly, with the lateral edges of the facets 00 the atlas banked u . a saucer, which somew stricts other than sagittal mov�s IgS . ,

1.5).

Atlantoaxial

joint488• S58

The r:Qugbly circlJlar facets of both atlas and axis are not quite reciprocally curved; the convex upper axial surface receives the irregularly concave inferior facets of the atlas 'like the epaulettes on a

pair

_{of sloping sho"lders';} the

facet-planes being about] ] 0° to tbe yertical

The

posterior

face of the anterior arch of atlas abuts against the front of the odontoid, a small synovial cavity intervening; a si!11ila all bursa or synovial oint intervenes between the posterior face 0 e odontoid and its strong retammg

4

COMMON VERTEBRAL JOINT PROBLEMS

Fig. t., The lateral atlantoaxial joint appears biconvex.

(Figures 1.6 and 1.7 are reproducM from Hohl M, Baker HR 1964 The atlanto-axial joint-r�ntgenographic and anatomical study of normal and abnormal motion. Journal of Bone and Joint Surgery 56A: 1739. by kind permission of the authors and the Editor.)

fibrQus band

Ihe Ir"D'Y'me

ligament (see below) (Figs

1

.5, 1.6, 1

.7

).

The craniovertebral ligaments

These shared by both articulations are of much functional

importance, as osteoarthrotic changes are common in this

re ion following stress and trauma and th

f

possible Igamentous lOsufficie

n

cy

myst be borne in mind

during treatment (Fig. 1 . 8).'98 From before backwards,

they are:

1 . The

anterior

occjpitoatlantal membrarJe,

continuous

below with the anterior longitudinal ligament and blend­

ing laterally with the capsules of the facet-joints.

2.

The \pin

qpical ligam!!,l,

attaching the tip of the

odontoid to the

�

[Jor margin of the foramen magnum

(Fig.

1.9).

-

-3.

_{The Q!ore l}

a

t

e

rally

placed

and tougher

alar ligaments,

attaching the posterior part of the odontoid tip to the

lateral margin of the foramen mag.num on each side.

4.

The

transverse liggmem of the atlas,

a strong fibrous

band connecting each lateral mass across the front of the

neural canal and passing behind the odontoid; it is a vital

re..!,aining structure stabilising the odontoid in the bony

ring of atlas, and is mainly responsible for the integrity

of the atlantoaxial joi . TJle ligament has a cruciate

form,

w

ertical bands of less functional imporrance

ex!endjng

"pward and

dowmva�.

5.

The

accessory atlqntOaxial ljgmueuu,

w.!!ich pass

upward

and

J�t"c:1L

v

f'21D the bas. QLlhl:jefcriN yertlcal

band of the

;

;;;;;:;f!Jis;:ent ;rnA cnnn;rt;h; ha

se of the

odontoid process with the inferomedial art of the lateral

he median atlantoaxial (or atlantodental)

Antertor

2 3 4

Posterior Cranial Fossa

Fig. 1.8 Median and paramedian section of cervical structures. I. Anterior longitudinal ligament

2. Anterior atlanto-occipital membrane

3. Synovial joint between anterior arch of atlas and odontoid

4. Odontoid process

5. Apical ligament of odontoid

6. Synovial joint between transverse ligament and odontoid.

NB. 3 and 6 comprise the median atlantoaxial joint (q.v.) 7. Transverse ligament of atlas

Posterior

10

"

12 13

8. Membrane tectoria-the upward continuation of the posterior longitudinal ligament

9. Posterior longitudinal ligament

10. Foramen for first cervical nerve and vertebral artery

II. Foramen for second cervical nerve

12. Ligamentum nuchae

13. Capsule of facet joint between the right side articular processes of C2 and C3.

(Reproduced from Kapandji IA 1974 The Physiology or the joints III (the trunk and vertebral column) p 187, by kind permission or the

author and Librairic Maloine S.A. Paris.'

joint is very frequently the seat

of

arthrotic change. more

s

o than in the two lateral articulations.1174

\

6.

The

membrana leeroo'a,

being the upward prolonga­

tion of the posterior longitudinal ligament,

covers

the

pc:cerljng stryctures

posteriorl)' j

it is attached below to

the base of the odontoid, and above to the clivus of the

basiocciput.

7.

_T.he

posterior occipitoatlamal membrane

completes

C2

Apical

l)9a

m<ent

--:'l---Accessory

Atlanto­

Axial Ligaments

Post.

Lon�.

