Cervical intervertebral disc degeneration and dizziness

Clinical studies have found that patients withcervical degenerative disease are usually accompanied by dizziness. Anterior cervical surgery can eliminate not only chronic neck pain, cervical radiculopathy or myelopathy, but also dizziness. Immunohistochemical studies show that a large number of mechanoreceptors, especially Ruffini corpuscles, are present in degenerated cervical discs. The available evidence suggests a key role of Ruffini corpuscles in the pathogenesis of dizziness caused by cervical degenerative disease (i.e. cervical discogenic dizziness). Disc degeneration is characterized by an elevation of inflammatory cytokines, which stimulates the mechanoreceptors in degenerated discs and results in peripheral sensitization. Abnormal cervical proprioceptive inputs from the mechanoreceptors are transmitted to the central nervous system, resulting in sensory mismatches with vestibular and visual information and leads to dizziness. In addition, neck pain caused by cervical disc degeneration can play a key role in cervical discogenic dizziness by increasing the sensitivity of muscle spindles. Like cervical discogenic pain, the diagnosis of cervical discogenic dizziness can be challenging and can be made only after other potential causes of dizziness have been ruled out. Conservative treatment is effective for the majority of patients. Existing basic and clinical studies have shown that cervical intervertebral disc degeneration can lead to dizziness.     

Dynamic response of the cervical spine to posteroanterior mobilisation

BACKGROUND: Posteroanterior mobilisation is a manual therapy technique that is commonly used in the examination and treatment of neck pain, but little is known about its biomechanical effect. The purpose of this study was to determine the intervertebral movements of the cervical spine produced by posteroanterior mobilisation. METHODS: The cervical spines of nineteen healthy subjects were scanned using an open interventional magnetic resonance imaging scanner. Posteroanterior mobilisation forces were applied to the fifth cervical vertebra whilst they were in the prone position. Sagittal images of the spine were obtained before and during mobilisation. FINDINGS: It was shown that posteroanterior mobilisation of the cervical spine generally produced extension of the upper motion segments and flexion of the lower segments. The middle segments were inconsistent in the direction of rotation. The cervical lordosis was found to increase with repeated PA loading cycles. INTERPRETATION: The magnitude of intervertebral movement produced by mobilisation is small. Forces applied at one spinous process produced not only movements at the target vertebra but also movements of the entire cervical spine resulting in an increase in lordosis. Mobilisation should be interpreted as three-point bending of the entire cervical spine, rather than simple gliding of one vertebra upon another.     

Use of Translatoric Mobilization in a Patient with Cervicogenic Dizziness and Motion Restriction: A Case Report

Abstract

Some physical therapists consider the report of dizziness at end-range cervical extension when coupled with side-bending and rotation to the same side (coupled lower cervical rotation in extension) to be a positive sign of vertebral artery compromise. However, degenerative changes and associated movement abnormalities in cervical motion segments may also produce dizziness. The use of mid-line translatoric joint mobilization in the presence of limited active cervical motion that is accompanied by dizziness during cervical extension, rotation, and coupled rotation in extension has not been addressed in the current literature. This case report describes the examination, evaluation, diagnosis, intervention, and outcomes for a 64-year-old woman who presented with limited cervical mobility and the complaint of dizziness during performance of these movements. Examination included a clinical differentiation process to determine the cause of the movement-related dizziness. Examination findings included increased translatoric joint play, tenderness, and reproduction of dizziness at the C4-C6 segments and decreased translatoric joint play at the C1-C4 and C7-T4 motion segments. Intervention included movement re-education and application of translatoric joint mobilization to the hypomobile segments. After 8 visits, there was complete resolution of dizziness during all active cervical movements and improved cervical mobility, as documented with the CROM. This case report demonstrates that clinical symptoms consistent with cervicogenic dizziness and limited cervical mobility may be treated safely and effectively using translatoric joint mobilization techniques. Confirmatory diagnostic ultrasound analysis of the vertebral artery revealed no compromise in flow velocity during the application of these translatoric mobilization techniques.     

