Approach to neck pain

Neck pain approach

1. APPROACH TO NECK PAIN
Dr. Yassir Hussain.P

2. In General
Difficult to arrive at an anatomical
diagnosis
Most important is to be able to recognize a
serious pain state
Differentiate neck pain due to common
diseases from neck pain due to local
pathology

3. EPIDEMIOLOGY
Very common; 2 out of 3 people
experience neck pain at some point in life
High among the working aged populace
Incidence in general populace is 10-20%
25-40% complain of associated radiation
to upper extremity

4. Epidemiology..
In the population>45 yrs old >50% have
neck pain/stiffness
Incidence is higher in women & 30-50
year old adults
Whiplash injuries are a common cause

5. RTA & Whiplash
62% of RTA victims have whiplash
33-66% develop symptoms within 24
hours
30-42% have continued intermittent pain
at 1 year
6% have continuous pain at 1 year
28% have chronic pain

6. CLASSIFICATION
Local
Acute-<12 weeks
Chronic->12 weeks
Radiating
Whiplash

7. Alternative classification
Arising from the muscles, ligaments &
joints of the neck
Arising from the cervical nerve roots or the
spinal cord

8. PAIN SENSITIVE STRUCTURES

11. Examination
History
Onset-Acute or Insidious?
Site of pain
Character
Radiation
Radiation-Dermatomal or diffuse?
Aggravating factors and relieving factors
Prior trauma

12. History..
Joint pain?
Prior general diseases?
General symptoms-fever ,weight loss etc.
Symptoms of neurological complications-
weakness, parasthesiae, gait disorders,
vertigo, visual disturbances

13. Examination..
Inspection
Supraclavicular fossae-asymmetry?
sternocliedomastoid-spasm/swelling
Palpation
Midline tenderness posteriorly-
spondylosis/infections
Paraspinal tenderness-swellings/muscle
spasm

14. Examination..
Anterior neck-supraclavicular fossae-
swellings/cervical ribs
Thyriod?/ salivary glands?
LNE?
Temporal artery tenderness/induration?

15. Examination..
Movements
Flexion
Extension
Lateral flexion
Rotation
Check for active and passive motion
The shoulders should be horizontal while
testing for movements
Normally the chin can touch the chest

16. Examination..
If lateral flexion cannot be carried out
without forward flexion this shows
involvement of the first two joints
When checking for rotation the shoulder
should be restrained by the physician
1/3 rd of rotation occurs at the first two
joints
The nose & forehead should be in the
horizontal plane on full extension
1/5 th of flexion-extension & lateral rotation
occur at the first two joints.

17. Examination..
When checking for passive motion place
the patient erect on a stool. standing
behind the patient the left hand stabilizes
the shoulder blades in the horizontal plane
while the left test for extension and
rotation starting from the neutral.
When testing for flexion the hands are
reversed.

18. Normal range of motion
Flexion :80°
Extension :50°
Lateral flexion :45°
Rotation :80°to either side

19. Examination..
If there is pain try to differentiate whether
pain arises from the neck or shoulder or
both.
Reflex muscle spasm due to pain will
cause limitation of movements but this
can be overcome passively
If real limitation of movements persists it
indicates structural damage within the
corresponding joints.

20. Examination..
Mechanical problems usually cause
asymmetric limitation of movement
Inflammatory/ Neoplastic disorders on the
other hand are widespread and more or
less symmetric ; hence pain & movement
restriction will also be symmetric

22. Movements..

23. Movements..

24. PASSIVE MOTION EXAMINATION

25. Examination..
Specific tests
C1-C7 neurological exam & further as req.
Crepitus
Cervical rib
Radiculopathy
Myelopathy

26. Neurological exam
C1-C4 involvement will show no motor weakness
or reflex changes clinically C5 C6 C7 C8
Sensory Lateral arm Thumb Middle finger Little finger
Motor Deltoid Wrst extensors Tricep Finger flexion
Disc C4-C5 C5-C6 C6-C7 C7-T1
Reflex Bicep Brachioradialis Tricep

27. Examination..
It is possible to test the sensory supply of
C2-C4
Neck flexion/lateral flexion are by C2,C3 &
spinal accessory
Neck extension is by C3,C4,spinal
accessory & the posterior rami of spinal
nrves
Trapezius reflex is mediated by C3,C4

