Osteochondrosis of the cervico-thoracic spine

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

Pain in the cervical region (at rest or under load) is aggravated after resting, at the beginning of movement or during normal household loads (with sudden movements).

The severity of pain is of three degrees:

• I - pain occurs only when the maximum in volume and strength of movements in the spine;
• II - pain calms down only in a certain position of the spine;
• III - constant pain.

The status indicates stiffness of the cervical region, the forced position of the head, the painfulness of the zones of neuroosteofibrosis (with the duration of the process).

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 myadaptive (postural and vicar).

Compression syndromes are divided into:

• on radicular (radiculopathy);
• spinal (myelopathies);
• neurovascular

Reflex syndromes in turn are classified as:

• muscular-tonic;
• neurodystrophic (neuroosteofibrosis);
• neurovascular

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

[1], [2], [3], [4]

Periarthrosis of the shoulder joint

In addition to pain, irrigation of vegetative formations leads to the development of complex neurodystrophic disorders. Dystrophic changes in the joint capsule and reactive inflammation result in pain radiating to the neck and shoulder. Attempts to rotate and move the arm are usually painful, while the pendulum-like hand movements back and forth remain free. Specific pain when trying to pull the hand behind his back. The patient spares his hand, and this further aggravates the development of cicatricial degeneration of periarticular tissues. There is a "frozen hand" syndrome. In some cases, after pain subsides, ankylosis of the shoulder joint is determined to some degree or another - the shoulder and shoulder blade form a single complex during passive movements, therefore raising the arm above the horizontal level sometimes turns out to be impossible. All this is accompanied by the development of atrophy of the muscles surrounding the joint and during repercussion - an increase in tendon-periosteal reflexes on the same hand appears in the joint capsule.

[5],

Shoulder-hand syndrome, or Stein-broker syndrome

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

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

• factors causing (vertebral pathological foci);
• factors that implement (local lesions that cause neuro-dystrophic and neurovascular changes in the shoulder and hand, in their sympathetic periarticular plexuses);
• contributing factors (general cerebral, general vegetative, which lead to the implementation of specific reflex processes).

Visceral diseases transferred in the past, pre-preparedness of central vegetative mechanisms due to trauma, concussion, contusion of the brain, etc., are important.

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

The clinic consists of pain in the joints and muscles of the affected hand, hyperesthesia and increase in skin temperature, swelling and cyanosis of the hand. Later there is atrophy of the skin and subcutaneous tissue, limited movement of the arm with the formation of flexion contractures. Finally, in the third stage, muscle atrophy and diffuse osteoporosis of the arm bones (Sudek's bone dystrophy) is detected.

[6], [7], [8], [9]

Anterior scalenus 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 I rib. Lateral to this rib is attached having a similar direction of the fibers and the medial scalene. Between these muscles above the I edge there is a triangular slot, through which the brachial plexus and the subclavian artery pass. These anatomical relationships determine the possibility of compression of the neurovascular bundle in the case of spasm of the scalene muscle, the cause of which may be irritation of the roots of C ₅ _ ₇ innervating it and sympathetic fibers. Only the lower bundle of the brachial plexus (formed by the roots C3 and Th1) is usually subjected to compression.

The patient complains of a feeling of pain, heaviness in his hand. The pain can be light, aching, but it can be harsh. The pain increases at night, especially when you take a deep breath, when you tilt your head in a healthy direction, it sometimes extends to the shoulder girdle, axillary region and chest (therefore, in some cases, there is a suspicion of coronary vascular lesions). The pains are also aggravated by the abduction of the arm. Patients note tingling and numbness in the hand, usually along the ulnar edge of the hand and forearm. A swelling of the supraclavicular fossa, pain of the anterior scalene muscle, the place of its attachment to the I rib (the Vartenberg test) is detected on examination. The muscle under the fingers felt compacted, increased in size. There may be a weakness of the brush. This, however, is not true paresis, since with the disappearance of vascular disorders and pain, weakness also disappears.

