gms | German Medical Science

GMS Current Topics in Otorhinolaryngology - Head and Neck Surgery

Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V. (DGHNOKHC)

ISSN 1865-1011

Reconstitution of lost cervical spine function: management strategies

Review Article

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  • corresponding author Arne Ernst - Department of Otolaryngology at ukb, Hospital of the University of Berlin (Charité Medical School)
  • Andreas Niedeggen - Center for Paraplegics and Spine Injury at ukb, Hospital of the University of Berlin (Charité Medical School)

GMS Curr Top Otorhinolaryngol Head Neck Surg 2005;4:Doc20

Die elektronische Version dieses Artikels ist vollständig und ist verfügbar unter: http://www.egms.de/de/journals/cto/2005-4/cto000026.shtml

Veröffentlicht: 28. September 2005

© 2005 Ernst et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.de). Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.


Abstract

The cervical spine (CS) is the most vulnerable part of the whole spine because it has least protection. This is due to its high mobility (few bone, but largely muscle and joint support) which is associated with a high injury risk. The anatomical characteristics are based on evolutionary biological reasons, i.e. humans had to be able to freely controlling the surrounding space with their eyes and to have permanent postural control by an upright position of the head. The cervical spine, its joint and the surrounding muscles are highly interconnected (e.g. direct neuronal projections into the brain stem, connections to the TMJ, Head's zones with projections to the skin surface). Moreover, the spinal pain memory store can lead to a variets of multi-facette clinical pictures. In addition to reversible disorders of the cervical spine, posttraumatic disorders play a major role. The therapy options available include physiotherapy, drug therapy and surgical measures. However, a multidisciplinary approach is most favourable.

Keywords: cervical spine, physiotherapy, spine surgery


1. Introduction

The cervical spine (CS) and the craniocervical junction (CCJ) can be differentiated into three functionally distinct segments: the upper-CS (occipital condyles, C0/C1, atlas/axis), the mid-CS (C3-C5), the the lower CS and the cervico-thoracal junction (C6/C7, T 1 - 3) (Figure 1 [Fig. 1])

The upper-CS has an exceptional position insofar it combines high moveability [1] with limited bony support, but ligamentous and muscle support. This phylogenetic characteristics [2] make reversible hypomobility of CS joints quite likely and this part of the spine vulnerable. Moreover, other segments of the spine and their disorders (e.g. lumbar disc herniation) can affect the CS. This so-called "chain mechanism" has repercussions for therapy because an isolated therapy at the CS in recurrent disease does not lead to long-term success [3]. Disorders in childhood are not the subject of this review because they are very complex, spoecific and can therefore not be considered in this context.

Thus, it is the aim of the present review to outline therapy strategies in CS dysfunction. Conservative and surgical approaches have to be considered and discussed.


2. Reversible functional disorders of muscles, joints and ligaments

The neurophysiological model which describes the neural, mechanical and sensory interactions of the CS/CCJ structures has a central paradigm, i.e. "the segment of movement" (SOM) [3]. It consists of one intervertebral joint, the corresponding muscles, fascia, ligaments, soft tissue and skin. The connectivity is provided by the nerves and the spinal connections (Figure 2 [Fig. 2]). In turn, each disorder of the joint can be accompanied by an inflammatory reaction of the corresponding skin dermatoma, a muscle contraction etc. The basis principles of neurophysiology which correspond to these phenomena (afterdischarge, temporal and spatial summation, successive induction, spinal memory etc.) have already been described by Sherrington [4].

Manual therapy is used as an umbrella term to cover all the different techniques that are applied in those disorders of the musculo-skeletal system [5], [6]. They consist of chirotherapy, neuromuscular facilitation (PNF), osteopathy, Vota's, Bobath's conception etc.

Basically, there is agreement that primary disorders at the skin are to be treated by skin-related techniques, muscular disorders by muscle techniques, joint disorders by joint-related techniques etc. [3] In other words, there are different ways to reach the therapeutic goal (an undistrubed interaction of muscles, joint, ligaments and nerves of the CS/CCJ), but the philosophy (any treatment measure is influencing and normalizing an interconnected neurophysiological system) is the same.

