Cervical Dysfunction Research Articles

Cranial/cervical nerve dysfunction after carotid endarterectomy.

The purpose of this article is to review the results of patients who had cranial and cervical nerve dysfunction after undergoing carotid endarterectomy. The prospective study reviewed 183 consecutive carotid endarterectomies. Preoperative and postoperative cranial nerve assessments were accomplished on all patients. Neurologic evaluation included direct fiberoptic laryngoscopy. Patients found to be neurologically intact had no further follow-up. Patients with postoperative neuropraxia were entered into regular long-term follow-up to assess delayed recovery. Twenty-six (14.2%) nerve injuries were identified in 21 patients. There were 14 recurrent laryngeal, 8 hypoglossal, 2 marginal mandibular, and 2 greater auricular nerve dysfunctions. Two patients were lost to follow-up. Eighteen (9.8%) nerve injuries were transient, whereas two (1.1%) were permanent. Four patients are currently undergoing extended follow-up to assess delayed recovery. Two patients with recurrent laryngeal nerve dysfunction were found to have prolonged full recovery intervals: 20 months and 50 months, respectively. The incidence of focal neuropraxia after carotid endarterectomy is presented. Most injuries are transient. However, permanent injuries can lead to significant disability. Extended follow-up will identify the small subset of patients with delayed complete nerve recovery.

Inter-examiner reliability to detect painful upper cervical joint dysfunction

The presence of painful upper cervical joint dysfunction is a diagnostic criterion for cervicogenic headache. This preliminary study investigated whether independent examiners for a planned multicentre study of treatment of cervicogenic headache sufferers would agree on the presence or not of joint dysfunction for inclusion/exclusion of subjects into the trial. Ten subjects with or without neck pain and headache were recruited in each of four centres (total 40 subjects). Examiners manually assessed subjects' upper cervical regions in a single blind manner. There was excellent to complete agreement between each pair of examiners on which subjects should be allowed to enter the study and 70 per cent agreement between examiners on the two most dysfunctional joints in symptomatic subjects. There can be confidence that an homogenous headache group will enter the planned trial.

Potentiels évoqués somesthésiques dans la polyarthrite rhumatoïde avec atteinte radiologique du rachis cervical

Somatosensory evoked potentials (SEP) have been recorded in 11 patients with cervical spine involvement, with or without signs of myelopathy due to rheumatoid arthritis (RA). In three patients, SEP have been recorded both before and after cervical spine surgery. In seven cases, the P14 (particularly the P9/P14 amplitude ratio) or P30 potentials were abnormal, whereas other potentials and conduction times were less often modified. Vertebral luxation sites that were predominantly observed at the upper cervical level account for these findings, thus supporting the diagnostic utility of P14 and P30 potentials which respectively take origin in the lower brain stem, close to or into the nuclei cuneatus and gracilis. Postoperative SEP were strongly correlated with the surgical outcome. SEP could be abnormal in the absence of overt clinical myelopathy or vertebral luxations, thus revealing infraclinical damage to the somatosensory pathways. This suggests that SEP recording is useful to discriminate RA patients with upper cervical cord dysfunction from those in whom vertebral lesion proves to have no direct impact on somatosensory conduction.

In vitro multifrequency electrical impedance measurements and modelling of the cervix in late pregnancy

Idiopathic preterm labour is the greatest single perinatal problem occurring in an unpredictable 6 - 8% of all pregnancies and accounting for 75% of all perinatal deaths. Preterm cervical softening is used clinically as an important indicator of cervical dysfunction but the subjective nature of present clinical assessment methods prevents reliable prediction of preterm labour. This paper reports the finding of a pilot investigation concerned with obtaining quantitative measurements of the in vitro electrical impedance of the cervix using a four-electrode multifrequency impedance measurement system. Impedance measurements obtained from six samples of cervical tissue taken from different subjects at caesarean section were fitted to the Cole equation and parameters derived to describe the ratio of extra- versus intracellular impedance and the characteristic frequency. Subjects at term display a lower extra- versus intracellular impedance ratio than the preterm subjects. This appears consistent with the expected increase in the hydration of the cervix approaching term and the resulting decrease in the extracellular impedance. Further studies are required to determine if multifrequency electrical impedance tomography could be used as a non-invasive screening test for preterm labour.

