With the increasing tension of modern life, the incidence of neck and shoulder pain is on the rise. And it has become a more common cause of neck and shoulder pain, dizziness pain, chest tightness, and even bilateral upper extremity numbness and swelling pain. Clinical examination has no clear objective neurological signs of impairment, troubling patients and physicians, and there is instability manifestation in power imaging examination. The concept of cervical instability was proposed. It refers to a syndrome caused by anatomical displacement of the cervical spine beyond its physiological limits under physiological load and the appearance of corresponding clinical symptoms.
I. Pathogenesis
Static stability of the vertebral body, the arch and its protrusion, the intervertebral disc and the connected ligamentous structures, and dynamic regulation and control of the cervical muscles. Disruption of any one of these links induces loss of normal structure and balance of the cervical spine, resulting in cervical instability. Excessive and/or abnormal activity occurs under physiological load, and this is cervical instability; if this causes a series of corresponding clinical manifestations, it is called cervical instability.
Among the many causes, degenerative changes are the most common. The intervertebral disc is the earliest part of the human tissue to undergo degenerative changes.
It is divided into 3 stages.
① Early degenerative phase: degenerative changes of the intervertebral disc are mild, the small joint capsule is slightly relaxed, the articular cartilage is fibrotic, and clinical symptoms are generally mild.
② Unstable phase: degenerative disc degeneration is further aggravated in this phase, the fibrous ring is relaxed and expanded, degenerative joint cartilage is obvious, the small joint capsule is relaxed and aggravated, the vertebral body and small joint synapses can be mildly hyperplastic, disc herniation is most likely to occur in this phase, and the corresponding clinical symptoms appear.
(3) Fixed deformity stage: the degenerative changes of the intervertebral disc are at 3 to 4 levels, the height of the intervertebral disc is obviously reduced, the vertebral space becomes narrow, the vertebral body edge is osteophytic, and the cartilage of the small articular eminence is degenerated and fibrotic. The formation of the articular synovial joints and peri-disc bony flab may allow the spine to regain stability. It can be considered a protective response or natural regression.
However, the formation of bone flab can cause or exacerbate narrowing of the spinal canal or nerve root canal, resulting in compression of the spinal cord and nerve roots. Relative displacement and rotation of the vertebral body occurs, irritating and/or compressing the vertebral artery, resulting in spasm or folding and deformation of the vertebral artery, causing ischemic episodes in the basilar artery. Degeneration is the cause of the occurrence of cervical instability; cervical instability in turn promotes the occurrence and development of degeneration, forming a vicious circle.
Second, imaging examination
(A) Cervical spine X-ray film
The most commonly used is the lateral cervical spine radiograph, followed by anterior-posterior radiograph, dentate opening radiograph, flexion-extension power radiograph and left-right oblique plain radiograph.
Common signs are.
(1) Fracture of the cervical spine physiological curve in lateral cervical spine radiographs, suggesting increased mobility of the cervical segment corresponding to the fracture of the curve.
(2) A vertebral body shift on a flexion-extension powered lateral radiograph, such as a horizontal shift of >3.5 mm anteriorly, posteriorly or laterally, and/or an angle difference of >11° between adjacent intervertebral spaces. This is diagnostic of cervical instability.
(ii) Cervical spine CT
CT of the cervical spine can provide axial vertebral body, arch, articular protrusion injury and volume change of the spinal canal; CT cross-sectional images are non-overlapping, especially for C↓1 to C↓2 bony rings; CT cross-sectional images show the width of joint gaps and joint locking clearly, which can determine dislocation or not; but for joint surface alignment, especially upper and lower alignment, CT cross-sectional diagnosis is difficult. CT of cervical spine can be considered when the X-ray film does not show clearly, or when the position of the X-ray film is limited in acute trauma.
(C) MRI of cervical spine
MRI of the cervical spine can show abnormal changes in the medulla, the relationship between the spinal cord and the spinal canal, the travel of the spinal cord in the spinal canal, and the change in position to accommodate the deformed spinal canal. It is important to understand the compression of the spinal cord by the vertebrae and discs, hematoma, liquefaction, and degeneration of the nerve and spinal cord tissues, and soft tissue damage to the discs and ligamentous structures.
