Osteochondrosis of the cervicothoracic spine

Cervical vertebrogenic pathology almost always begins with pain or discomfort in the neck area.

Pain in the cervical region (at rest or under load) intensifies after rest, at the beginning of movement or with normal everyday loads (with sudden movements).

The severity of pain can be of three degrees:

• I - pain occurs only with maximum volume and strength of movements in the spine;
• II - the pain is relieved only in a certain position of the spine;
• III - constant pain.

The status is characterized by stiffness of the cervical spine, forced position of the head, and pain in the areas of neuroosteofibrosis (if the process is long-standing).

The described cervical symptom complex refers to vertebral syndromes. Cerebral, spinal, pectoral and brachial are defined as extravertebral syndromes. They can be compression, reflex or myoadaptive (postural and vicarious).

Compression syndromes are divided into:

• on radicular (radiculopathy);
• spinal (myelopathy);
• neurovascular.

Reflex syndromes in turn are classified as:

• muscular-tonic;
• neurodystrophic (neurosteofibrosis);
• neurovascular.

Myoadaptive vicarious syndromes occur when relatively healthy muscles are overstrained, when they take on the inadequate function of the affected ones. In the clinic of cervical extravertebral pathology, reflex syndromes are more common.

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Periarthritis of the shoulder joint

In addition to pain, irritation of vegetative formations causes the development of complex neurodystrophic disorders. Dystrophic changes and reactive inflammation occurring in the joint capsule lead to pain radiating to the neck and shoulder. Attempts to rotate and abduct the arm are usually painful, while pendulum-like movements of the arm back and forth remain free. Pain is specific when trying to abduct the arm behind the back. The patient spares the arm, and this further aggravates the development of cicatricial degeneration of periarticular tissues. The "frozen arm" syndrome occurs. In some cases, after the pain subsides, ankylosis of the shoulder joint is determined to one degree or another - the shoulder and scapula form a single complex during passive movements, so raising the arm above the horizontal level is sometimes impossible. All this is accompanied by the development of atrophy of the muscles surrounding the joint and, upon repercussion, an increase in tendon-periosteal reflexes appears in the joint capsule on the same hand.

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Shoulder-hand syndrome, or Stein-Broker syndrome

The main condition for the occurrence of shoulder-hand syndrome is the involvement of the cervical sympathetic formations, in particular, the sympathetic trunk.

The specificity of the syndrome is determined by a combination of several factors leading to damage to the hand and shoulder. The main ones are:

• factors causing (vertebral pathological foci);
• implementing factors (local damage that causes neurodystrophic and neurovascular changes in the shoulder and hand area, in their sympathetic periarticular plexuses);
• contributing factors (general cerebral, general vegetative, which lead to the implementation of specific reflex processes).

Past visceral diseases, pre-preparedness of central vegetative mechanisms due to trauma, concussion, brain contusion, etc. are important.

Considering the nature of the process of the shoulder and hand separately, it should be noted that in the shoulder area the process is predominantly neurodystrophic in nature, and in the hand area it is neurovascular.

The clinical picture consists of pain in the joints and muscles of the affected arm, hyperesthesia and increased skin temperature, swelling and cyanosis of the hand. Later, atrophy of the skin and subcutaneous tissue occurs, hand movements are limited with the formation of flexion contractures. Finally, in the third stage, muscle atrophy and diffuse osteoporosis of the arm bones (Sudeck's bone dystrophy) are detected.

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Anterior scalene syndrome

It is known that this muscle, starting from the anterior tubercles of the transverse processes of the III-IV cervical vertebrae, is attached to the upper surface of the 1st rib. Laterally, the medial scalene muscle, which has a similar direction of fibers, is attached to this rib. Between these muscles, above the 1st rib, there remains a triangular-shaped gap through which the brachial plexus and the subclavian artery pass. The indicated anatomical relationships determine the possibility of compression of the vascular-nerve bundle in the case of spasm of the scalene muscle, the cause of which may be irritation of the C5-7 roots innervating it _{andsympathetic} fibers. Usually, only the lower bundle of the brachial plexus (formed by the C3 and Th1 roots) is subject to compression.

The patient complains of a feeling of pain and heaviness in the arm. The pain may be mild and aching, but it may also be sharp. The pain intensifies at night, especially with a deep breath, when tilting the head to the healthy side, it sometimes spreads to the shoulder girdle, axillary region and chest (therefore, in some cases, there is a suspicion of coronary vascular damage). The pain also intensifies when the arm is abducted. Patients note a sensation of tingling and numbness in the arm, most often along the ulnar edge of the hand and forearm. During examination, swelling of the supraclavicular fossa, soreness of the anterior scalene muscle, the place of its attachment to the 1st rib (Wartenberg test) are revealed. The muscle under the fingers feels compacted, enlarged in size. Weakness of the hand may also occur. This, however, is not true paresis, since with the disappearance of vascular disorders and pain, the weakness also disappears.