---'--j6,

ligament

_{��I---��ir1aICorn}

the circle of connective tissue between occiput and atlas,

blending laterally with the capsules ofthe facet-joints, and

representing the ligamentum flavum at this segmen of the

spine.

8.

he a ticular capsules between cranium and atlas are

reinforced by the latera OCCtpllOal anta 19amems

ic

e ten

es

of th

e

lateral

mass of

the atlas on each side. In the two sets of

paired joints considered above, the capsules permit rela­

tively free movement, that of the atlantoaxial joint being

the looser of the two.

�B. The strong transverse ligament. aJar 1jgaments,

and accessory atlantoaxial ligaments mainly provide the

stability

between the fint and second ceryjcal

vertebrae.

Degenerative attenuation, or tearing, of the transverse

ligament is a serious injury, allowing the possibility of the

odontoid impinging on the spinal cord. Wbcp

the

tranS­

verse ligament is cut, the atlas is seen to displace forward

up to

7

mm,

_and

if the alar ligaments are then cut, the

a�las

woyes

forward a further

3

mm. )�2

The alar and accessory adantoaxial ligaments are im­

portant structures in checking rotation

of the bead wjth

atlas on axis, becoming taut at

30 -40 of rotatjon They

also restrict lateral ftexion.

B. CERVICAL SPINE (C2--C7) (see Vertebral move­

ment, p. 38)

The

imerperrebrql discs

contribute more than one-QJJ3rter

of the length of the

ceryjeal col"mn

and this proportion

is a factor in the comparatively free movement in the

region.

II?

By their function of withstanding the distortion

imposed during movement. by their ftexibility, elasticity

and resilience, the discs form the anterior. weight-bearing

liPk of each vertebral 'mobile segment'. Despite this im­

portant function, they have virtually no blood supply, as

befits non-osseous, weight-bearing structures. The

nucleus is avascular and onl the peripheral part of the

annulus enjoys a somewhat meagre bloo supp y urmg

t

rst decade of life; even this . . .

to virtual

avascularity in t e young adult.98.

The cervical interbody joints are a form of saddle

articulation, convex above in the anteroposterior direction

and concave from side to side (Fig. 1.4), thus forming the

upward projecting uncus or lateral margins of the

ver-tebral bodies.

_�

C. UNCOVERTEBRAL REGION

The uncoverrebra'

joinss

(or the so-called JOlOts of

Luschka) are formed between the uncinate rocesses the

elevated

I

t e u er surfaces of vertebral

bodies three to seven, and the bevelled lower border

the verte r

o y a ove (Fig. I. . ese small horizontal

•

APPLIED ANATOMY-REGIONAL

5

cleft-like cavities or fissures�"8 which appear macroscopic­

ally after the first

or

sec

o

nd decade of life but which can

be recognised microscopically much earlier, are bounded

anteromediall b the intervertebral disc and

posterola-terall b

ar

I

amen t, art

0

t e ann

fibrosus; oRposed

s

urfac

e

s

are covered by hyaline cartilage

and the space is hued by a synovium which sends small

�

jections into the cavity as 'memscoid' structures.98'

Shearing occurs here, especially during ftexion and exten­

sion movements, and the importance of the cleft-like

s aces lies in their specla e

e enerative

change, WIt t e consequent f

o

rmat jon

of thjckened

soft­

tissue and b

o

ny outgrowths in the neighbourhood of both

the nerve root and the

yertebral artery

Jung and Kehr

(1972)'"

have emphasised the especially

damaging effects ofuncoarthrosis in the aetiology of cervi­

coencephalic syndromes. The strong fibroelastic septum

of the

ligamentum

n!l

e

ha

e

(Fig.

1.8)

is much more than the

homologue of the supraspinous and interspinous liga­

mentS in other parts of the column ; by its attachment to

all bony segments

frow occipyt to the

seventh cervical

spinous process, it is an important non-contractile

structure contributing to postural stability of the head and

neck and also

to

the graduation of flexion movements.

]n flexion-acceleration injuries of the neck, the amount

of damage to the more intrinsic joint structures depends

upon whether the degree of applied

force was

syfficient

first to tear this thick

sepww, one of

the first lines of

defence when these injuries are sustained. Its degenera­

t,ion

in

advanced age is one of the reasons for the lowering

forward of the head in the elderly. when standing.