2.1. Craniocervical junction (CCJ) and cervical spine (CS) joints

A hypomobile disorder of any CS joint ("blockade") is the most frequent disorder with the highest clinical relevance [5]. Acute/chronic static overload of the CS (working at a PC station, over-head work, office activity) is the most common reason. The treatment of this joint blockade is the domain of chirotherapy. Chirotherapy is based on so-called "manipulative techniques" (manipulations) which are aiming to free the blocked joint by one special technique [7]. In brief, the opposite joint facets are liberated by a manipulation (low-amplitude-high-velocity) to normalize the joint play [8]. There are several contraindications against those techniques at the CCJ/CS (e.g. massive muscle contractions, active rheumatoid arthritis, hypermobility). In Europe, manipulations of the CCJ/CJ are only done by medical dosctors to minimize possible complications [5].

If the affected joint and the corresponding muscles are highly painful, mobilizing (passive mobilization) techniques should be applied. They consists of slow, repetitive tractions of the joint facets to increase the joint mobility (increasing-amplitude-slow-velocity) [6]. These tractions can comprise several CS segments/joints and can be combined with in/espiratory impulses of the patient (facilitation). If these passive techniques are unsuccessful, the use of neuromuscular techniques (NMT) should be considered [9]. They are called in Europe "active mobilisation". They primarily treat the muscles, ligaments running over/close to the joint to finally mobilize the blocked CCJ/CS joint. NMT is based on the fact that exspiration is muscle-inhibitory which can be used to stretch the required muscle in this post-exspiratory (post-isometric) phase [5]. Finally, this treatment leads to a normalization of the joint play by neurophysiological release.

2.2. Physiotherapy (PNF, NMT, osteopathy, MTT)

The acute muscular dysfunction of the CCJ/CS (myalgia, myogelosis) is caused by mechanical stress (over-stretching) or thermal irritation (coldness). The clinical picture is a stiff neck ("torticollis") with a highly limited moveability of the CS in all directions. Before any therapy is started, additional pain relief should be achieved by local or systemic pharmacotherapy.

Soft-tissue-techniques are comprised of inhibitory techniques, deep friction (due to Cyriax), and stretching techniques [5], [6]. They treat the soft tissue overlying the isolated muscle and the muscles themselves to initiate a release of their contration. PNF (proprioceptive neuromuscular facilitation) [10] and NMT (neuromuscular techniques) [9] are complex treatment regimes which have the CCJ/CJ as a whole structure. They are usually applied at the muscles/ligaments and painful trigger points, but their aim is the joint hypomobility as well. In addition to acute disorders (incl. herniation of a cervical disc), chronic-degenerative disorders or complex muscle diseases (e.g. multiple sclerosis) are classical indications. Osteopathy (craniosacral therapy, CST) is a complex, long-standing therapy tradition which is based in North America [11]. Those Colleges of Osteopathy teach the therapy system is a way that has some scientific flaws from a European, medical point-of-view. However, CST has several application as wholistic treatment technique (which has to be separated from its theoretical myths). For CCJ/CS disorders, CST is particularly helpful in patients with complex, painful, posttraumatic disorders. The effects of this approach are a general relexation of spinal and endogenous muscles, sympathetic effects in visceral organs and, thus, a relaxation of the musculo-skeletal system as a whole.

If the acute phase of any CCJ/CS disorder is over and manual therapy is fianlized, it should be considered whether a sports-based, medically supervised training therapy for the spinal musculature can be helpful to prevent similar events or to reach a long-term painfree period [12].

2.3. Systemic and local pharmacotherapy

All acute and some chronic disorders of the CCJ/CS are accompanied by a pain sensation of different extent and localization. The pain itself (if it lasts longer than about 24 hours) is a therapeutic handicap insofar it activates the so-called γ-loop of the corresponding spine segment [13], [14]. This γ-loop triggers the local, spinal memory mechanism ("pain hypersensitivity") which persists even if the acute disorder is gone [14]. This has serious therapeutic repercussions. Without adequate pain therapy, there will be no long-term therapy success [15].

Some therapeutic techniques (e.g. manipulations) cannot be performed (relative contraindication) if the corresponding muscles of the joint are painfully contracted [5].

Systemic pharmacotherapy is to suppress the release of inflammatory mediators and (peripheral or central) pain. This is preferably managed by using modern non-steroidal, anti-inflammatory drugs (NSAD). The most recent drugs available are COX-2 inhibitors ("coxibes") that are highly effective in the short-, medium- and long-term application. If the analgesic effect of these drugs is not sufficient, other drugs and/or measures have to be considered (ranging from ASS to morphinoids, TENS device).

