COMMON VERTEBRAL JOINT PROBLEMS Gregory P. Grieve FCS!' Dip T!' Honorary Fellow of the Chartered Society of Physiotherapy Post-Registration Tuto r, Department of Rheumatology and Rehabilitation, Norfolk and Norwich Hospital F ormer Supervisor and Clinical Tutor, Spinal Treatment Unit, Royal National Ortho paedic Hospital, London Fo,.ewo,.d by PHILIP H. NEWMAN CBE DSO MC FRCS the Royal National Latcly Consultant Orthopaedic Surgeon to the Middlesex Hospital, and Consultant Surgeon London Past President of the British Orthopaedic Association and formerl y Chairman of the British Council of Management of the Journal of Bone and Joint Surgery 10 Orthopaedic Hospital and Institute of Orthopaedics, c::J c::Jc::Jc::J c::Jc::Jc::J L7 CHURCHILL LIVINGSTONE EDINBURGH LONDON MELBOURNE AND NEW YORK 1981

CHURCHILL LIVINGSTONE Medical Division of Longman Group Limited DiSlributed in t he United States of America by Churchill Livingstone Inc., 19 West 44th Street, New York, N.Y. 10036, and by associated companies, branches and represematives t hroughout 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 Livingston e, 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 Printed in Great Britain by Butler & Tanner Ltd. Frome and London

Foreword Modern advance in prevention and treatment has elimi nated or brought under contr ol many of the severe illnesses which, a generation or so ago, afflicted man. Th e medical profession now has greater opportunity to pay attention to the challen ge of chronic arthritis and the effects of trauma, stress and strain and wear an d tcar of the musculoskeletal system, The population of the Western world of tod ay, its av erage age and demand for physical comfort gradually in creasing, presen ts an expanding and exacting problem. In hospital practice, to which the more di fficult cases 3fC referred, it is the consultant who examines, investigates, att empts to diagnose and prescribes treatment and having excluded a serious cause o r the need for inpatient treatment may refer the patient to the department of ph ysical medi cine for supervision and care. The therapist who carries out these in structions spends much time with the patient and learning from experience develo ps an unparalleled understanding of the nature of skeletal pain. Greg Grieve has dedicated his professional life to an extensive study of these physical problem s 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 o f Mennell, Marlin, Cyriax, Stoddard and others that he energetically became invo lved, 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 derangemen t and to train physiotherapists in the art of treatment by manipu lation. Followi ng the initial courses, with other teachers, between 1965 and 1967 he was the pi oneer who carried the torch of planning the curriculum and progressive develop ment of the annual cours es during the eight especially formative years, 1968 to 1975. During this time G rieve delved deeply into the vast literature that has accumulated on this subjec t. The variety and extent of this field is aptly expressed in this book: 'The mo untain of literature on spinal pathology is massive enough to have become all th ings to all men.' This book lists no less than 1400 references and its text is a stoundingly reverent to the galaxy of opinions and conclusions and the conflicti ng 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 spen t 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 man y textbooks written by the medical profession. This is a comprehensive aggregati on of the whole subject but there is nothing pedestrian in its teaching. It is p rov 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 sc hools into a language with a scien tific basis. It cannot fail to appeal to all t hose interested in the vencbral column whatever their clinical status. Aldeburgh , Suffolk 1981 P.H.N.

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, y et gathered together in a form which I hope will be useful to my colleagues. A c ommonly expressed regrct of therapists who strive to improve their handling of c ommon joint problems is that some of those whose prerogative it is to diagnose a nd pres cribe at times appear to have only a limited conception of the capabiliti es of modern therapists. Such is the speed with which the technology and capabil ities of all disciplines has riscn, this circumstance probably now applies to al l 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, aspi rations and capabilities. In any case, it is really no more than enlightened sel f 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 vert ebral 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 men t of common vertebral joint problems, and to know in which direction our knowled ge must be expanded. The easily portable knapsack-and-bedroll information and ru le-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 quickl y and accurately when assessing the multitude of facts ob tained by a good clinic al examination. As the more successful treatment of respiratory, nervous and met abolic disease, for example, has naturally evolved from a deeper understanding of the nature of the functional abnormality concerne d, it is surely axiomatic that abnor malities of the musculoskeletal system arc m ore 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 manip ulation, acupuncture, hydrocortisone injection, transcutaneous nerve stimulation , the 'back school', relaxation techniques, exercises, ultrasound or whatever, w ithout first making a comprehensive attempt to understand the clinical nature of the musculoskeletal abnormality as it affects each patient, is the road to Erew hon. The basic physical examination of common vertebral and peripheral joint con ditions has now been developed to the stage of a modern technology, and given th is as increas ingly standard practice, the steady accumulation of further knowled ge is certain. Without this basis, low back pain, fibrositis, muscular pains, sc iatica and tension headache, etc., will remain classically associated with paten t medicine advertisements, rubifacient unctions, generalised exer cises, other 's hot-gun' regimes like generalised relaxation or whatever piece of gleaming chrom ium-plated machinery happens currently to be in vogue. There is nothing sadder t han yesterday'S machine. While we make no real effort to understand the myriad c linical presentations of joint abnormality, troublesome joint pains will thunder on unabated. Since the level of useful knowledge in the world increases horrend ously, individuals have great difficulty in keeping up with advances in their ow n small sphere; there are the problems of assimilation and especially organisati on of the available information. I have had in mind the need for a new structura l framework, perhaps serving as a skeleton around which increasingly better-info rmed 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 inform ation 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 writ e on the many and diverse aspects of vertebral joint conditions must deal with s ome aspects about which they have little or no first hand knowledge. Without divi ne 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 informa tion about omissions, contradictions and ambi guities; suggestions from like-mind ed 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 th e primary interest. This is not so-the more we understand about the genesis of t hese conditions, the temperament and life-habits of the patients in whom they ar e occurring and more especially the infinite variety of presentation from patien t to patient, the better we help them; 'manipulation' is but one of our treatmen ts, albeit a subject in itself. The text is addressed to the members of no parti cular discipline other than like-minded professional colleagues, by whatever aca demic route they may have developed an interest in the conservative treatment of the ubiquitous, frustrating and depressing spinal joint problems suffered by su ch multitudes of people. I have not attempted to categorise, or elaborate on, th e 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 atten tion to treatment techniques. 3. Knowledge of the subject is expanding and chang ing 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, principle s only arc important, and do not change with the years. In The History of Impres sionismlO29 Renoir is quoted as observing, '. . . though one should take care no t to remain imprisoned in the forms we have inherited, one should neither, throu gh love of progress, imagine that one can detach oneself completely from past ce nturies.' 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 cl inical examination procedures and treatment techniques. While physiotherapists s hould not anempt [Q write com prehensively on problems of diagnosis, or the disci plines of pathology, medicine, surgery, neurology, radiology and epidemiology, e tc., perhaps in the devotion of a profes sional lifetime to this field of minor o rthopaedics 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 ap proach their training in 'clinical con ditions' as diseases of the various system s, 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 b eing relegated to the lower orders and boring peasants of this hierarchy. I beli eve this to be a profound mistake, since by meticulous examination and enlighten ed assessment each one of the 'old (and young) necks and backs' becomes an excit ing detective stOry of absorbing interest and amply repays informed and accurate treatment, which need not be vigorous or aggressive. The ample repayment lies i n the pure pleasure of relieving chronic and often disabling pain and other symp toms 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 co

n sequence, the process being influenced by direct and indi rect trauma or stress, and coexistent disease. Patients rarely attend because their spines are undergo ing gradual and silent degeneration with gradual diminution of movement, but bec ause they have pain and other troublesome symp toms in a specified area, and some times two or three. 'There is in medicine a natural law that any single man ifest ation, subjective or objective, may have behind it a multiplicity of organic cau ses, just as any single patho logical event is bound to project itself into a num ber of different clinical manifestations' (Steindler, 1962).1171 It is convenien t to use generalised treatment procedures for 'the arthrosis' or 'the spondylosi s' as the basic reason for the patient's attendance, yet always more rewarding t o 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 affec tions 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 t he 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 clin ical presentation of musculoskeletal joint problems.

