Cervical region
Cervical
spine due to its position, complex structure and great mobility is vulnerable
to injuries. It is a complex and vital region. Vital knowledge of cervical region
is essential for physician, while dealing with the patients having the problems
of cervical region.
Components
of the structure of cervical spine:
1. Bony Structure
The cervical spine is composed of first seven vertebrae
of the vertebral column. The seven cervical vertebrae are the smallest movable
vertebrae and identifiable by their transverse processes, which are perforated
by a foramen
a. Typical cervical vertebrae- 2nd to 6th cervical vertebrae:
b. The atlas – first cervical vertebra (C1)
c. The axis – Second Cervical Vertebra (C2)
d. The seventh Cervical Vertebra (C7)
e.
2. Musculature
The muscles of the neck are grouped according to their
position. These groups are
as follows
a. Superficial and Lateral cervical muscles
b. Anterior Vertebral muscles
c. Lateral Vertebral muscles
d. Deep muscles of the back of the neck
e. Sub – occipital muscles
3.
Articulations
(A)
Intervertebral articulations – It is divided into two parts.
a. Articulations of vertebral bodies
b. Articulations of vertebral arches.
(B)
Articulation of vertebral column with cranium:
The articulation of vertebral column with cranium
involves the paired atlanto-occipital joints and ligaments connecting the axis
and occipital bone.
4. Neural and Vascular
contents.
Cervical Spondylosis
Definition:
Cervical
spondylosis is a degenerative condition of the cervical spine. There is degeneration
of inter-vertebral disc, with its protrusion and bony overgrowth of adjacent vertebrae
causing compression of roots, cord or both. Occasionally it is associated with non-compressive
myelopathy consequent to vascular degeneration.
Pathogenesis:
This is
compound effect of the following processes:
a. The
initial change is a decrease in the water content of the nucleus pulposus, the
central
portion of the disc. As the disc dehydrates, it decreases in height and has
less ability
to resist loading and stress,
Disc
degeneration leading to its thinning and protrusion of the nucleus
pulposus
posteriorly or herniation through fear in the fibrous annuloses laterally;
posterior
herniation tends to produce compression of the spinal cord and lateral
bulging
produces compression of roots.
b.
Osteophytic spur formation on the posterior aspect of the vertebral body
leading
to the
‘spondylotic bar’, which is the core pathology resulting in a horizontal
compression
of the anterior aspect of the cord. Osteophytic extension of the bar,
laterally
associated with articulatory hypertrophic changes or encroachment of the
intervertebral
neural foramina by osteophytes developing from the rim of the
foramina,
often cause additional entrapment radiculopathy. Anterior ostephytic
spur
formation is usually symptom less but occasionally produces dysphagia.
c. Partical
sublaxation of vertebrae causing impinging of osteophytes on the nerve
roots during
movement of the neck.
d.
Hypertrophy of the dorsal spinal ligament and dorsilateral facet articulation
or
bucking of
the dorsal spinal ligament particularly during extension of the neck.
All these
may cause further narrowing of the sagittal diameter of a spinal canal,
which might
have been congenitally narrow.
e.
Encroachment of the vertebral foramina where the vertebral artery is lodged
producing
compromise of the arterial lumen and significant vetebro – basilar
ischaemia,
leading to brainstem signs like vertigo, tinnitus, intermittent blurring
of vision
and occasionally episodes of retroocular pain. This apart, the
architectural
pattern of the vasculature of the cervical cord may further affect the
cord lesion
significantly.
f. Presence
of congenital spinal canal stenosis; although the radiographic findings of
spondylosis
are fairly common in the elderly, patients develop myelopathy or
radiculopathy
only if spondylotic changes are associated with congenitally narrow
canal or
foramina. If the shortest AP diameter is 13mm or greater, it is unlikely
that
spondylotic changes are the cause of cord compression.
CLINICAL FEATURES:
The symptoms are related to
(a) Spinal
symptoms – Neckpain, medial scapular pain and shoulder pain probably
originate in
the disc and spine.
(b) Root
compression (Radiculopahty) – The range of movement is reduced
particularly
during rotation and lateral movement of the head. Pain starts from the
trapezius
ridge (C4), tips of the shoulder (C5), anterior part of the arm (C6), radial
forearm
(C6), and often the thumb (C8) or all the fingers (C6, C7, C8).
The pain
worsens with movement of the neck, coughing or sneezing or straining.