The effect of a soft collar, used as normally recommended or reversed, on three planes of cervical range of motion.

Clinicians recommend soft cervical collars to immobilize the cervical spine following trauma. They apply them either as intended by the manufacturer or reversed (collar rotated 180 degrees), purportedly to achieve limitation in a specific direction. This study investigated the effectiveness of soft cervical collars in limiting cervical range of motion when worn as recommended or reversed. All planes of cervical range of motion of 50 volunteer subjects without current or past cervical dysfunction were measured under three conditions (no collar, recommended use, and reversed) using the Orthopedic Systems Inc. Computerized Anatometry-6000 Spine Motion Analyzer. The instrument has been previously shown to produce measures with high reliability and to correlate strongly with known angular measures. Within subjects analyses of variance indicated significant differences in all six ranges of motions among the three conditions. Post hoc paired t tests showed that wearing a collar either as recommended or reversed decreased motion compared with not wearing a collar, and that the position of the collar affected range of motion in three of the six motions. Differences in range can be attributed to location of the collar closure and initial head posture. Soft cervical collars can physically limit motion when worn either way.

Case Report: Tennis Elbow Associated with Cervical and Elbow Dysfunction

"Case Report: Tennis Elbow Associated with Cervical and Elbow Dysfunction." Journal of Orthopaedic Medicine, 18(2), pp. 59–60

Assessment of intraspinal and intracranial conduction by P30 and P39 tibial nerve somatosensory evoked potentials in cervical cord, brainstem, and hemispheric lesions.

In routine recordings of tibial nerve somatosensory evoked potentials (SEPs), a global central conduction time is evaluated by measuring the interval between the segmental spinal N22 potential, recorded in the lumbar region, and the cortical P39 potential. In this study, we tested the reliability of the scalp far-field P30 potential, which originates in the vicinity of the cervico-medullary junction, in order to evaluate separately intraspinal and intracranial conduction in normal subjects and patients with cervical cord and intracranial lesions. P30 and cortical P39 potentials were studied in 23 healthy subjects and in 70 patients with cervical cord (n = 47), brainstem (n = 11) or hemispheric lesions (n = 12) selected on the basis of neuroimaging--computed tomography (CT) or magnetic resonance (MR)--findings. Median nerve SEPs were also recorded in all patients. Of the several montages tested to obtain the P30 potential, the Fpz-Cv6 derivation gave the highest signal-to-noise ratio; it permitted to obtain a P30 potential that peaked at 29.2 +/- 1.6 ms in all normal subjects. P30 abnormalities were observed only in patients with cervical or cervico-medullary lesions; these were associated with a normal P39 in only two of 33 abnormal recordings. Conversely, P30 was consistently normal in lesions situated above the cervico-medullary junction whether associated with normal, delayed, or reduced P39. P30 abnormalities were subclinical in 42% of abnormal recordings. All patients with normal tibial and median nerve SEPs on both sides had normal touch, joint, and vibration sensation in the four limbs. There was a strong correlation between tibial nerve P30 and median nerve P14 data in the whole series of patients; both potentials behaved similarly in all cases of intracranial supramedullary lesions. Combined abnormalities of P30 and P39 potentials thus indicate that conduction is impaired at the spinal level and proved to be particularly informative for detecting spinal cord dysfunction in patients with neuroimaging evidence of a narrowed cervical canal. Recording of abnormal N13, P14, or P30 potentials provided evidence of a cervical cord dysfunction in 66% of patients who had a suspected spondylotic myelopathy. Recording of tibial nerve P30 potential has proven to give reliable and useful information when a separate assessment of intraspinal and intracranial somatosensory conduction is needed; it merits inclusion, as does the upper limb N13 potential, in the evaluation of patients whose MR image indicates cervical canal narrowing.

Fiber composition and fiber transformations in neck muscles of patients with dysfunction of the cervical spine.

