Disorders of the Cervical Spine covers the advances in diagnostic imaging and surgical techniques for cervical spine disorders since the publication of the first edition in 1980. This book is organized into 11 chapters. The first chapter describes the anatomy of the cervical spine. This is followed by a discussion of the different cervical spine disorders including osteomyelitis, soft tissue injuries, cervical spondylosis, tumors, congenital malformations and deformities, and fractures and dislocations. There are also chapters on diagnostic imaging of the spine, cervical orthoses, and an evaluation of different approaches to cervical spine surgery. This book will be invaluable to people interested in understanding the diagnosis and management of cervical spine disorders.
Front Cover 1
Disorders of the Cervical Spine 4
Copyright Page 5
Table of Contents 6
Contributors 8
Preface 10
Preface to the first edition 11
Acknowledgements 12
Chapter 1. Applied anatomy 14
Introduction 14
Surface anatomy 14
The cervical vertebrae 15
The joints of the cervical spine 18
The ligaments of the cervical spine 18
Movements of the cervical spine 20
Stability and instability 22
The cervical fascia 23
The spinal cord and its meninges 23
The blood vessels of the cervical spine 25
Structures supplied in the cervical spine (the extraspinal blood supply of the cord) 28
The intrinsic blood supply of the spinal cord 29
The venous drainage of the cervical spine 29
Changes in the cervical spine due to normal ageing 29
References 30
Chapter 2. Diagnostic imaging of the cervical spine 32
Standard radiography 32
Computed tomography 34
Magnetic resonance 34
Radioisotope scanning 36
Atlanto-axial region 37
Lower cervical spine 39
Cervical myelography 46
Provocative radiology 48
Cervical discography 48
Cervical facet injections 51
Vertebral angiography 51
Conclusion 51
References 51
Chapter 3. Congenital malformations and deformities of the cervical spine 54
Development of the cervical spine 54
Classification of bony anomalies of the cervical spine 55
References 64
Chapter 4. Fractures and dislocations of the neck 67
Introduction 67
Epidemiology 67
Prevention 68
First aid 69
Mechanisms of injury 69
Process of repair 74
Clinical features 75
General examination 75
Observations on the neurological picture 77
Radiography 78
Radiological classification 80
Treatment 85
Treatment of spinal cord injuries 88
Treatment of spinal column injury 90
Conclusion 101
References 101
Chapter 5. Cervical orthoses 107
Which orthosis - the customer's choice 107
The halo vest 108
Minerva and her plaster 108
Conclusion 116
References 117
Chapter 6. Soft tissue injuries 118
Introduction 118
Acceleration extension injuries 119
Acceleration extension injuries in cervical spondylosis 122
Tetraplegia without bony damage 123
Acceleration flexion injuries 123
References 124
Chapter 7. Cervical spondylosis 126
Introduction 126
The structural changes associated with ageing 126
The sagittal diameter of the spinal canal 128
Blood supply 128
Trauma 129
The clinical syndromes associated with cervical spondylosis 129
References 136
Chapter 8. The cervical spine in rheumatic disease 139
Morbid anatomy 139
Diagnostic imaging of the rheumatoid cervical spine 140
The natural history of rheumatoid arthritis 141
Management 142
The cervical spine in ankylosing spondylitis 143
Other seronegative spondylarthropothies 147
References 147
Chapter 9. Osteomyelitis of the cervical spine 150
Pathology 151
Diagnosis 151
Clinical features 152
Laboratory investigations 152
Radiography 152
Isolation of the organism 154
Management 154
References 155
Chapter 10. Tumours of the cervical spine 157
Introduction 157
Pathology 157
Clinical presentation 159
Investigations 160
Myelography 161
Computed axial tomography (CT scanning) 161
Magnetic resonance imaging (MRI) 161
Haematological studies 161
Biopsy 161
Management 161
Benign tumours 161
Malignant tumours 161
References 163
Chapter 11. Surgical approaches to the cervical spine 165
Introduction 165
Consent 166
Anaesthesia 167
Anterior approach C3/4-C7 168
Position 168
Incision 168
Posterior exposure occiput-C1 168
Position 169
Incision 169
Lateral approach 169
Lateral and anterior exposure of C2-4 169
The lateral masses of C5-7 169
Junctional areas 170
Transoral approach 170
Disc excision (anterior) 170
Vertebrectomy 170
Ligamentum flavum excision-laminotomy/laminectomy 171
Foraminotomy 172
Bone grafting 172
Fixation devices 173
Summary 174
Further reading 174
Index 175
Applied anatomy
Publisher Summary
This chapter provides an overview of the anatomy of the cervical spine. The cervical spine conveys vital structures from and to the head and trunk. It enables the head to be placed in a position to receive from the environment all information other than that provided by touch. The chapter also discusses surface anatomy of the cervical spine, the cervical vertebrae, the joints and ligaments of the cervical spine, and movements of the cervical spine. Stability of the cervical spine can be defined as the maintenance of vertebral alignment throughout the normal range of movement. Its instability is the loss of this ability, allowing vertebral displacement. The factors contributing to the stability of the cervical spine at all levels are bony, ligamentous, and muscular. The chapter describes the cervical fascia, the spinal cord and its meninges, the blood vessels of the cervical spine, the venous drainage of the cervical spine, and changes in the cervical spine because of normal ageing.