When the head is moved to the healthy side, the blood filling of the palpated radial artery may change. If the pain increases when turning the head to the painful side, root compression is more likely.

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Epicondylitis (epicondylosis) of the elbow joint

Damage to the periosteal-ligamentous structures of this easily injured area (the attachment site of a number of forearm muscles) is manifested by a characteristic triad of symptoms: pain upon palpation of the epicondyle, decreased strength in the hand, and increased pain during pronation, supination, and dorsiflexion of the hand.

Characteristic muscle weakness is revealed by the following tests:

• Thompson's symptom: when trying to hold a clenched fist in a dorsiflexed position, the hand quickly drops;
• Welch's symptom: simultaneous extension and supination of the forearms - lags behind on the affected side;
• Dynamometry on the affected side reveals weakness of the hand;
• When I put my hand behind my lower back, the pain intensifies.

Thus, epicondylitis (epicondylosis) in cervical pathology is part of a wide range of neurodystrophic phenomena in places of attachment of fibrous tissues to bone protrusions. These phenomena arise under the influence of the affected spine or other lesions of nearby tissues. The formation of one or another pathological syndrome is caused by the background state of the periphery, where the substrate was prepared.

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Cardialgic syndrome

Pathology of the cervical vertebral structures also affects heart disease. The upper, middle and lower cardiac nerves, receiving impulses from the cervical sympathetic nodes, participate in the innervation of the heart. Thus, with cervical pathology, cardialgic syndrome may occur, which should be distinguished from angina or myocardial infarction. There are two main mechanisms at the root of this pain phenomenon:

• this is irritation of the sinuvertebral nerve, the postganglionic branch of the sympathetic chain, which then involves the stellate ganglion, which provides sympathetic innervation of the heart;
• pain in the muscles of the anterior surface of the chest wall, innervated by the C5-7 roots.

Cardialgic pains are not much inferior to drug treatment, and in particular, are not relieved by taking nitroglycerin and validol. The absence of changes in repeated ECGs, which do not reveal any dynamics even at the height of pain, confirm the diagnosis of non-coronary pain syndrome.

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Vertebral artery syndrome

The peculiarity of the structure of the cervical spine is the presence of openings in the transverse processes of the C2 _- C6 _vertebrae. These openings form a canal through which the main branch of the subclavian artery passes - the vertebral artery with the nerve of the same name.

The vertebral artery gives rise to branches that participate in the formation of the sinuvertebral nerve of Luschka, which innervates the capsular-ligamentous apparatus of the cervical spinal joints, the periosteum of the vertebrae and the intervertebral discs.

Depending on whether the spasm of the artery occurs due to irritation of the efferent fibers of the spinal nerve (plexus) or due to a reflex response to irritation of the afferent structures, the vertebral artery can manifest its clinical instability in 2 forms:

• in the form of compression-irritative syndrome of the vertebral artery;
• in the form of reflex angiospastic syndrome.

The compression-irritative form of the syndrome occurs due to mechanical compression of the vertebral artery. As a result, irritation of its efferent sympathetic formations occurs with disruption of vertebrobasilar blood flow and ischemia of brain structures.

The artery can be compressed at different levels:

• before it enters the canal of the transverse processes; most often, the cause of compression is a spasmodic scalene muscle;
• in the canal of the transverse processes; in this case, this occurs with an increase, deformation of the hook-shaped processes, directed laterally and exerting compression on the medial wall of the artery; with subluxations according to Kovacs, when the anterior upper angle of the upper articular process of the vertebra that has slipped forward exerts pressure on the posterior wall of the artery; a similar effect on the artery is exerted by the articular processes in the presence of their anterior growths due to spondyloarthrosis and periarthritis;
• at the exit site of the transverse processes canal; compression of the artery occurs with anomalies of the upper cervical vertebrae; possible compression of the artery to the C1-C2 joint by the spasmodic inferior oblique muscle of the head.

ATTENTION! This is the only area in the "canal" of the vertebral artery where it is not covered by articular processes from behind and where it is palpated ("vertebral artery point").

Reflex angiospastic syndrome of the vertebral artery occurs due to the common innervation of the artery itself, intervertebral discs and intervertebral joints. During dystrophic processes in the disc, irritation of sympathetic and other receptor formations occurs, the flow of pathological impulses reaches the sympathetic network of the vertebral artery. In response to irritation of these efferent sympathetic formations, the vertebral artery reacts with a spasm.