Biopsies of ventral neck muscles (sternocleidomastoid, omohyoid, and longus colli) and dorsal neck muscles (rectus capitis posterior major, obliquus capitis inferior, splenius capitis, and trapezius) were taken from 64 patients who underwent spondylodesis for cervical dysfunction of different etiologies. The muscle fibers were classified histochemically as type I, IIA, IIB, or IIC (transitional or intermediate fibers) according to the pH lability of their myofibrillar ATPase. Signs of muscle fiber transformations were observed in all muscles investigated, as evidenced by an increased relative amount of type-IIC fibers. The transformations occurred independently of (a) the type of muscle (i.e., more "postural" or more "phasic"), (b) the sex and age of the patient, (c) the type of condition, and (d) the presence of additional neurological deficits. Thus, the same pattern of muscular reaction was found in patients with rheumatoid arthritis as in patients with soft-tissue injuries of the neck (e.g., "whiplash injury"). In the ventral muscles and the obliquus capitis inferior, the occurrence of transformations correlated strongly with the duration of symptoms; in the ventral muscles the vast majority of transformations were encountered in patients with a shorter history of symptoms, whereas in the obliquus capitis inferior the reverse occurred. In the other dorsal muscles, no correlation with the duration of symptoms was found. Muscles in which transformations had ceased displayed, on average, a significantly higher percentage of fast type-IIB fibers than were found in muscles with ongoing transformations. This strongly indicates that the transformations proceeded in the direction from "slow oxidative" to "fast glycolytic."

Referred ocular pain relieved by suboccipital injection.

Pain originating from ophthalmic disease has been well documented. A series of patients presenting with eye or periorbital pain attributed to cervical region dysfunction were diagnosed and treated with injections of subcutaneous lidocaine followed by triamcinolone acetonide. Twelve patients, 11 women and 1 man, ranging in age from 20 to 82 years had an evaluation including a complete eye examination, and laboratory tests and neuroimaging as dictated by the history to exclude structural abnormalities or systemic disease. All patients had marked focal suboccipital tenderness ipsilateral to the side of their headache and eye pain. A subcutaneous injection with 2% lidocaine followed by triamcinolone acetonide 40 mg was administered directly to the site of focal tenderness. After injection, five patients described total relief of pain, five patients described some degree of pain relief, and two patients had no relief of headache. Duration of pain relief ranged from several hours to 3 months. Patients may present with periorbital or eye pain as a result of disease affecting the cervical sensory roots with subsequent stimulation of the trigeminal apparatus. Subcutaneous injection of lidocaine and triamcinolone acetonide may be of help in the diagnosis of these patients and provide temporary relief.

Cervical Musculoskeletal Dysfunction in Post-Concussional Headache

Persistent headache is a common symptom following a minor head injury or concussion, possibly related to simultaneous injury of structures of the cervical spine. This study measured aspects of cervical musculoskeletal function in a group of patients (12) with post-concussional headache (PCH) and in a normal control group. The PCH group was distinguished from the control group by the presence of painful upper cervical segmental joint dysfunction, less endurance in the neck flexor muscles and a higher incidence of moderately tight neck musculature. Active range of cervical motion and postural attitude were not significantly different between groups. As upper cervical joint dysfunction is a feature of cervicogenic causes of headache, the results of this study support the inclusion of a precise physical examination of the cervical region in differential diagnosis of patients suffering persistent headache following concussion.

Duration of pain and muscular adaptations in patients with dysfunction of the cervical spine

Biopsies of the sternocleidomastoid and omohyoid muscle were taken from 24 patients who underwent arthrodesis for cervical dysfunction of different etiologies. The two muscles, which are involved differently in movements of the head and cervical spine, were investigated histochemically. Muscle fibers were classified as type I, IIA, IIB, or IIC (transitional fibers) according to the pH lability of myofibrillar ATPase and calculated relative distribution. In both muscles, fiber transformations (as evidenced by an increase in the relative amount of type-IIC fibers) were regularly observed within the first 2 years after the onset of the symptoms. The occurrence of the transformation processes was independent of the patient's age and sex and was the same for the different etiologies. Since the overall fiber composition of the muscles remained essentially unchanged, the fiber transformations must occur alternatingly in both directions (from "slow" to "fast" and the reverse). Muscles of patients with a long case history showed no greater signs of fiber transformation. Therefore, fiber transformations in response to cervical dysfunction occur in the initial stage of the disease and involve different types of muscles. The muscles then return to a "stable" condition, independent of the continuation of the dysfunction and the chronic neck pain.