29. Specific..
Crepitus
Spread both hands on either side of the neck
and ask patient to flex and extend the neck.
Facet joint crepitus-a common finding in
spondylosis is felt
If in doubt auscultate

30. Crepitus

31. Specific..
Cervical rib
Look for vascular deficits in the upper limb
Adsons test-patient takes a deep breath and
turns his head toward the side of the lesion;
watch for radial pulse obliteration or decrease
Auscultate over supraclavicular area to check
for murmur of subclavian artery compression

32. Specific..
Radiculopathy
Lateral stretch test
Cervical compression test/anvil test/Spurlings
test
Distraction test
Shoulder abduction relief test
Tinels sign
Upper limb tension tests

33. Radiculopathy..
Lateral stretch test
Stretching of the neck in the opposite
direction will elicit pain along the nerve root
distribution

34. Contd..
Spurlings test
Sit the patient on a stool with head in
neutral position & with the head in 45
degree rotation to either side with the
head tilted toward the ceiling.
In each of these three positions apply
brisk compression in the line of the
spine standing behind the patient.
If the patient suffers from foraminal
stenosis of any cause there will be
root pain along the distribution of the
concerned root

35. Spurlings test

36. Radiculopathy..
Distraction test
Passively elevating the head in the
neutral position by holding it at the
occiput and chin will relieve
symptoms

37. Anvil & Distraction test

38. Radiculopathy..
Shoulder abduction relief test
Significant relief of pain with shoulder
abduction
Seen in soft cervical disk prolapse
Negative in radiculopathy due to
spondylosis

39. Radiculopathy..
Tinels sign
In radiculopathy direct palpation or
percussion over the exiting nerve
root may provoke the patients typical
pain
If it is found to be positive more
laterally ,such as over the
supraclavicular fossae then the
diagnosis should be questioned

40. Upper limb tension test 1

41. ULTT1

42. ULTT1

43. Upper limb tension test 2

44. ULTT2

45. ULTT2

46. Upper limb tension test 3

48. Upper limb tension test 4

51. Radiculopathy..
Radiculopathy may be associated with
myelopathy
Can involve one or multiple roots
Findings may overlap due to intraneural
intersegmental connections of sensory nerve
roots

52. Radiculopathy..
Neurological findings suggestive of
radiculopathy besides the above signs are
Pain/ parasthesiae aggravated by
coughing/sneezing
Parasthesiae along nerve root distribution
Pain & tenderness along muscles of the
involved myotome
Weakness of said muscles
Depressed reflexes corresponding to the
involved root
Basically LMN signs.

53. Specific..
Myelopathy
LMN signs in the upper limbs at the
level of compression (flaccid paralysis,
muscle atrophy, absent reflexes)
UMN signs below the level of the
lesion, mainly evident in the lower
limbs. (hypertonicity, hyperreflexia,
clonus, Babinskis sign)
Sensory deficit is non dermatomal
involving large areas e.g.-whole
arm/forearm/wrist
Bladder involvement may be present
Funicular pain (burning pain)

54. Other signs of myelopathy
Hoffman's test/dynamic Hoffmann's
test
Lhermittes sign
Inverted supinator jerk/inverted
radial reflex
Clonus
Myelopathy hand
Gait abnormalities such as ataxic
broad based shuffling gait

55. Myelopathy..
Hoffmann's test
Rapidly extend the distal phalanx of the
middle finger by flicking its pulp
Positive if there is flexing of the IP joints of
the index & thumb
Dynamic Hoffmann's test
Repeat while the patient flexes & extends the
neck which facilitates the response

57. Myelopathy..
Lhermittes test
Flexion or extension produces electric shock
like sensations , particularly in the legs.
Inverted supinator jerk
While eliciting the brachioradialis jerk instead
of brachioradialis contraction we get flexion of
the fingers of the hand
Highly specific for lesion at C5

58. Myelopathy..
Myelopathy hand
Kinetic
Inability to flex & extend the fingers rapidly
Time over 10 seconds
Usually in excess of 20 cycles
Postural
Deficient adduction & often extension of
the ulnar 1-3 fingers

59. Myelopathy..
In the mildest cases when the fingers are
extended the little finger lies slightly in
abduction; even if adduction is possible it
cannot be held for long. abduction is
normal (finger escape sign)
If severe the little, ring & sometimes the
middle finger may abduct and/or the same
fingers may flex & loose their power of
extension.
Myelopathy is most common at C5 ,first
affecting deltoid & infraspinatus