The clinical
signs are motor weakness and wasting of proximal muscles or small
muscles of
the hand depending on the roots compressed. In addition, there is also
areflexia
and redicular sensory impairment. Sometimes L’hermitt’s sign or
‘barber’s
chair sign’ can be elicited; this consists of tingling in all four limbs or
electric
shock – like feelings down the back on flexing the neck. The roots most
often
affected are, in order, C6, C7, and C5, C6, C8 and D1 are infrequently
affected.
Occasionally, the shoulderhand syndrome or the so – called frozen
shoulder
ensues if symptoms are unattended for some time.
(c)
Compressive cervical myelopathy – This condition occurs less frequently than
root
syndromes. There is some evidence that the patient has to be predisposed to
compression
by a congenitally narrow canal (Cervical canal stenosis) and usually
presents
with a progressive spastic paraparesis; later, bladder and bowel
involvement
is added to sensory inpairment with a level.
(d) Combined
root and cord compression – In a few cases, clinical features of both
radiculopathy
and myelopathy are combined. In such a combined lesion occurring
at C5 level,
the C5 root is compressed by lateral protrusion and the cord below
this level
is compressed by medial lesion. The reflexes are asymmetrical, with
classically
abscent or decreased supinator and exaggerated triceps jerks;
occasionally
an inverted supinator jerk is elecited when on testing for supinator
response,
there is finger flexion in the absence of the normal supinator response,
indicating a
lesion of C5 with myelopathy below.
(e) Vascular
insufficiency – Some times a completely different category of symptoms
may occur,
viz. evidence of vertebro basilar insufficiency, this may be due to
permanent
narrowing or kinking of the vertebral artery due to inter-vertebral
foraminal
encroachment by ingrowing osteophytes from the bony wall of the
vertebral
canal; it may produce intermittent or perpetual vertigo. Neck movement
may initiate
or exacerbate vertigo by temporary compression of the vertebral
artery
leading to further insufficiency.
The other
symptoms like tinnitus, visual blurring, etc. have already been
referred
too. As discussed earlier, there may be a non compressive myelopathy
due to
compromised vasculature. In such cases, pain is usually absent and
myelography
fails to reveal any spinal block; this is sometimes referred to as
cervical
myelopathy (or cervical spondylotic myelopathy).
Nystagmus,
though rare, is sometimes seen and is probably due to
involvement of the posterior
longitudinal bundle in a high cervical lesion.
INVESTIGATION:
A plain
X-ray of the cervical spine is helpful. There is impairment of natural
cervical
lordosis, reduction of intervertebral spaces, osteophytic projection leading to
distortion
and encroachment of intervertebral foramina (in appropriate obligue view), and
shortening
of AP diameter of the cervical canal in few cases.
For
demonstration of compressive myelopathy, a contrast myelogram is
necessary.
It shows the presence of multiple disc protrusions as a negative indentation of
the contrast
column or total extradural obstruction. CT scan with or without contrast is
preferred if available. MRI is
another useful mode of invetigation.
Ayurvedic
texts, there are many other ailments, which are related to neck and
demonstrate
the similar symptoms. So it is worthy to have a look on these manifestations.
This will
help in differential doagnosis and also in justification to the paralance with
Griva
Hundanam.
Those
diseases are:
1. Manya
Stambha
2. Manya
Graha
3. Griva
Stambha
4. Asthi
Majja Gatavata
5.
Sandhigata Vata
6. Visvaci
7. Sirograha
Manya Stambha: As noted earlier in the description of Manya Stambha, its
aetiopathogenesis
has been
dealt in almost all the texts. Manya – Stambha, entity cannot be
considered
as cervical spondylosis because of its acute onset, and having no mention of
pain and is
described along with Antarayama and Bahirayama. It is also considered as
main symptom
of Apatanaka. In addition, at the last in this condition Jatru Vakrata
happens.
Whereas in cervical spondylosis is a slow process with pain and restriction of
the
movements are the main symptoms. Moreover, the Manya Stambha occurs due to the
involvement
of muscles whereas in cervical spondylosis, actual pathology lies in the
cervical
intervertebral discs. So, it cannot be correlated with cervical spondylosis.
Manyagraha & Griva Stambha: These two disorders
have been described as symptoms
of other
disease as well as separate entities. The meaning itself suggest that the
stiffness
of Griva
muscles may cause this entity whereas in cervical spondylosis other symptoms
are also
accompanied.
Siro or Sira Graha has also the different
aetio-pathogenesis. In which severe headache
may be
found. But due to absence of other symptoms, it cannot be considered as
cervical
spondylosis.
Asthimajjagata Vata: The symptoms of Asthimajjagata
Vata explained in the texts can
be found in
this condition and these symptoms are similar to some extent in comparison
to cervical
spondylosis. But, no justification can be given to the neurological symptoms
exhibited.