Thoracic Segmental Flexion During Cervical Forward Bending

The purpose of this study was to assess the amount of thoracic segmental flexion associated with cervical forward bending. Twenty-four healthy men and women between the ages of 21-29, with no past or present cervical or thoracic dysfunction, participated. Spinal segmental mobility in the thoracic region was measured in the neutral sitting position and sitting with the cervical spine in the forward bent position. Mobility was measured by the Faro Metrecom Skeletal Analysis System. The Faro Metrecom is an external measuring device that records each individual spinal segment's position within the body. Descriptive statistics were used to describe the position of the thoracic segments when the cervical region was in the neutral and in the forward bent positions. Additionally, intrarater reliability, .83 and .76, and interrater, .72, were analyzed for the thoracic segments in the neutral position. The results show that with cervical flexion there was thoracic segmental flexion. Segments T1-4 demonstrated forward bending ranging from 2.88-4.42°. The greatest amount of flexion occurred at T2, 4.42 degrees, and T3, 4.19 degrees. Below T4 no pattern was noted. The results indicate that upper-thoracic segmental flexion occurs during cervical forward bending.During evaluation and treatment of patients with cervical dysfunction physical therapists routinely evaluate spinal segmental mobility. It is clear to clinicians that cervical segmental mobility is important to cervical range of motion. What it not clear is the role of thoracic segmental mobility in cervical range of motion. Physical therapists frequently evaluate and treat the thoracic region when patients have cervical dysfunction. Therefore, the purpose of this study was to assess the amount of thoracic segmental flexion associated with cervical forward bending.Since the early 1970s when the concept of joint mobilization was brought to American physical therapists, interest in spinal segmental motion has increased. Though interest in this area exists, there is a scarcity ofresearch documenting normal and abnormal spinal segmental mobility. Additionally, most of the studies on spinal segmental mobility have been conducted on cadavers or through radiographic methods.Lysell studied intersegmental movements of the cervical spine using autopsy specimens. Steel balls were placed in fixed points on each vertebrae and then a three-dimensional radiographic examination was used to measure movements of these points during cervical range of motion.1 Ball and Meijers studied cervical mobility using fresh cadaveric cervical spinal specimens. In this study steel pins were inserted into the cervical bodies and serial x-rays were taken.2 Panjabi, Dvorak, and Duranceau studied upper-cervical spine mobility using fresh cadaveric whole cervical spine specimens and steel balls. Their specimens were set into a quick-setting epoxy material to help align the centers of C2 and C7, thereby providing fixation.3 Yamamoto et al. studied three-dimensional movements of the lumbar spine and lumbosacral joint. They used fresh cadaveric whole lumbar spine specimens analyzing from L1 to the sacrum.4 Robert studied intervertebral motion of the whole spine. This was performed with cadavers as the segmental excursions were determined from a point at the inferior surface of the vertebrae to the tip of the spinous process.5Three separate noncadaveric studies were conducted by Penning,6 Felding7 and Moll and Wright.8 Penning studied normal movements of the cervical spine by superimposing two x-ray films representing the cervical spine in the end positions (i.e., flexion and extension). Fielding studied normal and abnormal motion of the cervical spine from C2 and C7 using cineroentgenography; roentgenograms were taken while the subjects were moving. Moll and Wright studied normal range of spinal mobility using live subjects with markers on the skin. When the subjects moved the separation of the skin markers was recorded.The above studies used procedures that are not convenient for use during clinical sessions. Additionally, the above studies did not evaluate thoracic mobility in relation to cervical motion.In the textbook, Common Vertebral joint Problems,9 Grieve presents a complete discussion of vertebral motion. This section is highly referenced as it pertains to segmental spinal mobility.9 White and Panjabi are the most frequently cited source on spinal segmental mobility.10,11 They reported flexion/extension degrees of motion for the thoracic segments. The ranges of the motion and the "representative angle" (most likely the mean angle) in degrees for each thoracic segment are T1-T5 2-5 (4); T6 2-7 (5); T7-T9 3-8 (6); T10 4-14 (9); and T11-T12 6-20 (12). However, they did not state how their estimated range and "representative angle" in degrees of segmental spinal mobility were measured.10,11 Valencia in the book Physical Therapy of the Cervical and Thoracic Spine states similar motion for the thoracic segments.12The upper-thoracic spine, T1-T6, has been related to the cervical region anatomically. The upper-thoracic facet joints are orientated like the cervical facet joints and have a similar pattern of movement.11,13 Additionally, the caudal attachment of many cervical muscles is in the thoracic region.13.