61. Myelopathy..
Motor weakness when present is
asymmetric & usually affects multiple
levels
Vibration & position sense are often
reduced
Babinskis sign becomes positive only late
in the disease

62. Myelopathy..
Any lesion which compresses the cord can
cause myelopathy but in particular
consider
Canal stenosis
Spondylosis
Cervical kyphosis
Old dens # non union
Investigated best by CT myelography, MRI
or dynamic MRI

63. Anatomy of compression
Anterior compression-IVDP/osteophytes
Anterolateral compression-joints of
Luschka
Lateral compression-facet joints
Posterior compression-ligamentum flavum

64. How to differentiate the source of
neck pain
Pain from joints
ligaments/muscles
c/o pain & stiffness
Deep, dull aching &
often episodic pain
h/o
excessive/unaccustom
ed activity or of
sustaining an
awkward posture
Pain from nerve
roots or the spinal
cord
c/o root pain
Sharp, intense often
burning pain
Radiates to trapezial,
interscapular areas or
down the arm

65. Differentiation Contd..
No h/o injury
Localized asymmetric
pain
Upper cervical pain is
referred to the head,
lower cervical to the
arm
Aggravated by
movement, relieved
by rest
Numbness & motor
weakness in a
myotomal distribution
Headache may occur
with upper root
involvement
Symptoms aggravated
by neck
hyperextension.

66. When to suspect serious disease
Unrelenting symptoms and pain radiating
to both hands
Systemic causes such as
Ankylosing spondylitis
Polymyalgia
Malignancy/myeloma/metastasis
Osteomyelitis/tuberculosis
Myelopathy
Progressively increasing pain c.f episodic

67. Is the patient faking?
Non-organic signs of Waddell
Nonanatomic tenderness
Simulation sign
Distraction sign
Regional motor or sensory disturbance
Overreaction

68. Waddell's signs
Their interpretation depends on the
experience of the physician with a wide
range of patients
The signs are significant when more than
one are present in the same patient
The most sensitive sign is overreaction

69. Nonanatomic tenderness
Said to be present when the patient
complains of pain with extremely light
touch or tenderness whose distribution
does not conform to the distribution of
known anatomic structures
Verified by palpating areas that are not
usually tender
CRPS is an exception

70. Simulation sign
Positive under two circumstances
Patient c/o pain along the whole length of
spine or in the lower back in response to
spurlings test
Patient c/o pain when the rotation
simulation maneuver is done i.e head &
shoulders are rotated in a manner
coplanar with the pelvis

71. Distraction sign
Pertinent only in case of back pain
Patient c/o pain in the SLR test but fails to
do so when the knee is extended from the
seated position

72. Regional motor/sensory
disturbance
Regional sensory disturbance exists when
there is sensory disturbance in a
nonanatomic distribution such as glove &
stocking distribution
Regional motor disturbance is suspected if
there is diffuse weakness in multiple
muscle groups/in the whole limb etc or if
the examiner feels that the patients
muscles give way in an unphysiological
manner during strength testing

73. Overreaction
Present when the patient reacts physically
or verbally in an inappropriately theatrical
manner in response to light palpation or
gentle methods of examination

74. INVESTIGATIONS
Plain x rays
Stress x rays
CT
MRI
Myelography
Nerve conduction
studies/electromyography
Nerve blocks
Discography

75. Investigations..
As required
ECG
Blood R/E
LFT
S.electrophoresis

76. Investigations..
X rays AP, lateral, oblique
More useful when acute severe injury is
suspected
Tumors, infections are other instances
Oblique view shows foramina
Stress x rays
Used to demonstrate spinal instability in
patients without neurological deficits whose
plain films show no findings

77. Investigations..
CT
Detects # missed by x rays
Useful in assessing spinal canal/foramina
MRI
Helps in diagnosing disc rupture/herniation
Intraspinal soft tissue processes e.g.-
intra/epidural abscesses, hematomas,
Intraspinal tumors

78. Investigations..
Degenerative disc changes present in 25% of
asymptomatic adults under 40 yrs,60% of
those over 40 years & 70% of those over 70
yrs

79. Investigations..
Myelography/contrast CT
To study the relation between bony & neural
structures for pre-op planning
Nerve blocks
Facet block/cervical sympathetic
blocks/trigger point blocks etc help to
diagnose the site of lesion as well as being
therapeutic occasionally