In vivo intersegmental motion of the cervical spine using an inverse kinematics procedure

Background

The main functions of the cervical spine are the stabilization and the orientation of the head. Pathologies are complex and difficult to diagnose. The first sign of the dysfunction is an abnormal intervertebral motion. It is the purpose of this feasibility study to determine the intersegmental motions and loading conditions of the cervical spine in vivo with standard clinical investigation methods.

Methods

We propose a new approach which merges full flexion–extension X-ray images, and continuous motion of the whole cervical spine obtained with a tracking motion system. These data were used as input for a subject-specific rigid body model of the cervical spine computed with the software MSC.Adams. This model simulates the cervical spine extension/flexion, the intervertebral motions are deduced using an inverse kinematics procedure.

Findings

Subject-specific rigid body models were computed from data of two subjects. The intersegmental motion and loading conditions were calculated. We found that the loading amplitudes depended on the intervertebral level, and that subject specific patterns were highlighted. We noticed an unsymmetrical behavior in flexion and extension. Furthermore intervertebral rotations were correlated with the global motion of the cervical spine.

Interpretation

A subject-specific rigid body model merged data from classical flexion–extension radiographs and noninvasive external motion capture. Our approach is based on inverse kinematics allowing the estimation of the intervertebral motion and mechanical behavior of the cervical spine in vivo, which gives valuable information concerning biomechanics of the cervical spine in vivo for cervical spine clinical investigation.     

闭目原地踏步试验对头晕/眩晕患者病因筛查的诊断价值

目的：探讨闭目原地踏步试验对头晕/眩晕初步病因筛查的诊断价值。方法对564例头晕/眩晕患者采用原地闭目踏步试验、眼球震颤检测、Dix-Hallpike 试验,分析闭目原地踏步试验对头晕/眩晕病因初步筛查的诊断价值。结果本组患者闭目原地踏步试验发生倾倒72例(12.8%),其中合并眼球震颤68例(94.4%),诊断为：前庭周围病变59例,其他13例;偏向一侧310例(55.0%),其中合并眼球震颤43例,Dix-Hallpike 阳性102例,诊断为：位置性眩晕41例、前庭周围病变4例、复发性前庭病168例、椎基底动脉供血不足50例、精神性头晕26例、其他原因21例;踏步试验阴性182例(32.3%),Dix-Hallpike 阳性96例,诊断为：位置性眩晕94例、精神性头晕58例、椎基底动脉供血不足12例、复发性前庭病6例,其他12例。头晕/眩晕前庭周围病变、复发性前庭病、椎基底动脉供血不足患者闭目原地踏步试验多为阳性表现(χ2=34.97、58.18、16.20,P <0.01),而位置性眩晕、精神性头晕患者多为阴性表现(χ2=14.11、8.26,P<0.01)。结论闭目原地踏步试验结合眼球震颤、Dix-Hallpike 检查是快速筛查头晕/眩晕患者初步病因的有效方法。     

Acute neck pain: cervical spine range of motion and position sense prior to and after joint mobilization

Despite the relatively high prevalence of cervical spine pain, the efficacy of treatment procedures is limited. In the current study, range of motion and proprioception was assessed prior to and after specific cervical spine mobilisation techniques. A 44-year-old male office worker presented with a history of cervical pain of 1 day duration. He had woken with pain, stiffness and a loss of range of motion. Examination findings indicated pain to be at C5–6 on the left side. Measurement of maximal three-dimensional cervical motion was undertaken using a Zebris system. A position matching task tested the individual's ability to actively reposition their head and neck. The treatment undertaken involved grade III down-slope mobilisations on the left side at C5–6 and C6–7 in supine lying. This technique was then progressed by placing the subject in an upright sitting position, and sustained natural apophyseal glides were performed at C6.Immediately following the treatment, the patient reported a considerable decrease in pain, less difficulty in movement and reduced stiffness. Motion analyses showed the most marked percentage improvements in range of motion after treatment were in flexion (55%), extension (35%), left rotation (56%), and left lateral flexion (22%). Ipsilateral lateral flexion with axial rotation was also notably improved following treatment. No change in proprioceptive ability was found following the treatment. The findings showed that the application of standardised specific mobilisation techniques led to substantial improvements in the range of motion and the restitution of normal coupled motion.     