Clinical manifestations of vertebral artery syndrome include:

• paroxysmal headaches;
• irradiation of headache: starting in the cervical-occipital region, it spreads to the forehead, eyes, temples, ears;
• the pain covers half of the head;
• a clear connection between headaches and head movements, prolonged work associated with tension in the neck muscles, and an uncomfortable head position during sleep;
• when moving the head (tilting, turning), pain often occurs, a “crunching” sound is heard, cochleo-vestibular disorders are observed: systemic dizziness, noise, ringing in the ears, hearing loss, especially at the height of pain, fog before the eyes, flickering “flies” (visual disturbances);
• high blood pressure ("cervical hypertension").

Although the clinical manifestations of both forms of the syndrome are similar, reflex angiospastic syndrome still has its own distinctive features. It is characterized by:

• bilaterality and diffuseness of cerebral vegetative-vascular disorders;
• predominance of vegetative manifestations over focal ones;
• relatively less association of attacks with head turns;
• compression-irritative syndrome is more common in pathology of the lower cervical spine and is combined with brachial and pectoral syndromes, reflex - with damage to the upper and middle cervical levels.

One of the main places in the clinic of Barre syndrome is occupied by general neurotic symptoms: weakness, malaise, irritability, sleep disturbance, constant feeling of heaviness in the head, memory impairment.

Unlike the anterior cervical sympathetic syndrome, characterized by Horner's complex, the posterior cervical sympathetic syndrome is as poor in objective symptoms as it is rich in subjective ones.

Radicular syndrome

Spinal root compression in the cervical spine is relatively rare compared to reflex syndromes. This is explained by the following circumstances:

• strong ligaments of the uncovertebral “joints” protect the root well from possible compression by a foraminal disc herniation;
• the size of the intervertebral opening is quite small and the probability of a hernia falling into it is the lowest.

Compression of the root or radicular artery is carried out by various structures:

• the anterior part of the intervertebral foramen narrows due to a herniated disc or bone-cartilaginous growths in uncovertebral arthrosis;
• the posterior part of the opening narrows in spondyloarthrosis and cervicospondyloperiarthrosis;
• with osteochondrosis, the vertical size of the intervertebral foramen decreases.

Radicular syndrome can also occur with irritation of the wall of the radicular artery with spasm of the latter, which leads to ischemia of the root.

Compression of each root is associated with certain motor, sensory and reflex disorders:

• The C1 root (craniovertebral vertebral motor segment) lies in the groove of the vertebral artery. It manifests itself clinically as pain and impaired sensitivity in the parietal region.
• Root C2 (non-disc spinal motor segment C1-2). When damaged, pain appears in the parieto-occipital region. Hypotrophy of the hyoid muscles is possible. Accompanied by impaired sensitivity in the parieto-occipital region.
• Root C ₃ (disc, joint and intervertebral foramen C ₂ _ ₃ ). The clinical picture is dominated by pain in the corresponding half of the neck and a feeling of swelling of the tongue on this side, difficulty using the tongue. Paresis and hypotrophy of the hyoid muscles. The disorders are caused by anastomoses of the root with the hypoglossal nerve.
• Root C ₄ (disc, joint and intervertebral foramen C ₃ _ ₄ ). Pain in the shoulder girdle, collarbone. Weakness, decreased tone and hypertrophy of the splenius, trapezius, levator scapulae and longissimus capitis and cervicalis muscles. Due to the presence of phrenic nerve fibers in the root, respiratory dysfunction is possible, as well as pain in the heart or liver area.
• Root C5 ₍ disc, joint and intervertebral foramen C4_5 ₎. Pain radiates from the neck to the shoulder girdle and outer surface of the shoulder. Weakness and hypotrophy of the deltoid muscle. Impaired sensitivity along the _outer surface of the shoulder.
• Root C ₆ (disc, joint and intervertebral foramen C ₅ _ ₆ ). Pain spreads from the neck to the scapula, shoulder girdle and thumb, accompanied by paresthesia of the distal zone of the dermatome. Weakness and hypotrophy of the biceps muscle. Decreased or absent reflex from the specified muscle.
• Root C7 ₍ disc, joint and intervertebral foramen C6_7 _{). Pain radiates from the neck under theshoulder} blade along the outer posterior surface of the shoulder and the dorsal surface of the forearm to the II and III fingers, paresthesia is possible in the distal part of this zone. Weakness and hypotrophy of the triceps muscle, decrease or disappearance of the reflex from it. Impaired sensitivity of the skin along the outer surface of the forearm to the hand to the dorsal surface of the II-III fingers.
• Root C8 ₍ disk, joint and intervertebral foramen C7 - _Thj ). Pain radiates from the neck to the ulnar edge of the forearm and to the little finger, paresthesia in the distal parts of this zone. Partial hypotrophy and decreased reflex from the triceps muscle and the muscles of the eminence of the little finger are possible.

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