80. Investigations..
Discography
May help in identifying the affected disc
May identify disc rupture missed by MRI
However the risks generally outweigh the
benefits.
Nerve conduction studies/electromyography
Help confirm radiculopathy
Only way to diagnose C3,C4 radiculopathy is
EMG

81. Differential diagnosis
“Tension neck”
Torticollis
Fibromyalgia
Myofascial pain syndromes
Cervical spondylosis
Cervical IVDP
Whiplash (#, dislocations, ligamental
injuries)

82. Dd
Contd..
Infections-TB, Osteomyelitis, epidural
abscess
Tumors-primary & metastatic
Myelopathy
Cervical stenosis
OA of facet joints/joints of Luschka
Brachial plexus pathologies

83. Dd
Contd..
Thoracic outlet syndrome
CRPS
Herpes Zoster
Inflammatory pathology e.g.-Rheumatoid
arthritis, Ankylosing spondylitis
Syringomyelia
Transverse myelitis

84. Dd
Contd..
Meningism
Severe arterial hypertension (suboccipital
pain)
Epidural heamorrhage
CVJ/vertebral anomalies
Myopathies
Pain from shoulder joint/rotator cuff

85. Dd
Contd..
Pain from the upper limb e.g.-lat.
Epicondylitis, CTS
angina pectoris/MI-if risk
factors/associated with exertion, ”cervical
angina syndrome”
Abdominal irritation e.g.-cholecystopathic
pain

86. Nonspecific neck and shoulder pain
Torticollis
“Tension neck”
Fibromyalgia
Myofascial pain syndromes

87. Torticollis (Wry neck)
Rotational deformity of upper cervical
spine causing turning & tilting of the head
Head tilted to involved side & chin to
opposite side
Due to wide number of causes
Congenital
Neurologic
Inflammatory
Traumatic

88. Torticollis..
Congenital may be due muscular wry neck
or due to anomalies of upper cervical
spine like klippel-feil syndrome, basilar
impression, odontoid anoimalies, Atlanto-
occipital fusion etc
Neurologic abnormalities like ocular
dysfunction, syrigomyelia,s.cord/cerebellar
tumors can lead to torticollis

89. Torticollis..
Inflammation can cause torticollis such as
cervical lymphadenitis, rotatory
subluxation of childhood
Trauma of any sort to upper spine
especially C1-C2 is another cause

90. Tension neck
Patient c/o neck pain usually in the
suboccipital & posterior aspects
Muscle tenderness will be present
H/o stress/holding head in abnormal
position/unaccustomed work/faulty
posture will be present
Pain may radiate to scalp due to irritation
of superior occipital nerve

91. Fibromyalgia
Clinical syndrome charachterized by
diffuse vague pain, extreme fatigue,
stiffness, tender points, sleep disturbance
Thought to be due to disturbance in stage
4 NREM sleep
Diagnosed by
h/o widespread pain especially shoulder/pelvic
girdle
Pain at 11 out of 18 tender points on 4 kg
force

92. Fibromyalgia tender points

93. Fibromyalgia Contd..
Pain in muscles & joints
Worst in the morning
muscle tone, breakaway weakness,
livedo reticularis may be present
Joints are not tender.
Skin fold roll test-rolling of skin fold at T12
level from below upwards will cause
severe pain

94. Myofascial pain syndrome
Diagnosis is made when on examination
we find trigger points in the affected
muscles
Trigger points are tender knotted points
that on palpation will cause pain at a
different site
Infiltration with lignocaine is useful both
as a diagnostic & therapeutic test

95. Cervical Spondylosis
Actually is a combination of degenerative
& herniated IVDP
Also called osteoarthritis, osteoarthrosis,
chronic herniated disk, chondroma, spur
formation, osteophytosis
Seen in 75% of those .65yrs old
May present as neck pain & myelopathy
,Neck pain & radiculopathy or progressive
myelopathy

96. Spondylosis..
Radiculopathy due to osteophytes
Myelopathy due to stenosis, osteophytes &
PLL calcification
Most commonly affects C5-C6,C6-C7 & C4-
C5
Occiput to C3 involvement is uncommon
Vertebral artery maybe involved in the
transverse foramen