PREFACE ix 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 way s, legislate in all sorts of ways (see p. 205). There are too many factors invol ved; very many of the so-called typ ical syndromes arc surprisingly uncommon. Thi s becomes more apparent in direct relationship to the comprehen siveness of histo ry-taking, initial examination and careful palpation. Because there appears to b e a gross imbalance among the weight of literature on degenerative change, in th at the lumbar disc has cornered a fashionable and ridiculously large share of an emion, I have devoted more space than may be customary to arthrosis, and to seem ingly 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 rich es-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 dea l more is being learned about what appears to a clinical therapist to be, in man y cases, of little shopfloor clinical value, and we wistfully hope that more tim e 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 prob lems; where convenient to do so, reference as is necessary is made in the 'Clini cal presentation' section rather than in the more detailed section on 'Pathologi cal 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 presentati on of important aspects in parti cular spinal regions, e.g. in the section on 'wh iplash' in juries, the discussion of surgical problems in the section on biomecha nics of the cervical cord and meninges, and the discussion of soft tissue change s. Bourdillon (1973)'" expressed a salient feature of spinal musculoskeletal pro blems: The paucity of clinical signs and the diversity of symptoms produced by spinal j oin( disorders confused the medical profes sion [Q it, or the facilities for help are not as adequate as desired, the patient is gi ven 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 press ing aches and pains, they tend to be regarded as the least rewarding to treat an d thus may be the worst pro vided-for. The run-of-the-mill standard of clinical e xamin ation of these 'uninteresting' conditions is perhaps not always as painstak ing as it might be, and the patience of patients is at times unbelievable. The a mount of real need is calamitous, and the clinical wherewithal to cope with it e thically, knowledgeably, effectively and with a minimum of vigour, has been sadl y thin on the ground. For this reason, the energetic attack with limited means o n 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 p roblems of cervical spondylosis, have also received an increasing vol ume of expe rt attention 1 11 and, together with the advances in the understanding of pain b ehaviour, today's clinical workers arc immeasurably better equipped than those o f two decades ago. I t may be that the word 'manipulation' will conjure in the m inds 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 authorita tive voice and responsibility over the years, have tended to alienate the modera

tely minded by an habitual style of unbuttoned rhetoric and noisy self-aggrandis ement. I quote F. Dudley Hart''': In medicine the authority in the past for some theory of ae tiology or drug actio n or pathological or physiological process was often some (often professorial) G od-like figure and was sometimes based on precious little evidence, but it was a ccepted as true because (l) it seemed to explain things nicely and often relativ ely 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 afterward s medical progress by an ... utterance based on inadequate evidence .... It is s o much easier for us all to believe in somebody reputable than to work it out fo r ourselves and see if he was right. ... Most of us perform our medical duties a cting on working hypotheses rather than on fixed beliefs, but it is very easy fo r the one gradually and very insidiously [0 become the other, particularly if on e is teaching and lecturing. What I say three times is true, is true, is very tr ue. 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 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 the ir vocabu lary of anatomical information and their capacities for assessment, bec ause superficial conclusions derived from casually observed phenomena are not al ways justified. The fact that most strip-clubs audiences are said to comprise

x PREFACE the occult nature of many visceral lesions; much efort f required [0 baldheaded old men should not lead to a 'logical' conclu sion that looking at lad ies 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 clinica l 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 knowle dge, will get more interest and fun out of the pro ceedings and will find the wor k 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 t he 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 occu rred, important though three of these may be. I plead that the medical and physi otherapy schools might devote much more attention to the teaching of ver tebral a natomy and the comprehensive management of benign articular pathology of the spi nal column because, like the common cold, there's a lot of it about and its depr edations 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 its elf into re search of one kind and another and it is plain that a minor proportio n of it might acquire considerable cost-effective ness by being channelled into t eaching very many more clinicians and therapists how to recognise and treat by r elatively simple means the early painful manifestations of vertebral degenerativ e joint disease. A summary (Wood, 1980)"'" of the proceedings of a Workshop on u ndergraduate 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 encourage all medical colleagues to examine joints properly ... It has been suggested that because the conundrum of rheumatoid arthritis will pr obably be solved within the decade, rheumatology must look to new fields and sho uld turn its main energies to backache. Together with these logical and reasonab le observations is included: Suferers f whose pains arc severe will seek help, some from family doctors and s ome from heterodox healers, the osteopaths, chiroprac tors, manipulating physioth erapists, unqualified bonesetters or others of the host described as 'fringe med icine'. 1971 survey) nevertheless there were still grounds for concern about the adequacy of rheumatological teaching in many undergraduate medical sch oolsj 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 co ncern, and tends to be encouraged by the fact that patients are usually aware of their problem, in contrast to The writer of such phrases about ethical and competent paramedical workers in th e health care team could nm have more plainly bared his deep anxieties. Those wh

o profess to handle the vertebral column must be awake [Q all aspects at all tim es. Problems, a few of them highly disconcerting, have a habit of looming sudden ly and the more so as one slides into an easy familiarity of handling after a 'r outine' history-taking. The possibility of serious pathology, and somelimes mali gnancy, hangs over all clinical presenta tions of vertebral pain. That which pres ents 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 therapis t must be soundly and com prehensively informed, always awake and always eco nomic al 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 s ections on assessmcnt. In its coordinated activity and usc of stored patterns th e mind is like a group of prime movers and syncrgic muscles and its ability to g rasp, sort and organise information can reach an artistry as perfect as an outfi elder's leap for a back-hand catch. I n his essay on Sir Isaac Newton, J. M. Key nes describes the mind-muscle as much like a lens; the ability to gather unrelat ed 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 probl ems. Anatomical infor mation, painstaking clinical method and basically simple th ings done carefully and well are more important than the facile acquisition of e xotic manipulation techniques. Since we tend, at times, to take ourselves much t oO seriously I hope the mild irreverence here and there in the text does not mak e 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. G.P.G.

Acknowledgments We climb on the shoulders of those who have gone before, and those who follow wi ll climb on OUf own; we also lean on the shoulders of colleagues and I express w ith pleasure a debt of gratitude to john Conway (from whom I learnt much about t he value of treating patients in (he side-lying position) and joe jeans (whose f riendly but incessant demands that I produce a book have now been met), also Fre ddie Preasrner, Brian Edwards, Peter Edgclow, Marjorie Bloor, Sue Adams, Freddy Kaltenborn, Beryl Graveling, Sue Barker, Shelia Philbrook, Chris Coxhead, and ji ll Guymer. I wish to acknowledge the fruitful working relationship between Geoff rey 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 physiotherapi sts 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 Geof frey Maitland, AVA FCSP MAPA, and Messrs Butterworth, London. There is an especi al 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 g raciously lent his immense tcaching au thority to the 1973, 1974 and 1975 CSP Man ipulation Courses, and has very kindly honoured me by writing the foreword to th is book. All therapists will join me in recording our considerable debt to Profe ssor 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, Profes sor P. D. Wall and Dr B. D. Wyke. To our debt I add my warm personal thanks, als o to Dr Basil Christie, Dr Ian Curwcn, Dr Desmond Newton and Mr Hugh Phillips; t hey 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 physiotherapist s 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 base d. Also to Mr W. j. Guest, Principal of the West Middlesex Hospital School of Ph ysiotherapy; his capacity for doing good unobtrusively has benefited physiothera py 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 da ys, and of myself over 30 years of professional association. Members of the Mani pulation Association of Charlered Physiotherapists have been most fortunate to e njoy 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 eru dition of my classmate of years now sadly past, Mr H. j. C. Cooper, and to his u nfailing 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 t echnical skills of Dr john Graves of the Graves Audiovisual Medical Library, Mis s Vta Boundy, Medical Photographer to the Institute of Orthopaedics, London, Mr john Tydeman of the Department of Medicallllustration, Norfolk and Nor wich Hospi tal, and to Anglia Photographics, Halesworth; they have devoted much care and te chnical skill to the illustrations. To those who patiently modelled during the l ong 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 Instit ute of Medical Education, and to Mr C. Davenport and Mr P. Smith, respectively t he previous

xii ACKNOWLEDGMENTS and present Librarians of the Institute of Orthopaedics, London, I gratefully ac knowledge 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 i n 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 Physi otherapy. I thank Mr B. Holden of Carters Ltd, Mr N. Peters of The Tru-Eze Co. I nc. 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 inadve rtently been used without due permis sion or acknowledgment, apologies are offere d to those concerned.