颈椎后前向松动产生的椎间运动和生物力学分析

目的:通过影像学研究颈椎后前向松动产生的椎间运动,分析其生物力学作用。方法:选取正常受试者12例,均采用多功能颈椎康复治疗仪给予后前向颈椎关节松动,力量为10～30N;松动前后,采用静态颈椎侧位片,比较运动节段矢状面的角度旋转及前后椎间隙变化。结果:松动后,C3～C6节段矢状面旋转角度均大于松动前(P<0.05);C3、C5节段前椎间隙均显著大于松动前(P<0.05),C5节段后椎间隙显著小于松动前(P<0.05)。结论:后前向松动明显增加C3～C7脊柱的前凸,在伸展同时椎体产生旋转,前椎间隙增宽,后椎间隙减小。     

Comparative studies of cervical spine anterior stabilization systems - Finite element analysis

BackgroundThe object of the study was to assess the impact of one-level stabilization of the cervical spine for both anterior static and dynamic plates. Segments C2–C6 of the cervical spine, were investigated, from which was determined the stress and strain fields in the region of implantation and adjacent motion segments. The purpose was the comparison of changes that affect the individual stabilizers.MethodsFor testing we used finite element analysis. The cervical spine model takes into account local spondylodesis. The study includes both an intact anatomical model and a model with implant stabilization.FindingsThe analysis covered the model loaded with a moment of force for 1 Nm in the sagittal plane during movement. We compared both the modeled response of the whole fragment C2–C6 and the response of individual motion segments. The largest limitation of range of motion occurred after implantation with static plates. The study also showed that the introduction of the one-level stabilization resulted in an increase in stress in intervertebral disc endplates of adjacent segments.InterpretationThe results indicate that the increase in stress caused by stiffening may result in disorders in remodeling of bone structures. The use of dynamic plates showed improved continuity strains in the tested spine, thereby causing remodeling most similar to the physiological state and reducing the stresses in adjacent segments     

颈椎过伸性脊髓损伤节段的相关性因素研究

目的 探讨颈椎过伸性损伤的退变性因素、损伤节段的分布及其原因.方法 温州医学院附属东阳医院89例颈椎过伸性损伤患者进行回顾性分析,统计颈椎退行性病变、T2WI相脊髓高信号的位置及颜面部外伤的位置.结果 间盘突出58例,居首位;其后依次为后纵韧带骨化(8例)、发育性椎管狭窄(7例)及椎间盘突出+黄韧带肥厚(6例).单节段T2WI相脊髓高信号在椎间盘水平:C2～3者4例,额部外伤1例;C3～4者12例,额部外伤10例,颧部外伤1例;CA～5者12例,额部外伤5例,额部+颧部外伤1例,额部+下颌部外伤1例;C5～6者11例,额部外伤3例,颧部外伤3例,下颌部外伤2例.单节段脊髓高信号位置不在椎间盘水平4例,脊髓高信号在两个不连续节段10例,脊髓高信号超过2个节段2例,脊髓高信号超过3个节段6例.结论 椎间盘突出是颈椎过伸性损伤患者最多见的退变性因素,T2WI相脊髓高信号的水平与额面部撞击的部位相关,拐点的剪切力(inflection point shear force)合并(或)颈椎过伸的前后挤压力是颈椎过伸性损伤的机制.     