‘Was common clay ta’en from the common earth, Moulded by God, and tempered with the tears Of angels to the perfect shape of man.’
‘To -’ Tennyson 1851.
Introduction
The cervical spine conveys vital structures from and to the head and trunk. It enables the head to be placed in a position to receive from the environment all information other than that provided by touch. We need to know as much as possible about these structures, about movement of the head relative to the neck, and the neck relative to the trunk; disorders of the cervical spine will affect one or other of these things.
Surface anatomy
Many of the important structures of the neck can be seen and felt in the thin patient. Less is apparent in the obese, pyknic individual with a short neck, but certain landmarks can always be found.
The sternomastoid muscle, running from one corner to the other of a quadrilateral area, formed by the anterior midline, the clavicle, the leading edge of the trapezius and the mastoid—mandibular line, divides the side of the neck into anterior and posterior triangles (Figure 1.1).
Figure 1.1 Muscular triangles of the neck.
The posterior triangle contains little which is visible on inspection. Palpation of the base of the triangle (which is really a pyramid) finds the first rib, crossed by the subclavian artery, the lower trunks of the brachial plexus and perhaps a cervical rib or its fibrous prolongation. Higher, the accessory nerve, running forwards to the sternomastoid, divides the triangle into an upper ‘safe’, and a lower ‘dangerous’ area (Grant, 1951).
There is more to be seen, and felt, in the anterior triangle. The external jugular vein, and the platysma, cross the sternomastoid; and both stand out in the thin singer. The ‘Adam’s apple’* moves with swallowing, and the pulsation of the carotids is often visible. Below the body of the hyoid, the neurovascular bundle can be compressed against the carotid tubercle of the sixth vertebra; demonstrating how easily accessible is the spine through this area. In the apex of the triangle, the transverse process of the atlas is palpable immediately behind the internal carotid artery; and the fingertip can roll over the tip of the styloid process and the stylohyoid ligament. In the anterior midline can be usually seen, and always felt, the anterior arch of the hyoid, the notch of the thyroid cartilage, the cricoid and the upper rings of the trachea. With advancing age, the horizontal creases in the skin become more pronounced. Whenever possible, operative incisions should occupy one of these creases, in the interests of healing, if not beauty.
The vertebra prominens, which may be the spinous process of the seventh cervical or the first thoracic vertebra, marks the lower end of the midline sulcus formed by the ligamentum nuchae in its leap to the occiput. The rounded ridge on either side of the sulcus is made by splenius capitis as the origin of trapezius is tendinous. The vertebra prominens is the tip of the ‘dowager hump’ seen in women with osteoporosis.
The cervical vertebrae
The atlas
The atlas has no body (Figure 1.2). The anterior arch is faceted to receive the tip of the odontoid process, and the medial aspect of each articular mass is indented by the attachment of the transverse band of the cruciate ligament. The spinal canal at this level is spacious. Its sagittal diameter may be divided into three; the anterior third being occupied by the odontoid peg; the middle third by the cord; and the posterior third by the subarachnoid space. Cisternal puncture by the posterior or lateral route is therefore safe under normal conditions.