The facet-joints

As the paired posterior components of each movement­

segment,

we

facet-jointS

are enyeloped

in a baggy capsule

which covers

them like a hOOd and has

a degree

of

elas­

ti£i!L This allows free movement, the

nature

of which the

facet-planes largely govern. Imaginary lines joining the

planes of these joints would roughly converge on the

region of the

eye,

so that

a

55 ansle with the vertical of

the upper ceprica' spine facet-plages becomes a 25 angle

at

the upper

thoracic hcer

planes.

The total surface area of these joints is about two-thirds

of the articular area of the vertebral bodies, and the joint

planes are approximately 45 to the vertical,

tbps

es�i­

ally at the more horizontally placed upper joints but also

in the rest of the cervical column the articular

' age

bears a degree

0

we'g t, s armg the load of the head with

the vertebral boalCS ana diSCS. AlI the posterior joints con­

tain small 'meniscoid'

srrJJcl!!res,

which project into the

joint space similarly to the alar folds of the knee, and

'ir!'

formed of tongue-like or semil"nar fringeS of synovium;

the subsynOyia) tissue is richly innervated according to

Kos

(1972)677

With all other weight-bearing joints, the

facet-joints inherit a marked tendency to degenerative

6

COMMON VERTEBRAL JOINT PROBLEMS

change and suffer as much of this as any other joints in the body.162.6U

VESSELS

The vertebral arteries

Arising from the subclavian vessels, these run the gauntlet of many hazards in their passage through the foramina transvcrsaria of the upper six cervical vertebrae, before

Right Vertebral Ar1ter"

111.\'J��

l.eft Vertebral Artery

�:lI[:Jl-

SoI".tic Roots

Inferior Cervical

and Stellate Ganglia

Right SUbclavian Art,erv-'

Fig_ 1.10 The vertebral arteries.

--L.en Subclavian Artery

they pie[Cc the posterior atlanta-occipital membrane, enter the foramen magnum and unite on the front of the

b ain stem to form first the basila and then by dividing 3g3m, t e wo pas CrIor cerebral artenes Igs

1.10, 1.11).

The vertebrobasilar arterial system supplies the s inal cor, e meninges, nerve roo s, p exuses, muscles and joints of the neck and, intracranIally, the medulIa with its vital centres. the cerebellum, the vestibular nuclei and

Fig. 1.11 Posterior aspect of craniovcrtebral region. After emerging through the foramen transversarium of the atlas, the vertebral artery winds around the anicular pillar and, together Y'ith the first cervical nerve and veins, pierces the posterior atlanto-occipital membrane, to unite with its fellow on the front of the brain stem to form the basilar anery.

their connections with the

equilibratory

ontans and tbe

vjsual cortex; in the lower cervical spine other arteries contribute to the supply of extracranial structures such as muscles and nerve roots. Transient compression of the vertebral artery by bony outgrowths and soft tissue thickening during upper cervical movements, especiaUf!' rotation and extenSion, or permanent narrOWIn due a

e s and facet-jomt margins in

the reSt of the region, can produce the alarming symptoms of vertebrobasllat insuffiCiency. A degree of atheroma of the vessel wall increases this possibility,

�

branch of the vertebral artery passes directly

back­

w rds at each se ment to su Iy the facet-joint structures, and it is es eciall Ii 1J e verteb a1

rte 's distorted by degenerative processes.

T� ood su I of t e cervI In cord IS der' d

in part from the radicular arteries, w

arranged branches from the vertebral artery lie on the front f the s ina! nerve roots, enter each mterverteb I foramen, give off ranches to nerve roots, ganglia, facet joints and other structures, and then proceed inwards to form free anastomoses with the anterior and posterior spr­ nal arteries. The former of these IS aenved Itom tne vet­ tebral arteries as they unite above to form the basilar artery near the foramen magnum, and the latter from the pos­ terior inferior cerebellar arteries in the same region.

These two apparently continuous Ion i vess s

are moses. Flow is

downwards in the anterior spinal artery in the upper cervi­ cal region, but succeeding arteries supply a length of spi­ nal cord both below and above their level of entry. ;The arteries on the cord surface are largely immune to athero­ matoJJS cbanges, but thiS complex and

lughly

variable sys­

�

(Fig. 1.12) of spinal cord supply is especially subject [0 remote effects by pressure, e.g. the radicular arteries are at hazard as they traverse the incervenebral foramina with the cervical nerve roots, and despite a certain degree of collateral supply, the vertebral artery itself is subject to compression as described, producing a pattern of CQrd and nerve root ischaemia wich signs and symp[Om�

wlJifh

mill

depend

upon the

paccprn qr wpply

in particular

c�t67.t8". )8".70",656

When the ischaemia is due to vessel constriction a few segments removed, the cord areas most likely to suffer are those lying morc centrally, the 'watershed' areas at the boundary of adjacent territories of supply of two end­ artery systems, i.e.