97. Spondylosis..
Arthritis of facet joints or joints of Luschka
can cause pain
Disk degeneration leads to IVDP
Cervical Spondylosis without pain is similar
to Multiple sclerosis (involvement above
f.magnum), Amyotrophic lateral sclerosis
(no sensory changes, mixed UMN & LMN
of all limbs), Syringomyelia and spinal cord
tumor

98. Spondylosis..
When there is cervical IVDP pain is a poor
guide to localization, sensory/motor loss &
reflex changes are a better guide
1/4
th
have sensory loss
1/3
rd
have subjective weakness
3/4
th
have objective weakness

99. Cervical canal stenosis
Risk of spinal cord injury is greater if trauma
occurs
Torg ratio
Diameter of canal: width of cervical body (AP)
<0.8 indicates stenosis
Pavlov ratio
Canal: vertebral body width
Normally 1 ,<0.85 stenosis,<0.8 high risk for
later injury-it also indicates congenital stenosis
Absolute stenosis-AP diameter<10mm
Relative stenosis-AP diameter10-13 mm (normal
is 17)

100. Spinal cord lesions
Produce deep, constant, progressive pain
not by coughing/sneezing
Spinal epidural abscess starts as localized
,boring pain which leads to muscle spasm
& cervical rigidity rapidly progressing to
cord progression. MRI is the investigation
of choice

101. Cord lesions..
Spinal epidural hemorrhage presents as
sudden severe pain with radicular
component and respiratory distress.50%
have motor symptoms in 12 hours.15%
are due to trauma. Investigated best by
MRI/CT

102. Herpes zoster
Usually affects 1 root occasionally 2-3
roots
Usually vesicles appear first then pain
Severe lancinating pain
Involves only one side of the body
In C2 involvement the pain appears first
as the vesicles are hidden by the hair/ear
Motor weakness in 60%

103. Syringomyelia
Due to disturbed hydrodynamics of spinal
fluid resulting in central syrinx formation
More common in thoracic than cervical
area
Maybe idiopathic, traumatic or associated
with spinal cord tumor
Idiopathic form associated with Arnold –
Chiari malformations

104. Syringomyelia..
Occurs in 1-3 % of spine trauma
Presents as radicular pain, spasticity,
dissociative anaesthesia in the form of
“cape” sensory loss, LMN signs at the level
of the syrinx (usually the arms)
If ir enlarges then UMN LL sings develop
25-80% have left thoracic scoliosis
MRI is investigation of choice

105. Brachial plexus pathology
Two types of brachial plexus pathology
cause neck pain
Preganglionic plexus injuries
Brachial neuritis

106. Preganglionic brachial plexus
lesions
Can cause severe pain along the neck
,shoulder & arm with an anaesthetic limb
when the upper plexus is involved
Look for features of C5, C6 involvement by
examining myotomes and dermatomes.
C5 myotome is mainly deltoid, dermatome
is lower deltoid
C6 myotome is tested by testing for
supination/ pronation, dermatome is index
finger

107. Preganglionic..
Reflexes affected are biceps &
brachioradialis
Preganglionic nature is diagnosed by
Nerve to serratus anterior involvement
Dorsal scapular nerve involvement (Levator
scapulae & rhomboids)
Long tracts of spinal cord involvement
Retention of sensory conduction in the
presence of sensory loss

108. Preganglionic..
Histamine test
Anaesthesia above the clavicle
Elevated hemidaiphragm (in CXR)
CT myelography

109. Preganglionic..
In the histamine test axon reflex i.e. flare
will be absent only in post ganglionic
lesions
EMG will show denervating potentials in
the segmental paraspinal muscles supplied
by the posterior primary rami
NCS will show retained motor & absent
sensory conduction
Sensory action potentials will be present

110. Preganglionic..
Sensory evoked potentials will also be
present
CT myelography-done after 6-12 weeks to
allow dissolution of blood clots will show
pseudomeningocoele/absence of nerve
root shadow at lesion site

111. Other suggestive features are
Involvement of all 5 roots
Severe pain in anaesthetic arm
Posterior triangle bruising and supraclavicular
sensory loss
Transverse process fracture
Horners syndrome

112. Brachial neuritis
Also called brachial plexitis/ plexopathy
/neuralgic amyotrophy/parsonage-turner
syndrome
Presents abruptly in a normal individual
Usually a male in his 3-7
th
decade
1/3
rd
it is bilateral
Severe neck/shoulder/arm/scapular pain
that may last hours to weeks