Closed lock: A survey of 400 cases

Four hundred consecutive classic closed lock cases were examined. Of these, 301 were treated Mandibular range of motion was restored by condylar distraction during jaw opening, anterior, and lateral movements. Mandibular appliances were used to prevent complete closure during healing. Of the 45 males and 355 females examined, almost all reported jaw restrictions, but 38% reported little or no pain. Secondary disorders of temporomandibular joint inflammation, muscle spasm, trigger points, and cervical dysfunction were seen on patients with temporomandibular joint pain. Of the 301 conservatively treated patients, 209 were successfully treated, 55 were moderately successful, and 37 failed. Occlusal factors did not appear as primary etiologic factors. Because all locks were preceded by clicking, treatment is recommended for clicking temporomandibular joint's that lock however briefly, to prevent future locking. Conservative closed lock treatment is successful in many cases.

The association of cervical spondylosis and multiple sclerosis

The diagnostic and therapeutic considerations produced by the coexistence of cervical spondylosis and multiple sclerosis are complex. We have encountered six patients, affected by both multiple sclerosis and cervical spondylosis, in whom neurosurgical procedures were performed. The diagnosis of multiple sclerosis was confirmed by a combination of clinical, neuroimmunologic, electrophysiologic, and neuroradiologic findings. The diagnosis of spondylosis with spinal cord compromise was confirmed by myelography and computed tomographic scan in all cases, and by magnetic resonance imaging in four. Surgery was followed by lasting clinical improvement in two patients, transient improvement in one, and no change in the other three Our experience confirms that multiple sclerosis and cervical spondylosis can coexist and suggests that this coexistence may result in an interaction that compounds the deleterious effect on the nervous system. Diagnostic evaluations of patients, particularly young patients, with symptoms of cervical spondylosis should include consideration of the possible coexistence of multiple sclerosis. The evaluation of a patient with known multiple sclerosis who develops new signs of cervical spinal cord dysfunction should always include spinal neuroimaging studies. When progression of symptoms coincides with documented progression of anatomic compression, surgical intervention can yield good results

Segmental dysfunction of the cervical cord revealed by abnormalities of the spinal N13 potential in cervical spondylotic myelopathy.

We studied somatosensory potentials (SEPs) evoked by stimulation of radial, median, and ulnar nerves in 11 patients with MRI evidence of cervical spondylosis. All patients presented with progressive spastic paraparesis that was either isolated or associated with lower motor neuron signs in the upper limbs, with preserved joint, touch, pain, and temperature sensations in the four limbs. In all patients, scalp SEPs reflecting the activity of the dorsal column system up to the parietal cortex were normal while segmental cervical cord dysfunction was manifested by an abnormal spinal N13 potential in 95% of radial, 90% of median, and 54% of ulnar nerve SEPs. These subclinical abnormalities of the spinal N13 SEP probably result from reduced blood supply due to compression of the anterior spinal artery in patients with cervical spondylotic myelopathy.