Even though these symptoms can be taken in to consideration up to the stage;
when nerve
root are not compressed. It can be considered as the later stage of
Asthimajjagata
Vata.
Sandhigata
Vata explained in the texts has quite resemblance with osteoarthritis
explained in
the modern texts. According to Ayurvedic description, i.e. painful flexion
and
extension are related to big joints and in this case no neurological symptom is
found.
Hence, this
cannot be taken as cervical spondylosis.
Visvaci is the disease in which vitiated Vayu affect the Kandara,
originated from the
finger and
palm of the hand and insert into the posterior side of Bahu, causes loss of
function of
the arm. This symptom can be found in the later stage of the cervical
spondylosis
but there is no mention of other symptoms. So, it cannot be considered as
cervical spondylosis.
Treatment Principle
Joints
in the neck are the seat of kapha.
It is a vata kapha
problem.
• Acute
<<<<<< >>>>> Chronic
·
The treatment management differs in
acute cervical prolapse and degeneration.
Acute
herniated cervical disc>>>>>>>>>>>>>>>>>>>>>>
Kaphaavrutha
vata>>>>>>>>Ashayapakarshya
gati
Chronic
degeneration>>>>>>>>>>>>>>Dhatukshaya
Treatment
in acute phase
Acute herniated cervical disc>>>>>>>>>>>>>>>>>>>>>>
Kaphaavrutha vata>>>>>>>>Ashayapakarshya gati
Lepam
· Apply the warm paste of Kottamchuckadi or Kolakulatthadi churnam with tamarind juice and little vinegar.
·
Apply twice daily .Keep it until it gets
dry and wipe it off with warm water.
·
Then do ruksha swedanm with kulattham for 20 minutes or until sweat appears.
·
Oil should not be applied for first few
days.
·
Rest position missing
Kashayam
·
Rasna sapthakam kashayam 20 ml before food
with warm 60 ml water twice a day.
·
Varunadi kashayam 20 ml before food with
warm 60 ml water twice a day.
Once the acute phase is over, thailam can be applied.
·
Kottamchuckadi tailam, prasaranyadi
tailam, murivenna and prabanjana tailam (all ushna veerya) are used externally.
·
Gandha tailam 1tsp with milk at bed
time.
·
Parinata kshiradi is used only when
pittanubanda vata is there.
1. It
is useful in sensory neuropathies and muscle wasting conditions.
2. It
is not effective in muscular pain and it will aggravate the pain also.
·
After sneha one can do dhanyamla sveda or kizhi. Then you can do nasya.
·
For nasyam
karpasastiyadi tailam is useful in both marsha and prati marsha forms.
·
Siro virechana ganam can also be used in
kapha related conditions. In Brmhana phase kshirabala is applied .Thalam is optional.
·
Based on Sutram “urdhwa jathru vikareshu nishi” gugguluthikthakam or mahasneham can be
given 15 ml slightly melted in half glass of milk at bedtime.
·
Aba guggulu 2 tablets twice a day after
food.
·
To strengthen the nerve roots
Asvagandarishtam or Balarishtam 25 ml can be given twice a day after food.
Cervical spondylosis with dominancy of pain:
·
Rasna saptakam 20ml BD before food with
warm water
·
Kottamchukkadi oil ext application
·
Chanda marutham 1 pinch with honey BD
after food
·
Aba guggulu 2 – 0 – 2 after food
Cervical spondylosis
with dizziness:
·
Vidaryadi kashayam 20ml BD before food with
warm water
·
Ksheerabala 1 tsp with kashayam
·
Sidardrakam 15ml bd after food
·
Maha kalyanaka gritham 1 tsp BD after
food
·
Kachoradi ksheera bala (for thalam).
Cervical
spondylosis with numbness:
Varunadi kashayam
20 ml BD before food
Rasonaadi vati 2 – 0 – 2 after food
Prabhanjana kuzhambu for external
application
Management
Wholesome
·
In cervical spondylosis, when acute
phase is over, patient can do exercise.
·
Patient is should be advised to sleep in
supine position with small pillow.
·
Computer operators are should be taught
by Ayurvedic people to do flexion, extension, and rotation once in every half
an hour for two – three times.
·
Bed rest is advised for seven days.
·
A smooth massage is recommended.
·
Lumbar traction is more useful in
clinical practice than cervical traction.
Unwholesome
·
While giving massage, pressure should
not be given.
·
Cervical neck traction aggravates
the problem.
·
All other physiotherapies are not much
useful
·
Keeping hand as pillows must be avoided.
·
Riding two wheelers must be reduced.
Please give your valuable suggestions ........
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