Contents 1. Applied anatomy-regional 7. Clinical features 159 160 161 176 189 196 196 199 200 202 Cervical Thoracic Lumbar Pelvic Surface anatomy 2. Applied anatomy-general 3 13 17 29 31 36 36 36 38 53 56 62 64 69 74 77 82 82 88 94 110 121 Articular cartilage Lubrication of synovial joints Vertebral movement Inrcrvcrtc bral foramen Biomechanics of spinal cord and meninges Venous drainage Autonomic nervous system Patterns of somatic nerve root supply 3. Aetiology in general terms 4. Incidence 5. Pathological changes-general Neurological changes Pain and tenderness The autonomic nervouS system in vertebr al pain syndromes Referred pain Abnormalities of feeling Changes in muscle and s oft tissue Deformity Functional disablement The psychological aspect of vertebra l pain 8. Common patterns of clinical presentation 205 205 206 229 232 250 279 300 303 303 322 322 324 326 327 328 334 336 341 Arthrosis and spondylosis Upper cervical region Cervico-thoracic region Thoracic region Lumbar spine and pelvis The pelvic joints Neoplasms 9. Examination Synovial joints Symphyses (Intervertebral body joints) Nerve root involvement So ft tissues Neoplasms 6. Pathological changes-combined regional degenerative 125 125 129 134 138 150 151 157 Cervical spine Cervico-thoracic region Thoracic spine Lumber spine Sphincter dis turbance The pelvis Serious pathology simulating musculoskeletal pain Introduction Regional Examination procedures Cervical region Shoulder and clavic ular joints Thoracic region Lumbar region Pelvic joints Hip Passive physiologica l movement tests Recording examination 10. Assessment in examination-Prognosis 350 369 11. Investigation procedures

xiv CONTENTS 12. Principles of treatment 376 377 378 38 38

Aims of treatment Definition of passive movement techniques Manipulation in gene ral terms Grouping of techniques 13. Recording treatment and clinical method

Localised manipulation Regional manipulation Exercise Contraindications 16. Supports and appliances and adjunct physiotherapy treatments 17. Medication and alternative methods of pain relief 18. Prophylaxis 19. Invasive procedures 463 464 464 465 435 468 Use of technique Selection of technique Assessment during treatment 14. Exercises 15. Indications for passive movement techniques and exercise 441 442 444 45 1 483 496 51 4 5 14 525 535 559 460 460 460 46 1 462 462 462 General indications Soft tissue techniques Localised mobilisation Regional mobilis ation Stretching CA) Mechanical harness traction Minor procedures Major surgery with indications for seeking surgical opinion References Index

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 du al features require morc extended discussion, this has been included in the appr opriate sections throughout the text . Because structural variations have considerable impor tance in this clinical fiel d, and their likelihood always worth bearing in mind, some anomalies have been i n 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 configuT8l ions and size of spinous processes.

2 COMMON VERTEBRAL JOINT PROBLEMS frequently, cardiac and renal abnormalities occur, and there may be congenital m alformations of the gastro intestinal and respiratory system. lOGO 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 articu lar 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 spin e, totalling 25 including the upper 2 atypical segments. 3. In the cervical spin e only, a further group of small articulations rcquires consideration (Fig. 1.4) : these are 1091 j the Q!ired oinlS of Luschka, the uncovertebral orneuro central articulauoQs. situated in the uncovertebral region on each side between the out er posterior margins of the vertebral bodies, at the five segments berween the s econd nd seventh yerrebrae.548 The join" of the vertebral column (Figs 1 . 1 , 1 . 2 and 1.3) at:! of three kin ds: 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. ArtICular facet on supenor ____ -= aspect -of atlas Lateral t op ofatlas --- 1' Transverse m- ---- , -- _ Cl--{;2 ofC2 Bifid C2 facet joint spflnous 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 o f the temporal bone would lie laterally to the margins of the illustration. ocess

APPLIED ANATOMY-REGIONAL 3 CERVICAL SPINE Because the consequences of arthrotic and spondylorjc changes in the neck arc us ually more marked and wjde_ spread than degeneration of other spinal regioos, th e salient facts of anatomy and articular function in this area need careful cons ideration.' '" 475,1)54,1)55.1)57,1364,967,1242 A. UPPER CERVI C AL SPINE (Fig. 1 .5) T niovertebral re ion is of importance, as some 0 the most essential atwrcor jmp ulses 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 vertebr al synovial joints. The impor tance of their func[tonal role is clearly demonstra ted, for example, in consideration of the tonic neck reflexes. posture governs b ody posture and limb control; abnor malities of afferent impulse traffic from joi nt receptors, because of degenerative changes, can be expected to reduce the eff iciency of postural control and produce the alarming symptoms of defective equil ibration. Experimental cervical lesions jn monkeys jmm)ving u ilatera! section o f 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 F11r. 1.5 Anterior aspect of upper cervical region. There is chondro osteophytosi s at C3-4 facet-joints on either side, and also at C4-5 on patient's left side. OccipitoatlantaJ joint verging anteriorly, with the lateral edges of the facets 00 . the atlas banked u a saucer, which somew IgS . , 1.5). stricts other than sagittal mov s The r:Qugbl ycirclJlar facetsofboth atlas and axis are not quite reciprocally curved; the co nvex upper axial surface receives the irregularly concave inferior facets of the atlas 'like the epaulettes on a pair ofsloping sho"lders'; the facet-planes bei ng about]]0 totbeyertical Theposterior face of the anterior arch of atlas abuts a gainst the front of the odontoid, a small synovial cavity intervening; a si!11il a all bursa or synovial oint intervenes between the posterior face 0 e odontoid and its strong retammg The convex occipital condyles, and reciprocally concave articular surfaces of th e atlas, have their long axes conAtlantoaxial j oint488 S58 Fig. 1.4 Anterior aspect of cervicothoracic region. The uncovenebral region at C 5-6 level shows the sclerosis of bony margins and flanening of the C6 uncus on t he patient's right side. Compare with uncovertebral region of C6-7 space. Fl. 1.6 Frontal view of the atlas and the axis.

4 COMMON VERTEBRAL JOINT PROBLEMS Posterior Cranial Fossa Antertor Posterior 2 3 4 10 " 12 13 Fig. t., Fig. 1.8 The lateral atlantoaxial joint appears biconvex. 2. 3. 4. 5. 6. 7. 8. 9 . 10. I. Anterior longitudinal ligament Median and paramedian section of cervical structures. (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 E ditor.) 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 fun ctional importance, as osteoarthrotic changes are common in this f re ion follow ing stress and trauma and th yst possible Igamentous lOsufficiencym be bornein m ind during treatment (Fig. 1 . 8).'98 From before backwards, they are: 1 . The a nterior occjpitoatlantal membrarJe, continuous below with the anterior longitudi nal ligament and blend ing laterally with the capsules of the facet-joints. l 2. The \pin qpica ligam!!,l, attaching the tip of the odontoid to the [Jor margin of the foramen magnum (Fig. 1.9). 3. The Q!ore laterallyplaced and tougher alar lig aments, attaching the posterior part of the odontoid tip to the lateral margin o f the foramen magnum on each side. . 4. The transverse liggmem of the atlas, a s trong fibrous band connecting each lateral mass across the front of the neural c anal and passing behind the odontoid; it is a vital re..!,aining structure stabi lising 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 ertica l bands of less functional imporrance ex!endjng"pward and dowmva . 5. The accessor y atlqntOaxial ljgmueuu , w.!!ich pass upward and . f2 th bas QLlhl:jefcriNyertl cal ' 1D e band of the se of the odontoid process with the inferomedial art of t he lateral he median atlantoaxial (or atlantodental) II. 12. 13. Anterior atlanto-occipital membrane Synovial joint between anterior arch of atla s and odontoid Odontoid process Apical ligament of odontoid Synovial joint betwe en transverse ligament and odontoid. NB. 3 and 6 comprise the median atlantoaxia l joint (q.v.) Transverse ligament of atlas Membrane tectoria-the upward continu ation of the posterior longitudinal ligament Posterior longitudinal ligament For amen for first cervical nerve and vertebral artery Foramen for second cervical n