The terminal distribution of arterial supply accounts for many apparent anomalies in level of the lesion relative [0 the cause, e.g. compression at the foramen magnum can cause wasting of the hands by interruption of the downward flow in the anterior spinal artery. 704

It should be apparent that degellerative challge in the cervi­

APPLIED ANATOMY-REGIONAL

7

VA VA

Fig. 1.12 Anterior aspect of cervical spinal cord and brain stem. Examples of the highly variable arrangement of spinal cord and nerve root arterial supply. The numbers and arrangement of radicular arteries arc very inconsistent (s� text), (After Dommisse GF 1974 The blood supply of the spinal cord. Journal of Bone and Joint Surgery 568: 225.)

addition to local pain and joint stiffness,

the ischaemic

c an

vo vmg t e spinal cord due to spon­

dylosis may lead to c Imca eatures

W

Ie can be puz­

zling, and to cervical myelopathy, onc of the most com­

rhon, if not the commonest, neurological diseases of the

middle-aged and elderly (see

p. 228).

Venous drainage

This is extensive, as befits the haemoQoictic function

of

the vertebral bodies; Iym in the extradural space, the

mternal venous lexus receives the

r

veins, which drain the spongiosa of venebral bodies, and

then forms a rich

anastomosis

with

the external

venous

plexus. The two plexuses form the interyertebral veins,

accompanying the spinal nerves through

the inter­

vertebral foramina and draining into the vertebral

vein of

the neck.

'12.

'JJ5

Following its formation in the suboccipital triangle, the

ver;esral vem, which IS connected to the lDtracranial

venous system (see

p.

62),

enters the foramen trans­

versarium of the first cervical vertebra and descends to

C6

as it gathers the tributaries described; it c;.mpties into

th.e bracbjocephaljc

yejn of the

same side.

he rhythmic, ulsatile ctivity of veins in the cervical

canal

0

served during myelograp y a ter contraSt

medIum IS lDJected mto the subarachnoid space) is

vigorous, and a sudden single rise in pressure (ana

ttius venous distenSIOn) also occurs dunng a coughll5

(see p. 62).

NERVE

SUPPLY

An

understanding of the function of receptor endings in

vertebral joints and blood vessels helps a better under­

standing of the clinical features of degenerative disease.

Details of the complex innervation of the vertebral

column are of practical importance in terms of the likely

level of origin of the pain resulting from tissue changes,

the areas to which pain is commonly referred, the abnor­

malities of posture and changes in the quality of move­

ment, and the confusing

concomitant

symptoms and signs

�

:::

�

.I1'1���

\1st Anterior

/ Primary Ramus

....

r>"\-

2nd

A.P.

R.

1Ii'?,..,J-

Arthrosis

,,::.�+-

31d

A.P.

R.

��f--

4th A.P. R.

.

�--j'---

5th A.P.R.

Fig. 1.13 Laleral aspect of upper five cervical verlebrae. The first two cervical roots emerge behind the facet-joints; all others emerge in front of the facet-joint. Arthrosis of the joint �twr:en C2 and C3 frequently involves the nerve rOOt and rami by trespass upon il of degeneratively thickened tissues. (After Lazorthes G 1972 Ann. de Me-d. Physique 15:

8 COMMON VERTEBRAL JOINT PROBLEMS

other than pain (sec p. 299), some of which arc certainly

due ta involvement of the autanamic system and which

often accompany vertebral pain syndromes.

At the u er

two se menlS

the spinal nerve roots emerge

postero aterally behind the articular pillar an a ove the

posterior arch at the numencatly correspondm vertebra'

the first cerVlca nerve root s ares a foramen in the pos­

terior atlanta-occipital membrane with the vertebral

artery and vein ( Fig. 1 . 1 3). All the orher spinal nerve

ropts

down to the level of the 5th lumbar e�erge in front of

the facet-jojnts

Shore (1935)"" mentions that while the skin does not

receive a direct supply from the first cervical nerve,

because ofa communication with the second cervical nerve

C l has a share in supply of the cutaneous area to which

the greater occipital nerve is distributed.