X线侧位片判定颈椎损伤单侧关节突交锁

目的　通过X线侧位片判定颈椎损伤单侧关节突交锁 ,以提高对单侧关节突交锁的诊断率。方法　常规拍摄包括损伤节段上下至少两个椎体的X线侧位片。结果　在颈椎损伤单侧关节突交锁的病例中 ,由于交锁的椎体处于旋转状态 ,在侧位片上可以见到损伤节段上 (或下 )位的椎间孔。结论　X线侧位片可作为判定颈椎损伤单侧关节突交锁的最初筛选方法 ,再结合其他征象 (如斜位等 )可对单侧关节突交锁作出诊断。     

Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine

Passive intervertebral motion of the cervical spine was assessed independently by two physical therapists. The therapists had equal backgrounds concerning education and clinical experience. Sixty-one patients seeking care for cervical problems at a private clinic were included in the study where three segments of the cervical spine and the mobility of the first rib were graded as stiff or not stiff. Data were analysed by percentage agreement and kappa coefficient which indicates inter-examiner reliability greater than expected by chance. Results demonstrated inter-examiner reliability of between 70 and 87% and kappa coefficients ranging between 0.28 and 0.43 considered to be only 'fair to moderate'.     

颈椎矢状面序列与椎间盘退变以及临床疗效的相关性研究

目的 探究颈椎矢状面序列与椎间盘退变以及临床疗效的相关性.方法 回顾性选取2019年1月至2020年1月西南医科大学附属医院收治的脊髓型颈椎病(CSM)患者80例作为研究组,另随机选同期无症状成人志愿者80例作为对照组,均行颈椎磁共振成像(MRI)检查.比较两组一般资料、颈椎矢状面序列参数[C2～7 Cobb's角、T...     

羟基磷灰石/聚酰胺66颈椎融合器在颈椎间盘突出症前路手术重建中的临床疗效

目的探讨纳米羟基磷灰石/聚酰胺66（nano-hydroxyapatite polyamide66,n-HA/PA66）颈椎融合器在颈椎间盘突出症前路手术重建中的临床疗效。方法 2008年12月-2010年6月,对14例颈椎间盘突出症患者行前路椎间盘切除、椎管减压,以n-HA/PA66椎间融合器支撑植骨、钢板螺钉内固定治疗。随访时间3～12个月,平均6.3个月;随访时以日本矫形外科学会（Japan Orthopaedic Assoctiation,JOA）评分改善率评价患者神经功能恢复情况,复查X线片评估椎间融合器植骨融合情况,包括椎间高度及椎间融合器下沉情况。结果 14例患者均成功完成颈椎前路减压手术以及椎间融合器的安放固定。所有患者术前症状均得到不同程度的改善,术后3、6、12个月的JOA改善率分别为87.0%、94.0%、97.0%。影像学检查显示所有患者植骨融合,椎间高度及椎间融合器的位置维持良好,无下沉、移位。结论 n-HA/PA66颈椎间融合器具有早期支撑稳定功能,可有效维持颈椎椎间高度;术后植骨融合率高且便于X线片观察,是颈椎间盘突出症患者前路手术植骨的理想支撑材料,但长期效果需进一步随访观察。     

下段颈椎脊椎功能单位活动度与椎管狭窄程度间相关性分析

目的：探讨退变性下段颈椎的脊椎功能单位（FSU）活动度与相应节段椎管狭窄程度间相关性。资料与方法：随机选取拟行手术治疗的脊髓型颈椎病病人62例。全部拍摄MRI及动力位（过伸-过屈位）颈椎侧位CR片。测量参数包括C2~C7过伸/过屈位Cobb角和,反映颈椎整体活动度;选取C3~C4、C4~C5、C5~C6三个水平的颈椎FSU过伸/过屈位Cobb角和表示FSU的节段性活动度。依据椎管狭窄等级（Ⅰ、Ⅱ、Ⅲ级）,分别对该3个FSU活动度行统计学分析。结果：Ⅰ级椎管狭窄病人的C4~C5、C5~C6椎间活动度大于C3~C4水平,其中C4~C5、与C3~C4水平间显示统计学差异。C4~C5、椎间活动度在Ⅲ级椎管狭窄时显著降低,与Ⅰ级、Ⅱ级有统计学意义。8例未显示Ⅲ级椎管狭窄病人与54例Ⅲ级椎管狭窄病人的椎体整体活动度间差异无统计学意义。结论：颈椎FSU作为维持颈椎稳定性的基本单元,随着椎管狭窄程度的增加稳定性增加,但却以牺牲椎管空间为代价,出现椎管狭窄,联合应用动力位CR侧位片及MR检查在判定颈椎活动度与椎管狭窄程度间关系显示重要价值。     