erve Ligamentum nuchae Capsule of facet joint between the right side articular p rocesses of C2 and C3. (Reproduced from Kapandji IA 1974 The Physiology or the joints III (the trunk an d vertebral column) p 187, by kind permission or the author and Librairic Maloin e S.A. Paris.' joint is very frequently the seat ofarthrotic change. more so than in the two la teral articulations.1174 \ 6. The membrana leeroo'a, being the upward prolonga ti on of the posterior longitudinal ligament, covers the pc:cerljngstryctures poste riorl)' it is attached below to j the base of the odontoid, and above to the cli vus of the basiocciput. 7. T.he posterior occipitoatlamal membrane completes Apical l)9am"\2nd . --j'--- 5th A.P.R. Fig. 1.13 Laleral aspect of upper five cervical verlebrae. The first two cervica Anterior \1st

l roots emerge behind the facet-joints; all others emerge in front of the facetjoint. 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 Lazort hes G 1972 Ann. de Me-d. Physique 15: 192.)

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 arti cular 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-occipita l membrane with the vertebral artery and vein ( Fig. 1 . 1 3). All the orher spi nal nerve ropts down to the level of the 5th lumbar e erge in front of the facet-j ojnts Shore (1935)"" mentions that while the skin does not receive a direct supp ly from the first cervical nerve, because ofa communication with the second cerv ical nerve C l has a share in supply of the cutaneous area to which the greater occipital n erve is distributed. I5liiTrlg their passage towards the foramina, the fibres of the roots leaye thes pjnalcordat the level of the numeric ally corresponding vertebral body, and do no t pass later r all in such close relationship to the disc as do the I nerve roots see p. 24). onsequent y, although spinal cord and nerve root compression can oc cur by pathologi cal changes in the discs, its mode of production differs somewha t to that in the lumbar region. During their pass en t s are age through the inte rverte boun e 10 front and behjnd bygtrpcwres very likely to sympathetIC trunk C2-C8 Fig. 1.14 Innervation of related cervical vertebral structures in transverse sec tion. Muscular branches of the dorsal ramus supply the articular capsule. Pans o f the vertebral plexus are seen within the foramen transversariuffi, together wi th vertebral vein and artery, and showing smaller but macroscopic ganglia in thi s situation. Communications of the plexus are seen with the spinal ganglion, dor sal and ventral rami, and the sympathetic trunk (and via this branch to the peri osteum 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 b ody and via the meningeal ramus to the dura mater and posterior longitudinal lig ament. (After: Stillwell DL 1956 The nerve supply of the vertebral column and it s associated struCtures in the monkey. Anatomical Record 125: 139. Reproduced by counesy of the Director, Wistar Press.)

APPLIED ANATOMY-REGIONAL uce pressure or irritation by exos(Osis, these being the p fa e -'oint structure s postero atera y and the 'neuro central joints' anterome la y. Cervical spine ne rve roots have a rough segmental identity, i.e. after union of the ventral and d orsal rootlets, the roots emerging frow thejnteryertebral foramjna cor respond ny merically with the vertebra below (excepting that of the 8th cervical) and the a ppropriate 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 r ootlets contributing to a spinal root may be lower than the foramen for that ner ve, and therefore have to ascend slightly to reach their exit from the neural ca na1. 537 Paradoxically, the nerve supply to the vertebral column structures them selves is much I seqmentall ed, 1177 a rich netbem en work of fibres occupying t he region of the somatic nerve roots and the sympathetic ganglia (Fig. 1.14). Wy ke (1979)"'" observed that, articular branches of its own segmentally related spinal nerve Each cervical apo physeal joint 9 is innervated not only through ut .1.0 it and ascend to it from the caudally located nerve rOOt. also by articular nerves that descend to it from the nerve root rostra , There are plentiful interconnections with the sympath etic grey rami communicante s, 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 rived from this plex-us -fo-rm (ramus meningeus), usually compnslOg two or more b ranches which re-enter the foramen to supply structures ,\,ithin the vertebral c anal (Fig. 1.15). Mixed branches from the paravertebral plexus also pass externa lly to the sides, front and back of the vertebral bodies, supplying periosteum a nd 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 popu lation of the facet-joint structures (see p. 10). Each 'mobilit se ment' receive s fibres derived from es together with sympathetic three a postganglionic fibres innervating the blood vessels therein, and these approach from a variety of dir ections; in addition to this segmental overlap, from outside, the branches of th e 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 supplyin g the vertebral column beyond their segment of o r' . om arable to the mal innervation on the body s Ascending branches ofmixednen res withjn thenellra! 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 > r The autonomic nerve supply The supply to the head and neckis derived Cal from th e three cervical sympathetic ganglia in this region, with (b) Fi,. 1.15 Posterior aspect of spinal canal. The sinuvertebral nerve (ramus menin

geus) 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 su pply of the intervertebral disc. Acta otthopaedica scandinavica 19: 211.)

10 COMMON VERTEBRAL JOINT PROBLEMS parasympathetic connection,L contributed by cranial y nerves (particularl the gl ossopharyngeal and vagus) (Fig. 1.14). ", 4" Although it is customary to regard the first thoracic segment as the uppermost l evel for emergence from the neuraxis of preganglionic sympathetic neurones, the work of Laruelle,699 Guerrier,4L Delmas and Laux2r2 Coccyqeol Fig. 2.13 The level of spinal cord segments i n .elalion lO Cocc y x vertebral levels. The spinal cord ends a l L 1 - L2. foramen varies between 1 2 and 19 mm, but the transverse diameter may be as litt le as 7 mm, and the opportunities for foraminal encroachment due to hon'zomal tr espass are much greater. Diminution of the transverse diameter is more likely to embarrass the foraminal contents, and this space-occupy ing effect can be due to abnormalities of the disc and facet joints, so often the cause of acquired spina l stenosis. Nerve tissue will tolerate slow compression quite we1l282, )92 and m arked trespass may not give rise to much detectable dis turbance of function, alt hough repeated frictional trauma against encroaching degenerative thickening, an d exos tosis, may be the more likely cause of reactive changes in the nerve and c onsequent development of signs and symptoms. It is a curious fact that in both the lower cervical and lower lumbar regions, w here spondylotic changes are very frequently responsible for a reduction in fora minal dimen sions, the foramina should be naturally smaller than in the middle an d upper parts of these regions (see also 'Bio mechanics of spinal cord and mening es', below). When the transverse dimensions of the lumbar fora mina appear develo pmentally reduced, and this is detect able on plain lateral films in the absence of acquired foraminal encroachment by spondylosis and arthrosis, a narrow neural canal (spinal stenosis) is almost certainly present. ----___I

