06_chapter 2-3.pdf
TRANSCRIPT
6
CHAPTER – 2
AIMS AND OBJECTIVES
AIM :
To observe the effects of “Panchamrut Loha Guggul” &
“Trayodashang Guggul” in the management of Vishwachi w.s.r. to cervical
spondylosis.
OBJECTIVES :
1) To study Vishwachi w.s.r. to Cervical Spondylosis.
2) To explain Nidan Panchak regarding Vishwachi.
7
CHAPTER - 3
REVIEW OF LITERATURE
REVIEW OF LITERATURE - (Ayurvedic):
REVIEW OF PREVIOUS WORK -
Search from the book “Researches in Ayurveda” by Dr. M. S. Baghel
revealed two references about the previous work done regarding Cervical
Spondylosis, the topics of the study were
i) A study of asthigata vata with special reference to Cervical
Spondylosis, and role of Snehana and Nasya karma in its management.
ii) A clinical study on the development of subtype of Abhyanga with
reference to its role in the management of “Griva Hundana” (Cervical
Spondylosis).
In Ayurvedic Samhita Granthas disease Vishwachi is explained under
Vata Vyadhi & described in short. While following these Samhita Granthas
some literature regarding Vishwachi was found which is as follows
A. SUSHRUT SAMHITA:
In Vata Vyadhi Nidan Adhyaya Sushrut explains Vishwachi as,
Prakupit Vata Dosha affects the Kandara (Tendons) of Tala (palm),
Pratyanguli (fingers), Bahuprusthatha (Dorsal aspect of the upper extremity)
& there by produces loss of functions of the upper extremity.
8
B. ASTANG HRUDAYA:
Vagbhatacharya explain Vishwachi as similar to Sushrutacharya. Word
Bahu chestapharani again denotes kriya hani of uppar extremety.
According to ashtang hrudayakar When severity of pain in Grudhrasi
& Vishwachi is very high, then both these conditions are listed under one
heading i.e. Khalli.
C. CHARAK SAMHITA:
Charakacharya does not explained Vishwachi as a separate entity but
while describing Khalli his explanation is asfollows
[kYyh rq iknt?³®:djewykoe®Vuh AA p-fp-28@57
In this quotation Charakacharya mentioned that when severity of pain
in Ghrudhrasi & Vishwachi is more, then it is named as Khalli.
D. MADHAV NIDAN:
This quotation also gives similar description as that of Sushrut samhita.
Bahu karmakshya due to affected kandara of upper extremity by vata
dosha is called as Vishwachi.
9
E. YOG RATNAKAR:
n'kewyh cyk DokFkek"karSykT;fefJre~A
lk;aÒqDRok pjsUuL;afoÜokP;kapkoCkkgqdsAA
;®-j-@ok-O;k-fp- 144
¼n'keqG $ Ckyk $ mMhn½ DokFk $ frGrSy $ Ä`r & fl/nÄ`r &
jk=© T®o.kkuarj uL;
While describing chikitsa of Vishwachi & AvaBahuk in the vatvyadhi
chikitsa addhyaya, siddha ghrut with Dashamul, Bala, Masha & tilatail is
mentioned. Nasya with this ghrut after diner is very useful in Vishwachi &
AvaBahuk.
F. HARIT SAMHITA:
foÜOkkph x`/kzlh p¨Drk [kYyh rhoz#TkkfUork A gjhr lafgrk
Harit explain that when severity of pain in Vishwachi & ghrudhrasi is
very high then both these conditions are called as Khalli. His description is
similar to Astang hrudaya.
G. SHARANGDHAR SAMHITA:
ikng"k¨ZXk`/kzlh p foÜokph pkoCkkgqd% A 'kk-la-&[kaM 1 v-7@8
'kk[kkdaia f'kj%daia foÜokphefnZra rFkk A
ek"kkfndafena rSya loZokrfodkjuqr~ AA 'kk-la-&[kaM 2 v-9@6
10
While describing the Phalashruti of Mashadi Taila Sharangdhar
explained that Snehan with Mashadi Taila is very usefull in the treatment of
Vishwachi, Kampa, Shirkampa & Ardit.