Effects of Cervical Spine Manual Therapy on Range of Motion,Head Repositioning,and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

Objective

To evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.

Design

Randomized controlled trial with 12-week follow-up using blinded outcome assessment.

Setting

University School of Health Sciences.

Participants

Participants (N=86; mean age ± SD, 62.0±12.7y; 50% women) with chronic cervicogenic dizziness.

Interventions

Participants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.

Main Outcome Measures

Cervical ROM, head repositioning accuracy, and balance.

Results

SNAG therapy resulted in improved (P≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, −7.5°; 95% confidence interval [CI], −13° to −2.0°) and right rotation (mean difference, −6.8°; 95% CI, −11.5° to −2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy.

Conclusions

SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.     

Functional radiographic examination of the cervical spine in patients with post-traumatic headache

The segmental extension-flexion motion of the cervical spine and the overall C1-C7 motion were measured on functional X-rays in 19 patients with post-traumatic headache and 19 age- and sex-matched controls. The extension-flexion C1-C7 motion was reduced in patients with post-traumatic headache due to reduced motion in three segments: C2-C3, C5-C6 (p less than 0.05), and C6-C7 (p less than 0.01). In both groups a negative correlation between the C1-C7 motion and age was found, but the regression coefficients were different. Only in the control group could a negative correlation between segmental motion and age be demonstrated. In the patients with post-traumatic headache a statistically significant negative correlation between the log (pain index) and the age-corrected C1-C7 motion was found (p less than 0.04). On the segmental level a negative correlation between the log (pain index) and the age-corrected C1-C2 and C5-C6 motion could be demonstrated (p less than 0.05). Regarding C6-C7 there was a tendency to negative correlation. Furthermore, a negative correlation between the frequency of associated symptoms (dizziness, visual disturbances and ear symptoms) and the age-corrected C5-C6 motion was found. Consequently the decrement of motion primarily affected C2-C3, C5-C6, and C6-C7, whereas the analysis of correlation with pain index indicated C1-C2 and C5-C6 (C6-C7) as the most important segments involved.     

Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force

OBJECTIVE: To determine whether repeated motion with low magnitude joint forces, and flexion/extension moments consistently produce herniation in a non-degenerated, controlled porcine spine motion segment. DESIGN: Combined loading (flexion/extension motions and compressive forces) was applied to in vitro porcine functional spinal units. Biomechanical and radiographic characteristics were documented. BACKGROUND: While most studies performed in vitro have examined uniaxial or fixed position loading to older specimens, there have been few studies that have examined whether 'healthy' intervertebral discs can be injured by low magnitude repeated combined loading. METHODS: Porcine cervical spine motion segments (C3-C4) were mounted in a custom jig which applied axial compressive loads with pure flexion/extension moments. Dynamic testing was conducted to a maximum of 86400 bending cycles at a rate of 1 Hz with simultaneous torques, angular rotations, axial deformations recorded for the duration of the test. RESULTS: Herniation (posterior and posterior-lateral regions of the annulus) occurred with relatively modest joint compression but with highly repetitive flexion/extension moments. Increased magnitudes of axial compressive force resulted in more frequent and more severe disc injuries. CONCLUSIONS: The results support the notion that intervertebral disc herniation may be more linked to repeated flexion extension motions than applied joint compression, at least with younger, non-degenerated specimens. Relevance. While intervertebral disc herniations are observed clinically, consistent reproduction of this injury in the laboratory has been elusive. This study was designed to examine the biomechanical response and failure mechanics of spine motion segments to highly repetitive low magnitude complex loading.     