56 COMMON VERTEBRAL JOINT PROBLEMS Dura mater (open sac) C7 ca Spmal cord of their significance for those who treat vertebral de generative change : The primary source of meningeal and neural tension is the lengthening of the spi nal canal on forward and lateral flexion. Normally, the soft tissues adapt freel y to these skeletal move ments ; bUl in [he presence of space-occupying lesions i nvolving the spinal cord or locatcd in the cord itself, and when there are scler otic or fibrotic lesions that restrict the mobility or extensi bility of nervous and meningeal tissues, the tension may be much increased. Even when the patholog ical lesion appears to be exert ing an essentially compressive effect, the result ing deformation leads to a local increase in tension ; it is the effects of this raised tension that appear to be of primary neurophysiological signifi cance . . . excessive tension in the cord may produce measurablc changes in motor, sensor y and autonomic function. These are accentuated whenever the cord is slretched, and may be reversed, and the symptoms relieved, if stretching can be eliminated and T1 T2 T3 T4 the aff ected tissues are kepl relaxed. Even in the presence of irre versible mye lopathic lesions, whether focal, sclerotic or space occupying. the existing sympt oms and neural function can be improved significantly by surgical measures desig ned to prevent overstretching of the cord. In the course of clinical enquiry ove r nearly two decades I have found that many neurological disorders in which no m echanical component has ever been suspected do in fact have their origin in tens ion in the nervous tissue; we are at present only just beginning to recognise th e histological and neurophysiological sequelae of this tension . . . . Biomechan ical T5 T7 m0 1

foot Ventral rootlets analyses were extended to the micToscopical level. These analyses have shown tha t tension in the nervous tissue that gives rise to symptoms is characterised by focaJ deformation of its complex three-dimensional fibre nerwork as seen in hist ological and microangiographical sections. It was evident that an important caus e of functional disturbance both of the axis-cylinders and the blood-vessels lie s in the reduction of their cross-section area resulting from tension. By slacke ning the nervous tissue the ten sion is relieved and the conductivity and circula tion are restOred. Cui edge of pedIcle Antenor aspect of dura mater Fig. 2.14 Scheme of cervicothoracic root angulations-anterior aspect (sec leXt). (Afler Nathan H, Feuerstein M 1974 Angulated course of spinal nerve roots. Jour

nal of Neurosurgery 32: 349.) BIOMECHANICS OF SPINAL CORD AND MENINGES In the presence of mechanical derangements such as disc pro lapse, or the bony an d soft tissue hypertrophy of osteoarthrosis where there is encroachment upon the dura and nerve roots, and where adhesions may follow a local irritative state, there is need to distinguish between the possible causes of pain on movement. (T roup, 1979) 12'10b I n his foreword to Breig's ( 1 978) " '" detailed observa tions on adverse mecha nical tension in central nervous system tissues, Verbiest remarks that the obser vations are of much importance not only to specialists in the neurosciences and orthopaedic surgery, but also to anaesthetists, whose activities regularly invol ve the positioning of defenceless patients, and last but not least to physiother apists, for reasons which need no elaboration. Breig introduces his study in wor ds which leave no doubt Nervous tissue and the meninges have different proper ties and therefore show dif ferent behaviour under mech anical stress ; this has important inferences when co nsider ing the effects of vertebral movement. Nerve tissue is almost semifluid-if cut transversely it tries to flow. The sciatic nerve, for example, can stretch, it is elastic.l Okf, 4 1 6 While a sudden stretch may interfere with it conside rably, a slow stretching may be tolerated without undue reactive changes. The me ninges differ. The more delicate of them can stretch and enlarge circumferential ly, because much of the arrangement of their fibres is around the long axis, pre sumably to accommodate arterial pulsation, but they can not stretch very much alo ng the longitudinal axis of the cord, e.g. when extended to around 5 per cent of their nor mal length they are taut. STRUCTURE The outer layer of the dura marer) basically white fibrous tissue predominating over some elastic fibres, is con-

APPLIED ANATOMY-GENERAL 57 tinuous above through the foramen magnum with the in ner layer of the intracrania l dura mater. The spinal canal continuation of the outer (endosteal) layer of th e cranial dura mater is represented by the periosteum lining the vertebral canal . In the canal the space between the two layers is the epidural or extradural sp ace, almost entirely occupied by fat, loose areolar tissue, and the rich plexus of vertebral veins,'n7 The caudal limit of the subdural cavity lies level with ( he second sacral segment, the dural tissue then extending caudally, as an increm ent ofthe filum terminale of the spi nal cord, both of which structures end by bl ending with the periosteum on the back of the coccyx. In addition to these cepha lic and caudal attachments the spinal dura mater is attached by fibrous slips to the back of the vertebral bodies of C2 and C3, ' " and also to the posterior lo ngitudinal ligaments of the lumbar segments. In the lumbar region the binding of the dura is most firm along the lateral edges of the long superficial strap fib res of the posterior longitudinal ligament, with numerous cross connections of t he epidural venous sinuses passing between the trabeculae of connective tissue w hich join the dura and ligament. cm Investments of dura mater are continued late rally through the intervertebral foramen (see p. 54) with the combined spinal ne rve roots for a short and variable dis tance, as a root sleeve, or root ostia, bl ending with the con nective tissue perineurium. Variations occur with regard to angulation and maldevelop ment and/or malformatio n of cervical root pouches and root sleeves. }O2 the lower extremity of the subdural cavity at the second sacral segment. It line s the dural root sleeves, providing with the dura an investment of the ventral a nd dorsal spi nal nerve rootS but is not, like the dura, continued distally beyon d the formation of the combined spinal root, i.e. it terminates by linking the a djacent layers of dura between the ventral and dorsal roots) thus contributing t wo laminae to the interradicular septum. In this situation both dura and arachno id are sus ceptible to the repetitive, minor, mechanical trauma of stretching, an d of impingement on adjacent foraminal margins as a consequence of degenerative change altering foraminal relationships; the resulting granulation tissue freque ntly leads to fibrosis and scarring, with the tethering effects of root sleeve f ibrosis'" (see pp. 1 00, and 102). The innermosl /ayer, the pia maler, is a highly vascular and delicate membrane c onsisting of fine areolar tissue sup porting numerous small blood vessels, separa ted from the arachnoid by the subarachnoid space, which contains the cerebrospin al fluid. The spinal membrane is alto gether firmer and thicker than the intracra nial pia mater, and it is intimately adherent to the spinal cord, lining the ant erior median fissure and forming a sheath for the ventral and dorsal spinal root s as far distally as the inter radicular septum. It forms the ligamentum denticul atum, a series of tri angular tooth-like processes lying between ventral and dors al roots and extending laterally to attach by their points to the inner aspect o f the dura mater. The 21 pro cesses on each side begin at the level of the C I sp inal nerve root and end between the levels of exit of T 1 2 and LI roots. The up per 'teeth' are almost perpendicular; the uppermost and stoutest of these is att ached to the dura inside the posterior cranial fossa, behind the canal for the 1 2 th cranial nerve. The ligaments are organised to sustain a degree of tension, and when cut from their dural attachments they contract right down to the cord. The position and form of the dentate l igaments change during vertebral movemen t. ) 1 4 The pia mater ends with the termination of the spinal cord, the conus m edullaris, at the level of L I-L2 vertebral segments, and thereafter a fine fila ment of connective tissue, the filum terminale, descends from the caudal apex of the conus to attach to the dorsum of the first coccygeal segment. The roots com prising the cauda equina therefore embrace the filum terminale. Particularly in {he cervical spine, the dural root sleeves are loosely attached to {he margins o f the intervertebral foramen. I IQ]

Bowden, Abdullah and Gooding ( 1 967) ' " observe that the paired root sleeves o f dura and arachnoid mater are loosely attached to the margins of the cervical f oramina. These attachments increase in strength with advancing years and degener ative change. Sunderland ( 1 974),"" with regard to the remainder of the spine, describes the nerve complex as not attached to the wall of the foramen, the arra ngement permitting the complex to move within and through the foramen ; Hollin sh ead ( 1 969)'" reports the first sacral nerve as attached to the margins of the intervertebral foramen. On leaving the foramen, the 4th, 5th, 6th and 7th cervic al roots are more strongly attached to the vertebral column, each lodg ing in the gutter of the transverse process in which it is securely bound by its epineuria l sheath and by reflections of the prevertebral fascia and other slips of connec tive tissue. 119l The middle layer, o arachnoid macer, is a more delicate f membrane and is separa ted from the dura mater by a potential space which contains a trace of serous fl uid. The arachnoid mater is continuous above with the in tracranial arachnoid mem brane, and ends caudally with EFFECTS OF VERTEBRAL MOVEMENT The coverings of the spinal cord permit it [0 move about within the limitations imposed by connective tissue tethering, the nerve roots, cranial and caudal attachments