Figure 1.2 Atlas. Superior aspect.
The oblique groove across the posterior arch of the atlas accommodates the vertebral artery after it has wound around the outside of the articular mass. The attachment of the posterior atlanto-occipital membrane is arched over the artery at this point, and this arch is sometimes outlined, completely or incompletely, by bone, to form the arcuate foramen. This bony arch is insignificant; but it has been said that its presence renders the atheromatous vertebral artery more vulnerable to compression during rotation of the head (Klausberger and Samec, 1975).
The side-to-side width of the atlas is greater than that of any other cervical vertebra, to increase the leverage of the muscles inserted into the transverse process. This transverse process is the only one in the cervical spine which is not grooved to allow egress of a nerve root. The articular masses are broader and deeper than any other because they shoulder the weight of the skull and because the odontoid process bears no weight.
The axis
The axis has stolen the body of the atlas (Figure 1.3) to form the odontoid peg which projects up from its centrum to lie behind the arch of the atlas. The tip of the odontoid is faceted in front to mate with its atlantic fellow, and behind to accommodate the synovial bursa which separates it from the transverse band of the cruciate ligament. On either side of the base of the odontoid, the centrum presents the inferior facets of the atlanto-axial joints. Below, the atlas begins to take on the characteristics of a typical cervical vertebra. Its laminae meet to project a bifid and massive spinous process whose depth and aquiline profile are very variable. The pedicles are thick and their upper margins continuous with that of the body. The inferior articular facet lies below and behind the superior, and subtends an angle of almost 90° with the transverse process. This articulotransverse angle is recessed at its apex to accommodate the tip of the pyramidal process of the third vertebra (Veleanu, 1975).
Figure 1.3 Axis. Lateral aspect.
Vertebrae three to six are so similar that it is not easy, or necessary, to identify an individual bone (Figure 1.4). In the articulated column they increase in size from above downwards. The margins of the bodies are sharply defined, particularly around the superior rim where the posterolateral edge projects upwards to articulate with the body above. Gray does not give this projecting edge a discrete name (Gray’s Anatomy, 1969), but Frazer calls it the neurocentral lip (Frazer, 1958), and European anatomists refer to it variously as the unciform or uncinate process, or the semilunate process. It is a structure of sufficient identity to deserve a name, and it is a significant structure in the pathology of cervical spondylosis. In this book it will be referred to as the neurocentral lip. The antero-inferior margin of the body projects downwards. This normal epinasty increases with the development of spondylotic osteophytes, a point to be remembered during discography and anterior interbody fusion.
Figure 1.4 Typical cervical vertebra. Superior aspect.
The spinal canal is large to accommodate the cervical enlargement of the cord. The laminae are slender, and in youth each slightly overlaps the one below. This overlap increases markedly with age.
The pedicles, apophyseal joints, transverse processes and neurocentral lips are peculiar and specific to the cervical spine (Figure 1.5). Together they constitute the boundaries of the intervertebral foramen and enclose the foramen transversarium. This foramen, which affords passage to the vertebral artery, separates the costotransverse bar from the pedicle. The groove which forms the floor and walls of the intervertebral foramen, becomes progressively more shallow as the vertebrae descend. Medial to the vertebral artery the groove is floored by the pedicle. Here lie the anterior root of the spinal nerve and the posterior root ganglion; the former usually, though not invariably, above the latter (Abdullah, 1958). Running above the nerve root are the radicular and spinal branches of the vertebral artery, and their accompanying veins. Tapering into the groove are the blending layers of the meninges and the nerve sheaths forming the dural root sleeve.
Figure 1.5 Relations in...
Erscheint lt. Verlag | 22.10.2013 |
---|---|
Sprache | englisch |
Themenwelt | Medizin / Pharmazie ► Allgemeines / Lexika |
ISBN-10 | 1-4831-9381-0 / 1483193810 |
ISBN-13 | 978-1-4831-9381-6 / 9781483193816 |
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