Local pharmacotherapy (local anaesthesia) can be performed by infiltrating muscles, ligaments or joint facettes and by injecting into trigger points (e.g. 2 % xylocaine without adrenalin) (Figure 3 [Fig. 3]) [5], [16]. In general, pain therapy is of highest clinical relevance because painful patients cannot be effectively treated by manual therapy and they tend to suffer from chronic complaints, including psychiatric, neurocognitive or behavioural problems [17], [18], [19], [20], [21].

Additional measures (e.g. breathing techniques) can be helpful in a pain management concept.


3. Hereditary or acquired structural deficits of the craniocervical junction and the cervical spine

Structural deficits of the CCJ/CS can be inborn (hereditary), acquired or posttraumatic. Macrostructural changes (e.g. fractures) require a surgical therapy preferably, microstructural changes (e.g. myelon degeneration, calcification of subligamentous haematomas, myositis after hyperextension) require largely manual and pharmacotherapy.

Structral changes can hardly be abolished by any means of treatment, but compensatory, symptomatic strategies are prevailing. The following chapter will outline those paradigms in treatment strategies, but cannot give all details.

3.1. Posttraumatic disorders

Surgical therapy after spine trauma is required when a larger destruction of bones and soft tissue compromises the integrity of the CCJ/CS (macrostructural changes). In general, spine surgery (in trauma, tumour, acute inflammation) has three basic principles which determine all surgical procedures [22]:

• Decompression of neuronal structures (myelon or cervical roots)

• Stabilization of the segment of movement

• Correcting false/irregular CJ position.

Surgery is limited to as few segments of the CJ as possible. This segmental preoperative definition of the target structure is achieved by imaging (CT, MRI) and neurological examination (EMG, MEP, SSEP examination). For details of the operative techniques encountered and the different types of fracture see [22].

In acute posttraumatic disorders of the CCJ/CS without bony destruction (microstructural changes) which are accompanied by a spinal trauma, a "medical myelon dempression" with high-dosage steroids (within at least 72 hours) [23], [24] and pain therapy (see above) are the primary measures. It could be shown that neuronal involvement (with subsequent axonal inury) and insufficient pain therapy (with subsequent spinal pain hypersensitization and following psychiatric illness) in the initial treatment phase are the most predictive characteristics for further chronicity [25], [11]. From all patients after spinal trauma (including classical "whiplash" mechanism, i.e. rear-end collision (Figure 4 [Fig. 4])), about 5 - 15 % have long-term complaints [26], [27], [28], [29].

This medical treatment should be accompanied in the acute phase by non-manipulative techniques (CST, PNF, NMT), followed by an integrative conception for chronic disease [5]. This should include manual therapy, pharmacotherapy and behavioural therapy.

3.2. Disorders after therapy for head & neck malignancies, iatrogenic disorders

Tumour surgery (and/or irradiation) for head & neck malignancy leads to scar formation, loss of muscle and soft tissue and these defects cannot simply be "replaced". There is one exception. In case of a palsy of the accessory nerve, the surgical transfer of the levator scapulae and rhomboidei muscles can reactivate shoulder mobility [30].

A realistic approach in those patients is therefore the combination of maula therapy, lymphatic drainage and pharmacotherapy to reduce lymph edema, reduce scar/skin tension and reduce tissue inflammation [5].

3.3. Acquired and chronic-degenerative disorders

One of the most prominent predictors for recurrent musculo-skeletal dysfunction of the CCJ/CS is skoliosis, kyphoskoliosis or hip dsyplasia [31], [32]. Those patients are the striking proof for the fact that the spinal segments are functionally interconnected ("chain mechanism"). It does only make limited sense to treate theose patients extensively, prevention by medical training therapy is most effective. The same holds true for the hypermobility of all joints which preferably affects young women on contraception [12].

The narrow spinal canal or neuroforaminal stenoses lead to radicvular symptoms. They are primarily treated with manual and pharmacotherapy, but have to be operated on if there is no therapeutic effect [22].

Rheumatoid diseases are a complex issue with multimodal treatment strategies which are beyond the scope of this review.


4. Management strategies and leading clinical symptoms

The physician should be aware of the leading clinical symtoms which signalize a CCJ/CS disorder. Vertigo (instability, unsteadiness, slipping away, feeling drunk) is the most prominent symptom of CS joint hypomobility. Differential daignostics should exclude otolith disorder, particularly after trauma [33], [34].

Hearing loss and tinnitus are cervicogenic insofar they affect the low-frequency range (joint hypomobility) [35].

Dysphagia has to be differentiated from neuro/myogenic dysphagia and otalagia from cranio-mandibular dysfunction (CMS) [36], [37].


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