In the management of Vishwachi Nasya & Snehana is very useful. As
work on this topic has been already done previously I prefer to use Guggul
kalpa.
GARBHA SHARIR & ASTHI DHATU UTPATTI :
After union of sperm & ovum, fertilized ovum grows by cell division.
This fertilized ovum is a jelly like mass & named as “KALALA” in
Ayurveda. According to ayurvedic science at the time of fertilization,
Panchamahabhuta & Atma enters the fertilized ovum in sukshma swaroop.
Gradual development of this kalala swaroop garbha to the fully developed
fetus is due to the panchabhautik agni which divides, converts & develops the
embryonic cells to form various body structures. Thus after nine months
period fully developed fetus is delivered.
According to modern science, fertilized ovum grow by cell division.
These cells then get arranged to form Trophoblast, Notocord, & Embryonic
plate. Due to specific movement & rearrangement of the cells, embryonic
plate becomes three layered i.e. Endoderm, Mesoderm, & Ectoderm. Further
during the development of embryo various organs & structures are developed
from these three layers. With the help of advance techniques modern science
has brief knowledge, that which organ or structure get develop from which
embryonic layer.
In Ayurveda while describing the Trayo-rogamarga, Abhyantar
rogamarga, Madhyam rogamarga, & Bahya rogamarga are mentioned. If we
study the organs or structures mentioned in each rogamarga, we can observe
the resemblance to the specific organs & structures developing from the
specific embryonic layer i.e. organs mentioned in abhyantar marga & organs
11
developing from endoderm are nearly same. So as is with madhyam marga &
mesoderm & bahya marga & ectoderm.
’kk£kjDRkkn;LRod~pckáj®xk;uaºhrr~A
rnkJ;ke"kO;axxaMkyT;cqZnkn;%A
cfºÒkZxkÜp nqukZe xqYe 'k®Qkn;® xnk%AA
v-â-lw-&12@44]45
f'kjksân;cLR;kfn EkEkZk.;LFkakp laèk;%
rfUUkcènk% f’kjk LUkk;qd.Mjk|kÜPk eè;e%AA
v‐â‐lw‐&12@47
vUrd¨"B¨egkL=¨rvkeiDok'k;kJ;%A
rRLFkkukr~ NfnZ vfrlkj dklÜokl¨njTojk%A
vUrÒkZxap '¨Qk'kksZ xqYe foliZ fonzfèkAA
v‐â‐lw‐&12@46 47
It means three Sadya Pranahar Marma i.e. Shira – Hridaya – Basti,
Asthi & Asthi Marmas, Asthisandhi & Sandhi Marmas, Sira, Snayu,
Kandara, that binds the Asthi & Asthisandhi together & their related
Marmas, are included in Madhyam Maarga.
According to modern embryology Mesemchymal cells are developed
from Mesoderm & from these Mesemchymal cells Chondroblast, Osteoblast,
Myoblast, Lymphoblast, Haemocytoblast are developed. These specialized
cells further develop Connective tissue, Muscle, Tendons, Ligaments, Bones,
Bony joints, Cartilages, Inter muscular Septum, Adipose Tissue, Vessels,
Lymphatics, Kidney, Uterus, Ovaries, Testies, Peritoneum, Cornea, Sclera,
Iris, etc. From above description it seems that Madhyam maarga is nothing
12
but the Mesoderm of embryonic plate. From this Mesoderm / Madhyam
maarga, Asthi Dhatu nirmiti & vriddhi takes place.