58 COMMON VERTEBRAL JOINT PROBLEMS and the ligamentum denticulatum. The dural sac changes its configuration conside rably during exertion and strain ing. These effects are observed myelographically when the patent is asked to strain.'15 While the spinal cord, meninges and nerv e roots are affected by vertebral movement, postures and pressure differences, 1 l 9 the cord does not slide up and down the neural canal to any appreciable deg ree-its movement in the cervical spine, for example, is only 2-3 mm at the most, although Reid ( 1 960) 00" refers to higher averages. The cord and its attachme nts deform like an accordion as the dimensions of its protective canal change wi th move ment. I l06 I t sustains tension, and its position relative to the anteri or and posterior wall of the canal is changeable. The reason why cord and dura b ecome taut together appears to lie in the nature and number of ligamenta den ticu lata. Any small up-and-down movement of either cord or dura is quickly transmitt ed one to the other. Pull on nerve roots transmits its effects to the cord via t he dural sheath and the dentate l igaments rather than via the root lets. Cephali c traction on the dura is found to be equally as effective in applying tension t o the cord as is caudal traction. 1 024 I njuries to the cord and nerve roots ma y come about as a result of loss of plasticity, ischaemia induced by either loca l or more remote effects, pathological displacement of vertebra, degenerative tr espass by structures forming the protective neural canal and by violent traumati c distrac tion of nerve root attachments. After degenerative change of the cervic al intervertebral discs, for example, when the vertebral bodies settle like a pi le of dishes, the neural canal is shortened and the relatively inelastic dura ma ter will fold. Since it is tough, in certain circumstances the folds may produce lesions due to trespass upon structures within the canal. 1 1 7 Adhesions following haemorrhages, exudes and inflammation will cause shrinkage a nd stiffening of the tissues and loss of elas ticity of membranes. This, in turn, leads to abnormal tensions on the cord and nerve roots. . . . rowing of the canal or by abnormal tethering of the cord in an anterior position . l20 A further and important factor is cord ischaemia due to trespass upon vess els sometimes remote from the site of its most potent effects.656, 426 The radic ular arteries invariably lie on the anterior aspect of the nerve root. Active mo vements normally exert effects of tension and relaxation of the spinal cord, men inges and nerve roots.981 Whenever the cord shortens or lengthens, its cross-sec tional area increases or decreases respectively. 1 20 During extension of the ce rvical spine, for example, the spinal cord and roots become relatively slack, l I7and the flaccid cord deviates according to gravity towards the front or back o f the spinal canal, depending upon the prone or supine position. 120 The canal i s nar rowed from front to back, and small ridges are raised over each disc on the anterior wall of the canal. 10201 The inelastic dura mater cockles up to a degr ee and the elastic ligamen tum flavum bulges forward into the neural canal. In fl exion , the slack in cord and roots is taken up, and tension in them rises ; the stretched cord is strongly applied against any spondylotic ridges or protrusion s which may be presenr. I )O Flexion of the cervical spine places tension on the lumbar and sacral nerve roots, as well as those of the cervi cal and thoracic re gion. l l 91 During rotation dorsal roots on the same side are stretched and ant erior roots relaxed, and opposite effects are produced on the other side. Latera l flexion, as would be expected, shortens the neural canal on the same side and lengthens it on the opposite side. The inextensible dentate ligaments ofrhe pia mater can, during neck move ments, exert undue traction on the spinal cord when r ela tionships have been disturbed by degenerative change. Microscopic studies s h ow that while the longitudinal neurones of the spinal cord are straight during f lexion, they assume a wavy course when the cord is relaxed during extension. DO On cervical flexion, extension and rotation, the spinal cord follows the shortes t route through the neural canal'" and consequently the form of the cord substan ce, its tracts and neurones and its blood vessels are modified by these tensions

, distortions and relaxations. A bony protrusion, thickened soft tissue or a ven tral neoplasm of the spinal cord will deftect the cord back wards as a flat bow, during cervical flexion. Further, a localised intramedullary haemorrhage, a glia l scar of demyelinating disease, intramedullary tumours and con nective-tissue sc ars from cord injury will force the sur rounding tissue into a spindle-shaped for mation. 1 2 1 The intensity of effect upon individual neurones increases with the size ofthe impinging structure and the degree of spinal cord tension. In a stud y of 42 unselected autopsy cases, Breig, Turn bull and Hassler (1 966)120 describ e deformations of the cord induced by flexion and extension movements in those It has been suggested that the dentate ligaments hold the cervical spinal cord a gainst the spondylotic ridges, 62b bur division of these ligamentous 'teeth' doe s not have any effect on minimising cord pressure against the ridges. 1 024 Cervical region Many authors have drawn attention to the discrepancy which may e xist between the severity of signs and symp toms in cervical spondylosis and cerv ical myelopathy, and the minor nature of protrusions into the canal, or lack of evidence of cord compression. Elucidations of the factors underlying the discrep ancy concentrate on the mechanical means whereby during certain movementS and po stures the cord may be forcedly compressed against any pro trusion present, and i ts free mobility hampered by nar-

APPLIED ANATOMY-GENERAL 59 with and without spondylosis. The spinal cord speci mens were grooved anteriorly where it has been pulled taut over t he spondylotic bars in 1 3 of the 17 prepar ations fixed in cervical flexion. The spinal cord became flattened with the A-P dimensions reduced. The flattening was fre quently bilateral, although unilateral in some. The authors observe that pressure on the anterior spinal artery or art eries during cervical flexion may inhibit blood flow past a spondylotic ridge du ring life. Little blood would flow through the capillary network when it had bee n flat tened by the stresses which flatten the cord opposite a spondylotic ridge during flexion. Nervous tissue is highly vulnerable to anoxia. Circulatory deple tion for around 1 0 minutes is enough to cause injury. Barre ( 1 924)" suggested that the myelopathy of cervical spondylosis was caused by ischaemia, noting tha t degenerative trespass upon radicular arteries would impair the blood supply of the cord. Freid, Doppman and Di Chiro ( 1970)'" studied the cervical cord blood supply in rhesus monkeys, and their findings indicated (a) that blood enters th e cervical spinal cord mainly from the radicular arteries, and (b) it is doubtfu l that the vertebral arteries provide its main blood supply. Gooding ( 1 974)'" draws attention to the fact that the myelopathic cord is seldom compressed when seen at operation, and even when compression is present, there is often a disapp ointing lack of clinical improvement when the compression is relieved. 1200 In less than half of the patients with this condition does the level of the neur ological abnormality correspond to the radiological levels of the bony lesions. I I Z uncommonly seen at operation and can be experimentally produced by trauma. In do gs, experimentally induced moderate cervical cord compression and ischaemia com b ined, produced more severe loss of vascular autoregula tion, and more severe myel opathy, than either mechanism alone.425 In summary of the author's comments, deg enerative change appears to remain the culprit, and possibly in the forms of spo ndylosis of the vertebral interbody joints IOgether with fibrosis of the meninge al lamella of the root sleeve. Whether cervical flexion, by exerting tension on the contents of the intervertebral foramen, or cervical extension, by approximat ing the margins of the foramen, be the more potent movement or posture exacerbat ing the condition is probably a factor varying between individual patients, but cervical flexion would appear to be the posture responsible for the two-fold eff ects postulated above. The probability that cervical myelopathy may be due to th e combination of compressive and ischaemic factors is supported by the experimen tal findings of Hoff et al. ( 1 977)'" who discuss the multifactorial nature of the pathological changes. When the cord is relaxed, the cord tracts and neurones are no longer subjected to pressure and distortion, and in a variety of neurolo gical disorders a striking reduction, and even abolition, of symptoms can be ach ieved by surgi cal immobilisation of the cervical spine in a position of slght ex tension. I Z l a i Cervicothoracic region Nathan ( 1 970)"" observed that in a majority (76 per cen t) of cases a variable number of spinal roots, more usually in the lower cervica l and upper thoracic segments, fol lowed an angulated course. Within the dura, th e rootlets proceeded downwards for a variable distance and on piercing the dura were sharply angulated upwards to reach the portal of the intervertebral foramen . Since the extra foraminal course is again downwards, a handful of spinal roots (commonly occupying a j unctional vertebral region prone to trespass by thickene d degenerative tissues) have undergone two fairly marked angulations by the time of their emergence from the foramen. The degree of angula tions may be as much a s 30 and can reach 45 (Fig. 2 . 1 4). Irregular and uneven development at the dura l sac has been considered as the possible cause of these angulations which may, of course, be further distOrted by degenerative changes, particularly dural teth ering within the neural canal and root-sleeve tethering at the foramen. The root s affected are those between C6 and T9, with T2 and T3 most frequently and sever