C2-C8

I5liiTrlg

their passage

towards

the foramina, the fibres of

the roots leaye

the spjnal cord at the

level of the numeric­

ally corresponding vertebral body, and do not pass later­

all in such close relationship to the disc as do the I

r

nerve roots see p. 24). onsequent y, although spinal

cord and nerve root compression can occur by pathologi­

cal changes in the discs, its mode of production differs

somewhat to that in the lumbar region. During their pass­

age

through

the interverte

en t

s are

boun e

10

front and

behjnd by gtrpcwres very

likely to

sympathetIC trunk

Fig. 1.14 Innervation of related cervical vertebral structures in transverse section. Muscular branches of the dorsal ramus supply the articular capsule. Pans of the vertebral plexus are seen within the foramen transversariuffi, together with vertebral vein and artery, and showing smaller but macroscopic ganglia in this situation. Communications of the plexus are seen with the spinal ganglion, dorsal and ventral rami, and the sympathetic trunk (and via this branch to the periosteum and marrow of the vertebral body and the anterior longi[Udinal ligament). Other branches are directed medially to the periosteum and spongy bone of the body and via the meningeal ramus to the dura mater and posterior longitudinal ligament. (After: Stillwell DL 1956 The nerve supply of the vertebral column and its associated struCtures in the monkey. Anatomical Record 125: 139. Reproduced by counesy of the Director, Wistar Press.)

p uce pressure or irritation by exos(Osis, these being the

fa e -'oint structures postero atera y and the 'neuro­

central joints' anterome la

y.

Cervical

spine

nerve roots

have a rough segmental

identity, i.e. after union of the ventral and dorsal rootlets,

the roots emerging

frow the jnteryertebral foramjna

cor­

respond nymerically

with the vertebra

below (excepting

that of the 8th cervical) and the appropriate segment of

the spinal cord. Nevertheless, a few rootlets of the cord

may ascend or descend to join and emerge with the spinal

root numbered one above or one below the cord segment

giving rise to them, and the lowest spinal cord rootlets

contributing to a spinal root may be lower than the

foramen for that nerve, and therefore have to ascend

slightly to reach their exit from the neural cana1.

537

Paradoxically, the nerve supply to the vertebral column

structures themselves is much I

seqmentall

ed,

bem en

1177 a rich

net-work of fibres occupying the region of the somatic nerve

roots and the sympathetic ganglia (Fig.

1.14).

Wyke

(1979)"'"

_{observed that,}

-Each cervical apophyseal joint

is

innervated not only through articular branches of its own segmentally related spinal ne

rv

e

,

ut

also _{by articular nerves that descend to it from the nerve root rostra}

.1.0 it and ascend to it from the caudally located nerve rOOt.

There are plentiful interconnections with the sympath­

etic grey rami communicantes, the inferior, middle and

superior cervical ganglia, the spinal posterior root gan­

glion and the anterior and posterior primary rami. Mixed

efferent autonomic fibres and afferent somatic fib

r�

APPLIED ANATOMY-REGIONAL

9

rived from this plex-us� -fo-rm

'the sinuverteb�ral nerve'

(ramus meningeus), usually compnslOg two or more

branches which re-enter the foramen to supply structures

,\,ithin the vertebral canal (Fig.

1.15).

Mixed branches

from the paravertebral plexus also pass externally to the

sides, front and back of the vertebral bodies, supplying

periosteum and ligaments; many join with the medial

branch of the posterior primary rami of each spinal root,

thereby reaching and serving the rich and varied receptor

population of the facet-joint structures (see p.

10).

Each 'mobilit se ment' receives fibres derived from

three a

es together with sympathetic

postganglionic fibres innervating the blood vessels

therein, and these approach from a variety of directions;

in addition to this segmental overlap, from outside, the

branches of the sinuvertebral nerve within the neural

canal may wander up and down for two or three or more

segments before they terminate in receptor endings (Fig.

1.15).

T.be

_{extension of nerves supplying the vertebral}

column beyond their segment of or' .

om arable to

the

mal innervation on the body

s

�

Ascending branches

of mixed nenres withjn the nellra!

canal, derived from the

upoer three

cervical segments,

sli Iy the dura mater of the posterior cranial fossa, and

may be concerne at urnes

10

the production of occipital

headaches.657

_>

The autonomic nerve supply

The supply to the head and neck

is

derived

Cal

from the

three cervical sympathetic

ganglia

in this region, with (b)

Fi,. 1.15 Posterior aspect of spinal canal. The sinuvertebral nerve (ramus meningeus) may wander up and down for two, three at more segments before terminating in receptor endings. (After: Wiberg G 1949 Back pain in relation to the nerve supply of the intervertebral disc. Acta otthopaedica scandinavica 19: 211.)