COMPARISION CHART
Organs included in
Madhyam marga
Structures developing from
Mesoderm
Shira, Hrudaya, Basti &their related
Marmas
Kidney, Uterus, Ovaries, Testis,
Cornea, Sclera, Iris
Asthi & Asthi sandhi, Asthi Marmas &
Asthisandhi Marmas Bones & boney joints
Sira, Snayu, & Kandara, Marmas
related to sira, Snayu & kandara
Connective tissue, muscles,Tendons &
Ligaments, Cartilages, & Inter muscular
septum
Adipose tissue, Vessels & Lymphatics
Peritoneum
Organs included in
Bahya marga
Structures developing from
Ectoderm
2- Urdhva shakha External ear, Nervous system
2- Addha shakha Lower part of anal cana,lDistal part of
Urethra
Twacha Epidermis, Nasal Mucosa,Internal
surface of lips & chicks
Rakta dhatu Hair, Nails
13
GREEVA & BAHU -- RACHANA SHARIR:
I) Anguli praman of Greeva, PraBahu, & Prakostha :
prqfoZa'kfrfoLrkjifj.kkgaeq[kXkzhoaA lq+ lw+&35@12
In this quotation Sushrutacharya explained that length of Mukha is four
angul & circumference of the Greeva is Twenty angul.
bUnzcfLrifj.kkgaklihBdwiZjkUrjk;ke% "k¨M'kk³~xqy%A lq-lw-&35@12
The circumference of the forearm at the site of Indrabasti Marma is
Sixteen angul.The distance between Ansapeeth & Kurpar is also Sixteen
angul.
}kn'kk³xqykfuÒxfoLrkjesguukfÒân;xzhokLrukUrj
eq[kk;keef.kcUèkÁd¨"BLFk©Y;kfu A lq-lw-&35@12
Organs included in
Abhyantar marga
Structures developing from
Endoderm
Mahastrotas i.e. Ostha, Danta, G.I.tract, Lips, Dentures, Gums,Tongue
Dantamool, Jivha, Mrudu Talu, Soft & Hard Palate, Oesophagus
Kathin Talu, Gala, Annanalika, Stomach, Duodenum, Ilium, Caecum,
Amashya, Grahani, Madhyantra, Large Intestine, Upper part of Anal
Canal
Sheshantra, Unduk, Brihadantra Bronchus, Internal Ear, Urinary Bladder
Uttar Gud, Adho Gud, Gudnalika Mucosal membrane of different organs
Yakrut, Agnyashaya Liver, Pancreas
14
In this quotation Sushrut explained the distance between two parts of
the body. He also explained that circumference of wrist & forearm is Twelve
angul.
II) Anguli praman of Hastanguli :
v³xq"BewyÁnsf'kuhJo.kkik³XkkUrjeË;ek³~xqY;©iåpk³~xqysA
lq-lw-&35@12
In this quotation Sushrut explained that the distance between base of
the Thumb & Index finger, Ear & Outer canthus is five angul. The length of
the Middle finger is also five angul. The Index finger & Ring finger are Four
& half Angul long. The Thumb & Little finger are Three & half angul in
length.
III) Anguli praman of Hastatala :
rya "kV~prqj³~xqyk;kefoLrkje~ A MYg.k
Dallhana state that palm measures Six angul in length and Four angul
in breadth.
IV) Greeva & Bahu – Snayu Sankhya :
"kVf=a'kn~xzhok;ka A lq-'kk-&5@29
'kre/;/kZesoesdfLeu~lfDFuÒofUr,rsusrjlfDFkckgw pA
lq-'kk-5@29
In the sharir sankhya vyakarana addhyaya Sushrut explained that there
are Thirty six Snayu in the Greeva & One hundred fifty Snayu in each Bahu.
The distribution of Snayu in the arm is as follows.
15
Six Snayu in each finger i.e. 5 x 6 ------------------- 30
Ten Snayu near each Marma i.e. Talahrudaya,
Kurchashira, & Manibandha ------------------------- 30
Thirty Snayu in prakostha---------------------------- 30
Ten Snayu in Kurpara -------------------------------- 10
Fourty Snayu in Prabahu ---------------------------- 40
Ten Snayu in the Skandha --------------------------- 10
Total = 150
V) Asthi Sankhya in the Greeva:
xzhok;ka uo A lq-'kk-&5@19
While describing the Asthi Sankhya in the different parts of the body
Sushru Mentioned Nine asthi in the greeva.