Intertester Reliability of the Cervical Range of Motion Device

Intertester reliability is important for longitudinal assessment of patients by two different clinicians. The purpose of this study was to investigate the intertester reliability of the cervical range of motion device (CROM). The CROM was used to measure subjects with a history of cervical dysfunction. The sample consisted of 22 subjects (15 female and 7 male). Active cervical flexion, extension, right and left rotation, and right and left lateral flexion were measured with the client in the sitting position. Moderate to high intraclass correlation coefficients (ICC = +.76 to +.98) were found between testers. Furthermore, the mean differences between testers were also consistently low for all six measurements (.5-3.6 degrees ). These data suggest the CROM is a reliable measuring tool between testers for cervical range of motion. J Orthop Sports Phys Ther 1992;15(3):147-150.

Dorsal horn and dorsal column dysfunction in intramedullary cervical cord tumours. A somatosensory evoked potential study.

Median and tibial nerves somatosensory evoked potentials (SEPs) were recorded in 20 patients with intramedullary cervical spinal cord tumours. The longitudinal extent of the tumour was determined by magnetic resonance imaging (MRI) and the surgeon's intraoperative observations. Somatosensory evoked potentials to median or tibial nerve stimulation were abnormal in 85% of patients. Three groups were identified on the basis of the median nerve SEP findings: Group I (20% of cases) with normal SEPs responses; Group II (30% of cases) with impaired cervical dorsal horn postsynaptic activity (abnormal N13 potential) but preserved dorsal columns transmission up to the cortex (normal P14 and N20 potentials); Group III (50% of cases) where the dorsal horn activity and dorsal columns transmission were both impaired. The isolated abolition of the N13 potential observed in Group II reflects a functional dissociation between segmental dorsal horn and dorsal columns structures and should prompt myelographic investigations. Postoperative follow-up suggests that absent N13, P14 and N20 potentials before surgery carry an ominous functional prognosis. However, postoperative recovery of the N13 potential was found to occur in a few cases, suggesting that these tumours do not necessarily produce irreversible damage to the cervical dorsal horn neurons. Thus SEPs proved to have a high sensitivity in detecting cervical spinal cord dysfunction in intramedullary tumours, provided that a selective recording of the N13 potential is performed using a cervical-supraglottal derivation.

Intratester and intertester reliability of the cervical range of motion device.

The purpose of this study was to investigate the intratester and intertester reliability of the Cervical Range of Motion instrument (CROM) for measuring cervical flexion, extension, lateral flexion, and rotation. Twenty able-bodied subjects were tested by two testers on two different occasions. Pearson product-moment correlations for intratester reliability ranged from .63 to .90 for tester one and from .62 to .91 for tester two. Intertester reliability was good. Coefficients ranged from .80 to .87 for session one and .74 to .85 for session two. Paired data t-tests showed that there were no significant differences between testers or sessions (p = .01). The results suggest that the CROM has acceptable intratester and intertester reliability. The CROM has many benefits including ease of application and reliability. More research is needed on patients with cervical dysfunction.

The effects of manipulative physiotherapy on chronic cervical dysfunction

Little information exists concerning the efficacy of manipulation in the treatment of chronic cervical dysfunction. A single case study to test the efficacy of manipulative physiotherapy in a subject with chronic cervical dysfunction is presented. The manipulative physiotherapy used is based on the Maitland philosophy. The positive aspects of incorporating the single case study method of research into clinical practice are discussed and the difficulties highlighted.

Suggestions From the Clinic: The Importance of Shoulder and Cervical Dysfunction in the Etiology and Treatment of Athletic Elbow Injuries

Our clinical experience has demonstrated that the development of elbow injuries is often secondary to dysfunction of the shoulder and/or cervical regions. In response to this observation, we have developed a rehabilitation protocol for the entire upper quarter as the focus of our management of elbow injuries. Our approach addresses range of motion deficits in shoulder rotation, weakness of shoulder external rotation and abduction, cervical facet impingement, and other associated deficits, with the goal being restoration of the flexibility, strength, endurance, proprioception, and coordination needed for activity. Presented are specific elements of this approach, possible mechanisms of injury involved, and a case history. J Orthop Sports Phys Ther 1990;11(9):402-409.