With the abstraction of the head in a healthy direction, the blood filling of the palpable radial artery may change. If the pain intensifies when turning the head to the diseased side, compression of the spine is more likely.

[10], [11]

Epicondylitis (epicondylosis) of the elbow joint

The lesion of the periosteal-ligamentous structures of this easily injured area (the place of attachment of a number of forearm muscles) is manifested by a characteristic triad of symptoms: pain during palpation of the epicondyle, decreased force in the hand and increased pain during pronation, supination and dorsal flexion of the hand.

The characteristic muscle weakness is detected by the following tests:

• Thompsen symptom: when trying to keep a clenched fist brush in the dorsal position, the brush drops quickly;
• Welsh symptom: simultaneous extension and supination of the forearms - lags behind on the affected side;
• with dynamometry, weakness of the hand is detected from the affected side;
• when placing a hand behind the back pain increases.

So, epicondylitis (epicondylosis) with cervical pathology is part of a wide range of neurodystrophic phenomena in places of attachment of fibrous tissue to bone protrusions. These phenomena occur under the influence of the affected spine or other lesions of nearby tissues. The formation of a pathological syndrome is due to the background state of the periphery, where the substrate was pre-prepared.

[12], [13]

Cardialgic syndrome

Pathology of cervical vertebral structures affects heart diseases. The innervation of the heart is attended by the upper, middle and lower heart nerves, which receive impulses from the cervical sympathetic glands. Thus, in case of cervical pathology, a cardialgic syndrome may occur, which should be distinguished from angina pectoris or myocardial infarction. In the nest of this painful phenomenon there are two main mechanisms:

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

Cardiac pain is inferior to medical effects, and, in particular, is not alleviated by taking nitroglycerin and validol. The absence of changes on repeated ECG, which do not reveal any dynamics even at the height of pain, confirms the diagnosis of non-coronary pain syndrome.

[14]

Vertebral Artery Syndrome

A feature of the structure of the cervical spine is the presence of holes in the transverse processes of the C ₂ -C ₆ vertebrae. These openings form a channel through which the main branch of the subclavian artery, the vertebral artery with the same nerve, passes.

Branches that take part in the formation of the synuvertebral nerve of Lyushka, which innervates the capsular-ligamentous apparatus of the cervical PDS, the periosteum of the vertebrae and intervertebral disks, depart from the vertebral artery.

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

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

Compression-irritative form of the syndrome occurs due to mechanical compression of the vertebral artery. As a result, there is irritation of its efferent sympathetic formations with impaired vertebro-basilar blood flow and ischemia of the brain structures.

The artery can be compromised at different levels:

• until it enters the channel of the transverse processes; more often the cause of compression is cramped scalene;
• in the channel of the transverse processes; in this case, this occurs with an increase in the deformation of the hooked processes that are laterally directed and compressing the medial wall of the artery; in the case of subluxations in Kovac, when the anterior upper angle of the superior articular process of the anteriorly slid vertebra puts pressure on the posterior wall of the artery; a similar effect on the artery has articular processes in the presence of anterior growths due to spondylarthrosis and periarthrosis;
• in the place of an exit from the channel of cross processes; artery compression occurs when abnormalities of the upper cervical vertebrae; It is possible that the artery is pressed against the joint of the C1-C2 spasmed lower oblique muscle of the head.

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

Reflex angiospastic syndrome of the vertebral artery arises in connection with the common innervation of the artery itself, intervertebral discs and intervertebral joints. During dystrophic processes in the disk, stimulation 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 spasm.

Clinical manifestations of vertebral artery syndrome include:

• paroxysmal headaches;
• irradiation of headache: starting in the neck and occipital region, it extends to the region of the forehead, eyes, temples, ears;
• pains seize half of the head;
• a clear connection of headaches with the movement of the head, long work associated with the tension of the muscles of the neck, uncomfortable position of the head during sleep;
• when the head moves (bends, turns), pain often occurs, a “crunch” is heard, cochleo-vestibular disorders are observed: systemic vertigo, noise, tinnitus, hearing loss, especially at the height of pain, fog before the eyes, flashing of “flies” ( visual impairment);
• high blood pressure ("cervical hypertension").