VI) Urdhva shakha – Asthi sankhya :
,dSdL;karq iknk³~xqY;ka =hf.k =hf.k rkfu iŒpn'k]
rydwpZxqYQlafJrkfu n'k] ik".;kZesda]t³Äk;ka }s]
tkuqU;sde] ,dewjkfofr f=a'knsoesdfLeu~lfDFu ÒofUr]
,rsusrjld~fFk ckgw p f}rh;s·I;soa A lq-'kk-&5@19
While describing asthi sankhya in the upper extremity Sushrut
explained as,
16
Sushrut Modern Anatomy
Angulya asthi (Phalanges) ------ 15 14
Karabha asthi (Metacarpals) ---- 5 5
Panikurcha asthi (Carpals) ------ 5 8
Prakostha asthi (Radius & Ulna)- 2 2
Praganda asthi (Humerus) ------ 1 1
----------------------------------------------------------------------------------------------
( 28 + 1 Janu + 1 Parshni ) ----- Total = 30 Total = 30
It means 30 x 2 = 60 Asthis are in the upper extremity.
VII) Sandhi & Sandhi prakara in Greeva & Prusthavansh :
prqfo±'kfr%Á`"Boa'¨] rkoUr ,o ik'oZ;¨%]
mjL;"V© rkoUr ,o xzhok;ka A lq-'kk-&5@26
Sushrutacharya state that there are Twenty four Sandhi in
Prusthavansha, and eight Sandhi in the Greeva.
xzhokÁ`"Boa'k;¨% Árjk%A lq-'kk-&5@27
While describing the Sandhi prakara & their sthana, Sushrut mentioned
that Sandhi in Greeva & Prusthavansha are Pratar sandhi.
VIII) Prusthavansha & Maharajju (Ligament) :
egR;¨ ekaljTtoÜprLkz%& Á`"Boa'keqÒ;r%A
is'khfucUèkukFk± }s ckº;s] vkH;arjs p }s AA lq-'kk-&5@14
In this quotation Sushrut mentioned Four Maharajju (Long Fascial
bands) Two Bahya (External) & Two Abhyantar (Internal). These Maharajju
17
supports Vertebral column & holds the Paraspinal muscles. From this
explanation it seams that the Anterior Longitudinal Ligament & Posterior
Longitudinal Ligament are thestructures resembling to the description in
Sushrut samhita.
Urdhava shakha – Marma Sharir, Sankhya & Viddha Lakshana :
vrÅèo± lfDFkeekZf.k O;k[;kL;ke%&
r= iknL;k³~xq"Bk³~xqY;¨eZè;s f{kça uke eeZ]
r=foènL;k·{¨ids.k ej.ka] eè;ek³~xqyheuqiwosZ.k eè;s
iknryL; ryân;a uke] r= #tkfÒeZj.ka]
f{kÁL;ksifj"VknqÒ;r% dwp¨Zuke] r= iknL;Òze.kosius Òor%]
xqYQlUè¨jèk mÒ;r% dwpZf'kj%] r= #tk'k¨Q©]
iknt³§;¨ lUèkkus xqYQ%] r= #t% LrCèkiknrk[kåtrk ok]
ikÉ".kÁfr t³§keè;s bUnzCkfLr] r= 'k¨f.kr{k;s.k ej.ka] t³§¨o¨Z%
lUèkkus tkuq] r= [kŒtrk] tkuquÅèoZeqÒ;rL«;³~xqyek.kh]
r='k¨QkfÒo`fn§%LrCèklfDFkrk Å#eè;s moÊ] r= 'k¨f.kr{k;kr~
lfDFk'k¨"k%] mO;kZÅèoZeèk¨oa{k.klUèks##ewys y¨fgrk{ka]