113. Brachial..
Followed by severe muscle weakness and
wasting
Less of sensory changes
Maybe a h/o preceding
infection/immunization
Recovers over months
EMG & NCS help in c.f from root lesion

114. Thoracic outlet syndrome
Due to compression of neurovascular
structures at the thoracic outlet bounded
by the 1
st
rib, clavicle & scalene muscles
3 types
True neurogenic TOS
Upper cord compression
Lower cord compression
Vascular TOS
Disputed TOS

115. TOS..
Of these upper cord compression
neurogenic TOS can present as
neck/face/shoulder/ arm pain with
features of C5,C6,C7 involvement
Associated maybe features of ischaemia/
embolization/venous compression
Usually occurs in young to middle aged
females
Tests are
Adsons test
Military test
Hyperabduction manouver
EAST (Roos test)

116. TOS Contd..
Adsons, military & hyperabduction tests
are for the vascular component ,EAST is
what concerns us
The patient is asked to slowly open and
close his hands while keeping the arm
abducted, externally rotated and flexed to
90 degrees at the elbow for 3 minutes
Normal patients experience only fatigue,
neurogenic TOS patients experience pain
& parasthesiae

117. TOS Contd..
Investigated by
X ray cervical spine
EMG/NCS –which show prolonged conduction
times. Somatosensory evoked potentials can
be used to locate site of lesion

118. Whiplash
Two types
Hyperextension injury/acceleration injury/rear
end collision injury
Hyperflexion injury/decceleration injury/front
end collision injury

119. Hyperextension injury mechanism
Rear impact neck hyperextension 
protective flexor muscle spasm which
unfortunately acts as a compressive force
along the cervical spine resulting in
compressive hyperflexion

122. Hyperflexion injury mechanism
Front end collision hyperflexion 
protective extensor muscle spasm
hyperextension

125. NEWEST CONCEPT

127. Findings in whiplash radicular
damage
Neck rigidity & limited extension
Limited rotation to side of injury
Pain & parasthesiae aggravated by
cough/sneeze
Tenderness over affected vertebrae
Parasthesiae along affected nerve roots
Pain and tenderness along affected
myotome

128. Findings..
Weakness of supplied muscles
Depressed reflexes of corresponding root

129. INJURIES TO C1, C2

131. Facet dislocation
If on cervical spine lateral view the
dislocation of the vertebral body is ,1/2 of
its AP diameter it is U/L facet dislocation
If dislocation is >1/2 it is B/L facet
dislocation
Facet injury is responsible for pain in 50-
60% cases of whiplash
Post-traumatic headaches in 33%
Usually at C2-C3 & C5-C6 levels

132. Sympathetic nervous system injury
Called Barre-Lieou syndrome
Injury can occur at
Posterior cervical sympathetics
Sensory elements of C1,C2
Irritation of nerve root at neuroforamen
Compression of vertebral artery
Encroachment of basilar veins

133. Barre-Lieou syndrome
Characterized by
Aural-tinnitus/deafness/postural dizziness
Ocular-blurring/retro bulbar pain/pupil
dilatation on turning to affected side
Other-corneal hypoesthesia/ miosis/
rhinnorrhea/ sweating/ lacrimation/
photophobia/ cranial nerve dysfunction/
hoarseness/ aphonia/ upper extremity
dysesthesia

134. Barre lieou..
This is because the cervical sympathetics
contribute to carotid plexus, brachial
plexus, cardiac plexus, aortic plexus &
phrenic plexus

135. Central cord syndrome
h/o rear end collision in an elderly subject
No head collision/LOC
Sudden hyperextension
Numbness of whole trunk and extremity
Inability to move arms/legs
Inability to void

136. Central cord..
O/E
Motor weakness of UL>LL
Sensory loss below level of lesion
Bladder dysfunction 
Thought to be due to
Contusion of cord
Transient ischaemic damage to cord

137. Central cord..
Cord contusion is due to squeezing of the
cord between hypertrophic spur anteriorly
& ligamentum flavum posteriorly
Ischaemia is thought to be due to
vertebral artery being affected at
Atlanto-axial joint
Atlanto-occipital joint
# dislocation above c6

138. Central cord..
In contusion there is both motor &
sensory loss
In vascular injury usually sensory loss is
minimal/absent with mainly motor loss