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

• bilateralism and diffusion of cerebral vascular disorders;
• prevalence of vegetative manifestations over focal;
• relatively less association of seizures with head turns;
• compression-irritative syndrome is more common in the pathology of the lower cervical spine and combined with brachial and pectoral syndromes, reflex - with the defeat of the upper and middle cervical levels.

One of the main places in the clinic syndrome Barre occupy neuropsychiatric symptoms: weakness, malaise, irritability, sleep disturbance, constant feeling of heaviness in the head, memory impairment.

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

Radicular syndrome

Compression of the spinal root in the cervical spine is relatively rare compared with reflex syndromes. This is due to the following circumstances:

• strong ligaments of the uncovertebral "joints" well protect the root from possible compression of the foral disc herniation;
• the size of the intervertebral foramen is rather small and the probability of a hernia falling into it is the smallest.

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

• the anterior part of the intervertebral foramen is narrowed due to disc herniation or bone and cartilage growths in case of uncovertebral arthrosis;
• posterior opening narrows with spondylarthrosis and cervicospondiloperiarthrosis;
• when osteochondrosis decreases the vertical size of the intervertebral foramen.

Radicular syndrome may also occur if the wall of the radicular artery is irritated with a spasm of the latter, which leads to ischemia of the root.

Certain motor, sensory and reflex disorders are associated with the compression of each root:

• The root of C1 (craniovertebral vertebral motor segment) lies in the vertebral artery sulcus. Manifested in the clinic by pain and a violation of sensitivity in the parietal region.
• C2 radicle (diskless vertebral motor segment C1-2). With the defeat there is pain in the parietal-occipital region. Hypotrophy of the hypoglossal muscles is possible. Accompanied by a violation of sensitivity in the parietal-occipital region.
• C ₃ root (disc, joint and intervertebral foramen C ₂ _ ₃ ). In the clinical picture, pain prevails in the corresponding half of the neck and a feeling of swelling of the tongue on this side, language skills are difficult. Paresis and hypotrophy of the hypoglossal muscles. Violations are caused by anastomoses of the root with the hypoglossal nerve.
• C ₄ root (disc, joint and intervertebral foramen C ₃ _ ₄ ). Pain in shoulder girdle, clavicle. Weakness, reduced tone and hypertrophy of the belt, trapezoid, lifting the scapula and the longest muscles of the head and neck. Due to the presence in the root of the fibers of the phrenic nerve, respiratory function may be impaired, as well as pain in the region of the heart or liver.
• C ₅ root (disc, joint and intervertebral foramen C ₄ _ ₅ ). Pain radiates from the neck to the upper arm and the outer surface of the shoulder. Weakness and malnutrition of the deltoid muscle. Impaired sensitivity on the outer surface of the shoulder.
• C ₆ root (disc, joint and intervertebral foramen C ₅ _ ₆ ). The pain spreads from the neck to the scapula, shoulder girdle and to the thumb, accompanied by paresthesias of the distal zone of the dermatome. Weakness and hypotrophy of the biceps. Reduction or absence of reflex from the specified muscle.
• C ₇ root (disc, joint and intervertebral foramen C ₆ _ ₇ ). Pain radiates from the neck under the scapula along the outer-back surface of the shoulder and dorsal surface of the forearm to the II and III fingers, paresthesias in the distal part of the specified zone are possible. Weakness and hypotrophy of the triceps, decrease or disappearance of the reflex from it. Violation of the sensitivity of the skin on the outer surface of the forearm on the brush to the dorsum of the II-III fingers.
• C ₈ root (disc, joint and intervertebral foramen C ₇ -Thj). The 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 reduction of the reflex from the triceps, the muscles of the elevation of the little finger are possible.

[15], [16], [17]