The open design of the MRI scanner allows the subject to complete the examination in a normal upright position, under weight (the weight of the head itself) and under dynamic conditions, thus ensuring consistency with the daily physiological state at the time of the examination and obtaining more information than the supine examination, such as slippery herniation of the disc, abnormal increase in spinal mobility, and narrowing of the spinal canal and nerve root canal. It reflects the true physiological state and can distinguish whether the abnormal curvature is due to the patient’s posture or to a painful muscle contracture. It is expensive and is not yet widely available.
III. Clinical manifestations
Instability is a common cause of shoulder pain, and the clinical manifestations of degenerative cervical instability are more frequent. There are many symptoms and few signs.
1.Neck and shoulder pain or upper limb pain Especially for those who sit in a low posture for a long time, they often feel that the neck and shoulder pain is aggravated when the head is low for a long time, and there is a feeling of fatigue in the neck and upper back, and there is a heavy distension in both upper limbs, and the symptoms can be alleviated in the early stage by appropriate backward leaning activities.
2, sensory disorders often have the extremities (especially the upper extremities fingers) tingling, burning, numbness or pain, hair plate hard, cool sensation of the extremities, hypesthesia. Both upper extremities and hands are mainly hyperalgesia.
3.Mobility impairment Self-perceived loss of muscle strength of the extremities, with poor hand grip and inflexible finger movements being the most common, and the hands cannot make small movements.
4.Other may involve scalp numbness and pain, headache and dizziness, nausea and vomiting, tinnitus, blurred vision, vertigo, and unstealthy gait.
On examination, there is limited pressure pain at the back of the neck, more in the C↓4 to C↓7 segment, and spasm of the collar muscles. Cervical flexion and extension movements are limited by pain, but nerve examination is often unchanged, and the passive range of motion of the shoulder is normal. Continuous flexion and extension activities of the cervical spine can induce dizziness, blurred vision, neck and shoulder pain, and even Hoffman’s sign (+) are valuable for diagnosis.
IV. Treatment
There are three main purposes.
① To allow the damaged segment of the cervical spine to heal adequately in the desired functional position;
(2) To prevent further damage to other components of the cervical spine and spinal nerve tissue, and to restore the function of the originally damaged nerve tissue as much as possible;
③Prevent further aggravation of the original deformity of the cervical spine or the emergence of new deformities.
(I) Traction therapy
Relieve the spasm and fatigue of the muscles and ligaments of the neck, and adjust the position of small joints. It also plays the role of braking and resting, and relieves the stimulation and compression of nerve roots, vertebral artery, spinal cord and sympathetic nerve by the unstable cervical spine, so as to achieve the purpose of healing. Additional equipment and frequent hospital visits are required for poor compliance.
(II) Manipulative treatment
The strength and method of manipulation are not easy to measure and evaluate, and there are certain risks.
(iii) Medication
Reduce or relieve pain, thus relaxing tense or spastic muscles and facilitating the repair of local injury lesions and improving the disordered state of physiological functions. For example, non-steroidal anti-inflammatory analgesics: ibuprofen, diclofenac, etc.; muscle relaxants: clozoxazone, etc. The use of neurotrophic drugs can improve the tolerance of nerves to injury and improve symptoms, commonly used mecobalamin substance orally, the United States cheap compliance is good.
(D) fixation and exercise
Neck brace braking and muscle training is the most common method, safe and effective can be done outside the hospital. The neck collar is commonly used to maintain local stability, prevent the injury from continuing to worsen, maintain normal physiological curvature, reduce instability, support the weight of the head and reduce its pressure on the cervical spine. With the reduction of symptoms wearing 4-5 hours a day, it can obviously promote the absorption of inflammatory edema, reduce the mutual irritation and friction between joint surfaces, and facilitate the recovery of inflammatory response.
Early functional exercise is based on isometric training of the cervical muscles, which can be carried out while wearing the neck collar, and according to this put the front and back of the head to do confrontation training, which can promote the blood circulation of the whole body, accelerate metabolism, and improve the resistance of the body to prevent a variety of complications. Emphasis on the premise of maintaining the stability of the spine in a gradual and consistent manner. It can prevent disuse atrophy of the cervical muscles and promote efficient restabilization and repair.
After 3-4 months of treatment, most patients can be clinically cured. Prevention of instability is a complex anti-aging problem and may be of some significance if appropriate neck exercises are performed to avoid single positions, especially excessive head-down and neck-flexion positions.