ely angulated. The angulations are increased when the neck is extended. Thoracic spine Reid ( 1 960)'024 refers to the natural elasticity of the cord There is the paradox of ischaemic myelopathy without an obvious vascular lesion. Spondylotic trespass is plain, compressive dis[Qrtion of the cord's normal conf iguration on neck flexion is plain and local interference with its vascularity i s plain. Pathological studies of spinal cord lesions656 support the view that lo cal ischaemia is the final step in pathogenesis of spinal myelopathy. l zo Yet a theroma of the spinal cord vessels, even in severe myelopathy, is very rare ; 70 4 also, Breig observed that no occluded radicu lar artery had ever been demonstra ted postmortem in cases of cervical myelopathy. Gooding4Z5 comments that the rad icular arteries form an important part of the cord's arterial supply184 and men t ions that since they traverse the IVF they are almost always involved in fibroti c change of the dural and arach noid ostia of the root (Frykholm's root sleeve fi brosis, p. 102), associated with degenerative change. He observed that irritatio n of these vessels by trespass upon the fora mina by degenerative tissue, produci ng segmental vascular spasm of the pia mater arterial network, combined with mod erate cervical-cord compression, may be the twofold mechanism underlying the pro duction of myelopathy. Arterial spasm of the radicular and pial vessels is not

60 COMMON VERTEBRAL JOINT PROBLEMS and the dura, describing the degree of dorsal lift in the cadaver when the spina l canal is unroofed, but not specify ing the degree of longitudinal distraction o bserved upon experimentally applied tension to a portion of it. Dorsal movement by free lifting, of about 1 cm, was found at the TS level in about one-third of the cases, although in others the dura seemed rather tight; in the aged, especia lly, the entire dura appeared crinkled and slack. He studied cord and dura movem ent in 1 8 necropsy cases with spines nor mal for their ages, i.e. I I males and 7 females between I S-S7 years, with an age average of 37 years. At all levels o f roots C8 to TS, for example, movement took place both in flexion and extension with a total range of move ment of up to 1 .8 cm. It was not infrequent for the cervical dura to be quite taut in flexion, while that in the thoracic region was still loose and wrinkled, probably due to connective-tissue tethering and to a lesser extent the tethering effect of nerve roots. There were some differences b etween individuals. The amount of stretching was much less in the thoracic spine than in the neck, and the degree of compression against the anterior wall of th e spinal canal varied in dif ferent areas. He reports that the amount of movement in man appears to be more cephalically, and most over the lowest cervical and u pper three thoracic vertebrae, i.e. movements are minimal at the CS root and gre atest at ca TS approximately, and stretch is greatest between roots C2 and T I . Should thoracic stretch be prevented or modi fied by fixation of dura to disc pro trusions, then the full effect of flexion must be borne by such length of cord a s is isolated above the area with adhesions. Average amplitudes during the total flexion-extension movement were as follows : Root level C5 C6 C8 TI T3 T5 TIO and broader. A slight posterior disc protrusion is evident at all lumbar segment s, and the ligamentum flavum becomes slack and its cross-sectional area increase s as the dimensions of the intervertebral foramen are reduced. The available spa ce in the canal may be reduced to critical dimensions, this factor being more pr onounced if a degree of developmental stenosis is present, together with acquire d stenosis in the form of degenerative trespass by thickened sclerous and soft t issue. On flexion, the length ofthe posterior wall of the l umbar canal increase s by about 25 per cent, the vertebral canal lengthening by up to 7 cm. 59). 4)4 Meningeal tissue is un able to stretch that much, hence the need for the cord and its coverings to possess a degree of anteroposterior mobility and the roots to move in and out of the foramina to a degree. In the cadaver, full flexion exerts traction on the dural sac, so that the roots are perforce drawn into the inter v ertebral foramen for varying distances, i.e. : LI and L2 roots L3 root L4 root b etween 2-S mm less than 2 mm negligible movement4J4 Two points should be noted: No. o obserfJaricm f 3 Average (mm) 3.3 9.0 12.7 6.6 2.3 3 3 3 N.B. Reference should be made to the full data W24 The author observes that any discussion of root direc tion, whether based on radiological, surgical or patholo gi cal examination, must at the same time specify the position of the head and ne ck relative to the trunk. Lumbar region Sagittal and coronal plane movements of the lumbar spine exert bro

adly similar effects to those in the cervical spine, on the cauda equina, but ro tation movements can have little effect since they are much more limited. Breig' s ( 1 960) ' " studies of the cadaver indicated that on extension from flexion t he lumbar intervertebral canal shortens and the neural contents also become s ho rtened 1 . Movements imposed upon the cadaver may not have the same mechanical effect o n a living patient: a. bending forward from the neutral standing posi tion b. sit ting with legs dangling over the plinth edge while one knee is passively extende d. c. sitting on a horizontal surface with legs extended and then reaching forwa rd to the toes. 2. The straight-leg-raising test does not induce the same mechan ical disturbance of the dura and nerve roots as does lumbar flexion ; one essent ial difference is that in flexion, during clinical examination, the lumbar spine is bearing weight 2 one developed the acute tra umatic cervical syndrome after a fall in a shower. The inflammatory reaction to injury includes space occupying oedema, and if this persists and becomes in durate d, fibrotic hyperplasia of connective tissue adds to the chronic trespass upon n erve roots, arteries, veins and lymphatics, besides interfering with the normal free

COMMON PATTERNS OF CLINICAL PRESENTATION 223 adaptation of cervical soft tissues to functional movements and postures of the neck. Bleeding, between normally mobile planes of delicate intraspinal and extra spinal soft tissues, tends to become organised and to add to tethering effects b y adhesions. Tearing or auenuation of ligaments and capsules, accompanied later by patchy areas of firm fibrosis, may eventually produce a residual pattern of c hronic stiffness and instability in adjacent segments. Because of the chronic di sturbance of normal tjssue fluid exchange in collagenous structures and muscles, the normal biochemical environment of nociceptor and mechanoreceptor endings is almost certainly disturbed, adding chronic irritative effects to nociceptor endi ngs besides upset to the important afferent traffic from joint and muscle recept ors, upon which equilibration depends. Stoddard ( 1 969)"0" observes that pure f lexion/exten sion injuries do not normally involve the facet-joints, and that the re needs to be some element of side-bending and/ or rotation to involve the caps ules of these joints. A glance at the posterior surface of neural arches at C6, C7, T I and T2 indicates that forcible extension (of a flexible structure carryi ng a 3.5--4.5 kg weight, i.e. the head) will violently engage the lower edges of the inferior facets on the narrow horizontal bony ledge marking the base of the superior facets below. A multiple acute traumatic periostitis at facet-joint ma rgins is probably one of the family of lesions sustained in a severe extension-a cceleration injury. Stoddard also regards a tear of the anterior longitudinal li gamcnt to be more important than posterior ligamentous tcars, partly because the y are sometimes undetected but also because these ligaments provide the only ant erior support for cervical vertebral bodies. The upset to delicately balanced fu nctions is briefly dis cussed on page 183. Depending upon the nature and magnitud e of the vio lence applied, these cases present with one or more of the following : Suboccipital, neck and yoke area pains, unilaterally or bilaterally, with bout s of frontal headache which may be periodic and transient or remain as a dull an d constant background ache Facial and anterolateral throat pain Patches of subje ctive facial numbness Otalgia Retro-orbital pain-sometimes paraesthesiae 'in' th e eye Subjective laryngeal disturbances, with compulsive clear ing of the lhroal Upper pectoral area and axillary pain Feelings of instability or dysequilibrium, wim sometimes a tendency to list to one side Disturbances of hearing and/or vis ion Depression, and feelings of fatigue A belief that they are becoming neurotic and 'should pull themselves together.' Irritability, insomnia and l ight-headedness. They tend to move the neck cautiou sly and apprehen sively, and are glad to return to a neutral position in which th ey feel most comfortable. Bilateral muscle spasm is common, and is not always su perficial. Referred pain, without neurological signs, tend to spread to upper li mbs, and paraesthesiae with sub jective numbness begin to occur in the arm, eithe r with a patchy and changing distribution, or distally and more or less confined to the territory of a s ingle root, with later objective numbness. Roca ( 1 972 ) 1 0" described 1 5 patients with oc ular mani festations after whiplash injury, mentioning that blurred vision, strain, fatigue, diplopia, photophobia and inab ility to read may occur, with anxiety and a degree of depres sion soon to follow. Among the clinical features were in cluded amaurotic episodes, decreased accommo dation and convergence, anisocoria, possible vitreous detachment, hyperphoria, h ypertropia, ptosis and inability to focus. N.B. The most important clinical aspe ct is lhat of a highly reactive 'brittleness' of condition during the early stag es. It is quite different to the irritability of a single peripheral joint, for example, where unwisely energetic handling may stir up severe pain for hours or days. If the badly injured whiplash patient is handled vigorously with careless movement, the exacerbation can be very severe, with headache of hideous intensit y, bizarre vis ual upset, psychic distress amounting to abject misery, and cervi cal pain offrighrening viciousness. The 'brittle' stage may last for a week or f or two to three months, and may return for a few days during the following month