Retrospective Review: Effectiveness of Cervical Proprioception Retraining for Dizziness After Mild Traumatic Brain Injury in a Military Population With Abnormal Cervical Proprioception

ObjectiveThis study aimed to assess the outcomes of 2 treatments for patients with dizziness after mild traumatic brain injury (mTBI) who demonstrate abnormal cervical spine proprioception (CSP).MethodsA retrospective records review was conducted on the medical charts of patients treated for dizziness after mTBI who received either standard care (vestibular rehabilitation therapy [VRT]) or cervical spine proprioceptive retraining (CSPR) from 2009 to 2013. All patients included in the analysis were active-duty military with recurring dizziness after mTBI who had at least 1 abnormal CSP test. Patients were excluded for dizziness with a clear peripheral vestibular or central symptom origin, incomplete data, or no CSP assessment, or if both treatments were administered. Forty-eight total patients were included in the final dataset (22 VRT; 26 CSPR). Traditional VRT was compared with CSPR when abnormal CSP tests were present, regardless of the presence or absence of neck pain. A clinician review of records was used to determine improvement of dizziness based on patient reports of symptoms at discharge evaluation (ie, no symptoms for at least 2 weeks).ResultsPatients who received CSPR were 30 times more likely to report improvement in dizziness symptoms compared with those who received VRT (adjusted odds ratio: 30.12; 95% confidence interval 4.44-204.26, P < .001) when abnormal CSP tests were present. Patients with dizziness over 1 year were significantly less likely to improve.ConclusionThese results suggest that patients with dizziness after mTBI and who had abnormal CSP assessments responded better to CSPR compared with those who received VRT.     

Digital tracking algorithm reveals the influence of structural irregularities on joint movements in the human cervical spine

BackgroundDisc height loss and osteophytes change the local mechanical environment in the spine; while previous research has examined kinematic dysfunction under degenerative change, none has looked at the influence of disc height loss and osteophytes throughout movement.MethodsTwenty patients with pain related to the head, neck or shoulders were imaged via videofluoroscopy as they underwent sagittal-plane flexion and extension. A clinician graded disc height loss and osteophytes as “severe/moderate”, “mild”, or “none”. A novel tracking algorithm quantified motions of each vertebra. This information was used to calculate intervertebral angular and shear displacements. The digital algorithm made it practical to track individual vertebrae in multiple patients through hundreds of images without bias.FindingsCases without height loss/osteophytes had a consistent increase in intervertebral angular displacement from C2/C3 to C5/C6, like that of healthy individuals, and mild height losses did not produce aberrations that were systematic or necessarily discernable. However, joints with moderate to severe disc height loss and osteophytes exhibited reduced range of motion compared to adjacent unaffected joints in that patient and corresponding joints in patients without structural irregularities.InterpretationDigitally-obtained motion histories of individual joints allowed anatomical joint changes to be linked with changes in joint movement patterns. Specifically, disc height loss and osteophytes were found to influence cervical spine movement in the sagittal plane, reducing angular motions at affected joints by approximately 10% between those with and without height loss and osteophytes. Further, these joint changes were associated with perturbed intervertebral angular and shear movements.     

Cervical radiculopathy: the diagnosis and treatment of pathomechanics in the cervical spine

Lateral flexion anteroposterior roentgenograms of the cervical spine were obtained of patients suffering from cervical radiculopathy. Specific attention was given to the normal mechanical attitudes of the cervical motion segments at their end range. Deviations from the normal coupling mechanism in the cervical spine were directly related to the level of clinical radiculopathy. Aberrancies in the coupling mechanism of the cervical motion segments were reduced by manipulation, and post manipulative reduction examination revealed improvements in sensation, motor power, and deep tendon reflexes, as well as subjective patient improvement. Normal mechanical attitudes could be restored by manipulative reduction of the cervical motion segments.