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الكلية كلية الطب
القسم الجراحة
المرحلة 5
أستاذ المادة جميل تحسين محسن كاظم
5/18/2011 7:45:09 PM
the neck
symptoms:
1. pain the pain may be in the neck or radiating to the shoulders or the arm
2. deformity wry neck or torticollis.
3. neurological deficient result either from compression of the roots leading to lower motor neuron deficient or compression of spinal cord leading upper motor neuron lesion (myelopathy).
4. stiffness.
5. headache.
signs:
1. look: for deformity like wry neck which may indicate intervertebral disc lesion. spinal injury, inflammatory disorders and eye or semicircular canal disorder.
2. fell for tenderness or muscle spasm.
3. move by testing the flexion, extension, lateral flexion and rotation.
4. neurological examination
deformities of the neck
? torticollis in this deformity the chin is twisted upward & toward one side, it is either congenital or acquired.
a. infantile(congenital) torticollis:
this, also called congenital muscular torticollis, is a common condition in which the sternomastoid muscle on one side is fibrous & fail to elongate as the child grows leading to progressive deformity.
causes either birth trauma or malposition in utero causing muscle ischemia.
clinical features there may be a history of difficult labour or breech delivery, a lump may be noticed in the first few weeks of the life at this stage there is no deformity. within few months the lump has disappear, the deformity become visible when the child 1-2 years, the head is tilted to one side. there may be also asymmetrical development of the face.
treatment if the diagnosis is made during the infancy daily muscle stretching by the parents may prevent the deformity. if the condition presented after the first
year of the life operative treatment is indicated by division of the contracted muscle at its upper or lower ends followed by rigid collar then stretching exercise.
b. acquired torticollis: childhood torticollis may be secondary to
(1) trauma (2)infection (pyogenic, t.b, lymphadenitis, tonsillitis, discitis, retropharyngeal abscess)(3) juvenile rheumatoid arthritis (4)congenital bone anomaly(5)posterior fossa tumor (6)intraspinal tumor (7)ocular dysfunction(8)burn scar (9)disc prolapse (10)spasmodic torticollis.
? vertebral anomalies
a. klipple-feil syndrome (cervical vertebral synostosis)
it is a developmental disorder results from failure of segmentation of the cervical somites causing fusion of two or more of the cervical vertebrae. it is often associated with abnormalities in the genitor-urinary, nervous or cardiovascular systems.
clinical features the neck is short or non-existent, there may be webbing, the hairline is low & the neck movements are limited. the symptoms arise not from the fused vertebrae but from the compensatory hypermobility of the adjacent vertebrae causing pain or neurological deficient.
treatment for asymptomatic children not necessary, for symptomatic children may require spinal fusion.
b. basilar impression
in this condition the floor of the skull becomes indented by the upper cervical spine & the odontoid impinge upon the brainstem.
causes either primary bone abnormality or secondary to bone softening disorders like rickets, osteomalacia, rheumatoid arthritis.
clinical features the patient may present with symptoms of raised intracranial pressure from obstruction of aqueduct of sylvius, or the patient may present with neurological symptoms from direct pressure & ischemia of the cord.
treatment involve surgical decompression & stabilization of the spine.
c. odontoid anomalies
this may include odontoid hypoplasia or aplasia or the failure of fusion of the odontoid with body of the axis (c2 vertebra) causing instability of the atlanto-axial articulation.
the child may be asymptomatic or may complain from neck pain & torticollis (from instability) or the patient may present with neurological symptoms from pressure on the spinal cord.
treatment if the patient symptomatic this may require stabilization of the spine by fusion of c1& c2 vertebrae.
cervical disc prolapse
the disc prolapse in the neck is less common than in lumbosacral region because the loading stress in the cervical region is less than in the lumbar region. the prolapse usually occur at the c5/c6 or c6/c7 intervertebral discs, so the c6, c7 nerve roots are commonly affected
clinical features the prolapse may occur after injury or strain, the patient complain from neck stiffness & pain radiating to scapular region & occiput, pain and parasthesia in one of the upper limbs (radiculopathy)but rarely to both upper limbs, weakness may occur in severe cases.
on examination there may be torticollis, there is tenderness over the cervical spine, neurological examination may reveals deficient of c6 root (depress of biceps jerk, weakness of wrist dorsiflexion & decrease sensation in the lateral forearm, thumb & index fingers) or deficient of c7 root (depress of triceps & radial jerk, weakness of wrist flexors & fingers extensors and decrease sensation in the middle finger).
imaging x-ray may show loss of cervical lordosis (straightening of cervical spine) from muscle spasm. mri will show the prolapsed disc & its level.
differential diagnosis this include (1) neuralgic amyotrophic (2) cervical spine infection (3) cervical spine tumor (4) supraspinatus tendon lesion.
treatment this involve 3r (rest, reduce, remove)
? rest: by resting the spine in collar.