s if the patient stumbles, is badly jolted or is given unnecessarily vigorous tr eatment. A retrospective analysis 9 of 146 patients, after 5 years , indicated that there was a statistically significant correla tion between poor treatment result s and the following findings soon after injury: Numbness or pain, or both, in an upper limb A sharp reversal of cervical lordosis visible on X-ray Restricted mo tion at one segment on 'bending' films The need for a collar for more than three monlhs The need to resume physiotherapy more than once be cause of a recurrence of symptoms. CERVICAL SPONDYLOSIS The lower cervical region is especially prone to spondylosis (see pp. 1 26, 205) , radiographicall y evident in the majority of middle-aged people and certainly symptomless in many (Figs. 5. 2, 5.5, 6. 1 , 6. 2, 6. 3, 6.4).

224 COMMON VERTEBRAL JOINT PROBLEMS Frykholm ( 1 9 7 1 )'" mentions the consequences of a painful condition which need affect only one of the many neck joints j spa sm of neck muscles and a significant impairment of normal mobility may occur. A similar effect is produced by trauma, which may affect one or several of the joi nts and their ligaments. Pain and muscle spasm initiate vascular spasm, causing addilional pain. In those cases with some spondylosis existing, or with structur al anomalies predisposing certain segments to nerve root trespass, there is alwa ys the risk of radicular irritation. Nathan ( 1 970)90' observed that in a major ity (76 per cent) of cases a variable number of spinal rootS, more usu ally in th e lower cervical and upper thoracic segments, fol lowed an angulated course. With in the dura, the rootlets proceed downwards for a variable distance and on pierc ing the d ura were sharply angulatcd upwards to reach the portal of the interver tebral foramen. Since the extra foraminal course is again downwards, a handful of spinal roots (commonly occupying a junctional vertebral region prone to trespas s by thickened degenerative tissues) have undergone two fairly marked angulation s by the time of their emergence from the foramen. The degree of angula lions may be as much as 30 and can reach 45 . Irregular and uneven development at the dur al sac has been con sidered as the possible cause of these angulations which may, of course, be further distorted by degenerative changes, particularly dural tet hering within the neural canal and root-sleeve tethering at the foramen. The roo ts affected are those between C6 and T9, with T2 and T3 most frequently and seve rely angulated. The angularions are increased when lhe neck is extended. The pre viously silent progression of degenerative change may be stirred up by some slig ht trauma or stress, or the onset is insidious. The causative stress may be an u nusually long car journey, decorating a ceiling, hanging curtains, horseplay wit h children or a night in an un comfortable hotel bed. Frequently the stress is tr ivial, such as minor trauma to the head, neck or arm, e.g. the tugging of a dog on a lead, or an hour's reading, knitting or sewing with the head bent forward. Commonly, the epi sode begins as vague neck pain and slight stiffness, with pain later spreading from the base of the neck to upper trapezius and upper scapular areas, over the deltoid and down the lateral or posterolateral arm on the same s ide. It may begin as an upper scapular region ache, and arm pain may also involv e the posterior axillary boundary, sometimes involving the upper pectoral area. The dull aching pain is commonly unilateral but can be bilateral and is aggravat ed by movement of the neck towards the mOSt painful side, as well as by extensio n andl or flexion. Movement of the shoulder on the same side is slightly limited and often hurts ncar the extreme of range j this sign may be missed during curs ory examina tion. Patients often report pain along the lateral forearm Because of the complex anatomy and biomechanics of neck structures, the whole sy stem is vulnerable. A simple experiment which will give an idea of the stresses imposed on the neck in a working day is to grasp a 3.54.5 kg weight in the hand, resting the elbow on a table with the forearm vertically under the weight. Twis t the fore arm, lower the weight a little to one side or another, raise it again ; continue this for two minutes. The weight represents a head, and the wrist rep resents a neck. The cervical vertebrae with associated ligaments and muscles are stronger than similar structures of the wrist, of course, but this simple exper iment will give a good idea of why they need to be, and of the work they arc doi ng. Should the vertical forearm now be given an unexpected and forceful lateral push, the experimenter has experienced something like the stresses imposed durin g an acceleration or deceleration (whiplash) injury to the neck. Cervical spondy losis, so often the late retribution (see p. 75) exacted by cervical structures in response to physi cal stress, seems less a precise diagnosis than a statement drawing anention to the coexistence of head, neck, yoke and arm pain, in the pre sence of some loss of normal neck movement, sometimes with upper limb neurologic al ab normality and frequendy some radiographic change in the lower cervical regi on. None of the the four factors need have any frank relationship to the other t hree ; they may or may not be clinically associated in the great variety of pres

entation of neck pain considered to be due to spondy losis of the lower cervical spine. Myelopathy is discussed below.) The diagnosis may also include patients w ith associated peripheral changes in the upper limb ; these may go by proper nam es such as periarthritis, bicipital tendinitis, lateral epicondylitis and medial epicondylitis, etc."" (See pp. 1 1 6, 187). The radiological appearance of comp ression of a cervi cal articular process is a not uncommon finding, even though s ome patients may not be able to recall a recent traumatic incident. When its nat ure can be ascertained or strongly suspected, the trauma is usually a combinatio n of hyperextension with compression injury j Smith el al. (I 97 6)1 I"6suggests that attention to this possibility is war ranted when patients report persistent neck pain. The forms of presentation are many j cervical spon dylosis embraces c hanges of multiple genesis. They may in clude changes masquerading as cervical wh en the upper thoracic region, or more distal tissues, may largely be re sponsible for the clinical features. For example, paraesthesiae which are worse at night, and nOt provoked by neck movements, may be caused by first thoracic root compre ssion or by median nerve im pingement in the carpal tunnel ither may occur in assoc iation with cervical spondylosis 1 )70 and can be diffi cult to separate clinical ly, although electrodiagnosis will assist in detecting carpal tunnel compression .

COMMON PATTERNS OF CLINICAL PRESENTATION muscles on functional movements involvi ng wrist exten sion or wrist flexion (see p. 188). The pain and/or re stricted nec k movements may wax and wane over a period of weeks or months, to reappear some months later and trouble the patient more severely, or then to regress for years . Paraesthesiae may develop, for example, in the thumb and index finger (C6 root ), the middle three digi