? reduce: by using intermittent traction.
? remove: removing the disc by anterior discectomy & fusion for severe refractory symptoms.
cervical spondylosis
it is a common cervical disorder the disc degenerate & osteophyte develop causing pressure on the nerve roots & spinal cord.
clinical features the patient usually over the age of 40 years complain from neck pain & stiffness, the pain may radiate to the occiput or interscapular region & shoulders. there may be pain & numbness in the upper limbs (radiculopathy), rarely there is weakness & loss of the reflexes.
imaging x-ray may show narrowing of the disc space also osteophyte at the anterior & posterior margin of the vertebra. mri is the best to show the nerve root compression.
differential diagnosis
? carpal tunnel syndrome: the patient complain from numbness & parasthesia in the hand (the lateral three fingers), tinel’s signs positive at the wrist & ncs& emg show decrease nerve conduction across the carpal tunnel.
? supraspinatus tendinitis: characterized by tenderness in the shoulder & limitation of shoulder movements.
? cervical spine tumor: the x-ray will show the bone lesion.
? thoracic outlet syndrome: characterized by parasthesia along the ulnar side of the hand & forearm but the neck movement normal, x-ray will show the cervical rib.
treatment conservative treatment in form of analgesia collar, physiotherapy (heat, massage, exercise, passive manipulation & intermittent traction).
operative treatment in form of anterior discectomy & fusion or foramenotomy for nerve root compression or posterior laminectomy for spinal stenosis.
ossification of the posterior longitudinal ligament (pll)
it is a common condition & affects the cervical spine, the cause is unknown but it may be associated with bone forming disorders like diffuse idiopathic skeletal hyperostosis (dish) or fluorosis.
clinical features the patient usually a man 50-70 years, the patient may be asymptomatic or complain from neck pain which may radiate to the arm, the ossification may cause stenosis of spinal canal causing features of myelopathy (upper motor neuron weakness of the lower limbs)
x-ray show ossification along the back of the vertebral bodies in the mid-cervical spine.
treatment if the symptoms severe or the patient presented with spinal stenosis then surgical decompression by laminectomy or laminoplasty
spinal stenosis & cervical myelopathy
the sagital diameter of the spinal canal is the distance from the posterior surface of the vertebral body to the base of the spinus process, if this distance is less than 11 mm the canal is stenosed.
causes & risk factors (1) skeletal dysplasia like achondropinginglasia (2) disc degeneration with posterior osteophyte (3) osteoarthritis of the facet joints (4) ossification of the posterior longitudinal ligament (5) thickening of the ligamentum flavum (6) vertebral displacement.
clinical features the patient complain from neck pain which may radiate to the shoulders & arms , there may be numbness & parasthesia in the hands, there is signs of upper motor neuron lesion in the lower limbs (spasticity, increased reflexes, clonus) , in severe cases there may be urinary & rectal incontinence.
imaging x-ray the lateral film will show the sagital diameter less than 11mm
mri & ct scan will show the pressure on the spinal cord & nerve roots.
differential diagnosis (1) spinal cord tumor (2) vertebral tumor (3) neurological disorders (multiple sclerosis. amyotrophic lateral sclerosis).
treatment most patient can be treated by conservative measures like collar, analgesia & exercise, patient with myelopathy require decompression either anterior or posterior.
pyogenic infection
pyogenic infection of the cervical spine is uncommon & usually caused by staphylococcus organism, the infecting organism reach the spine by blood stream, initially affect the intervertebral discs & the adjacent vertebral bodies then the pus spread to the soft tissue & spinal canal.
clinical features the patient complain from severe pain in the neck with muscle spasm & neck stiffness, examination reveals tenderness of the cervical spine.
blood tests show leukocytosis, increased esr & c-reactive proteins.
x-ray initially either normal or show slight narrowing of the disc space, later there may be obvious bone destruction.
treatment by rest in collar & antibiotics, if there is abscess formation this require drainage.
tuberculosis
t.b of the cervical spine is very rare, the infection start in the intervertebral disc & spread to the adjacent vertebral bodies causing destruction & collapse of the vertebrae leading to kyphosis, cervical cord damage may occur from the collapsed bone fragments or from the extension of the infection to the cord causing tetraplegia. retropharyngeal may point behind the sternomastoid muscle at the side of the neck.
clinical features the patient complain from neck pain & stiffness, retropharyngeal abscess may cause dysphagia, examination may show swelling at the side of the neck with neck pain & tenderness there may be cervical kyphosis.
x-ray will show narrowing of the disc space with erosion of the adjacent vertebrae, mri may show pressure on the cord.
treatment by antituberculous drugs with immobilization of the neck in cervical collar or brace for 6-12 months. operative treatment indicated in the following:
1. presence of an abscess.
2. pressure on the spinal cord.
3. to fuse an unstable spine.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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