r= y¨fgr{k;s.k ej.ka i{kkÄkrks ok] oa{k.ko`"k.k;¨jUrjsfoVia] r=
"kk.<;eYi'kqØzrk ok Òofr] ,oesrkU;sdkn'k lfDFkeekZf.k
O;k[;krkfuA ,rsusrjlfDFkckgw p O;k[;kr© A
fo'ks"krLrq ;kfu lfDFk xqYQtkuqfoVikfu rkfu ckg©
ef.kcUèkdwiZjd{kèkjkf.k] ;Fkk oa{k.ko`"k.k;¨jUrjs foViesoa
o{k%d{k;¨eZè;s d{kèkja] rfLeu~ foènsr ,o¨inzok%] fo'ks"krLrq
ef.kcUèks dq.Brk] dwiZjk[;s dqf.k%] d{kèkjs i{kkÄkr%A
lq-'kk-&6@25
18
Figure showing Marma Position
1. Kshipra
2. Talahrudaya
3. Kurcha
4. Kurchashira
5. Manibandha
6. Indrabasti
7. Kurpar
8. Aani
9. Urvi
10. Lohitaksha.
11. Kakshadhar
12. Neela-2
13. Mannya-2
14. Matruka-4 15. Krukatika
19
In the Pratyek Marma Nirdesh Sharir addhyaya Sushrut explained that
there are Eleven Marmas in each Upper extremity & Nine Marmas in the
Greeva namely –
1. Kshipra. 7. Kurpara. 13. Mannya - 2
2. Talahrudaya. 8. Aani. 14. Matruka - 4
3. Kurcha. 9. Urvi. 15. Krutika - 1
4. Kurchashira. 10. Lohitaksha.
5. Manibandha. 11. Kakshadhar.
6. Indrabasti. 12. Neela - 2
Describing the Sthana (Position) of each Marma Sushrut explain as –
1. Kshipra – Between Thumb & Index Finger.
2. Talahrudaya – At the center of the Palm.
3. Kurcha – Just above the Kshipra Marma.
4. Kurchashira – Just below the Wrist joint.
5. Manibandha – At the junction of Forearm & Wrist.
6. Indrabasti – At midpoint of the distance between Kurpar & Manibandha
sandhis.
7. Kurpar – At the Elbow joint.
8. Aani – Three Angul above the kurpara Marma.
9. Urvi – At the midpoint of the Arm.
10. Lohitaksha – Above th Urvi Marma & Below the Kakshadhar Marma.
11. Kakshadhar – At the midpoint of te Axila.
12. Neela – On both the sides of the trachea.
13. Mannya – On both the sides of the trachea.
14. Matruka – On both the sides of the Neck.
15. Krukatika – At the junction of the Head & Neck.
20
Viddha Lakshana Of Each Marma :
Describing the viddha lakshana of each marma Sushrut explain as –
1. Kshipra – Death due to Convulsions.
2. Talahrudaya – Death due to severe Pains.
3. Kurcha – Loss of Rotation of Wrist & Tremors.
4. Kurchashira – Pain & Swelling.
5. Manibandha – Kunthata i.e. ¼djL; vdeZ.;Roe~½ Loss of function.
6. Indrabasti – Death due to excessive Blood loss.
7. Kurpar – Kuni i.e. ¼ladqfprckgqeè;½ Contracture.
8. Aani – Swelling & Stiffness of the Arm.
9. Urvi – Wasting of the Extremity due to Blood Loss.
10. Lohitaksha – Excessive Blood Loss & Death, Paralysis.
11. Kakshadhar – Hemiplegia.
12. Neela – Mookata (Loos of speech), Swaravaikrut (Defective voice).
13. Mannya – Arasagnyata (Loss of Taste).
14. Matruka – Sadhyo pranahar Marana.
15. Krukatika – Chala moordhata (Instability of Head).
HETU :
In Samhita Granthas disease Vishwachi is described under Vata
Vyadhi Nidan Adhyaya & there for common Vata prakopak Hetus are
considered as hetus of Vishwachi.
21
GRANTHOKTA VATA PRAKOPAK HETU :
r=cyof}xzgkfrO;k;keO;ok;kè;;uÁiruÁèkkouÁihMu]
vfÒ?kkry³~uIyouÁrj.kjkf=tkxj.kÒkjgj.k]
xtrqjxjFkinkfrp;kZ dVqd"kk;frä:{ky?kq'khroh;Z
'kq"d'kkdoYyqjojd®íkydd®jnw"k';kekd]
uhokjeqn~Xkelwjk<dhgjs.kqdyk;fu"ikoku'kufo"kek'kukè;'ku]
okrew=iqjh"k'kqØzPNÆn{koFkwn~Xkkjck"iosxfo?kkrkfnfÒÆo'¨"©okZ;q%
Ád¨ieki|rsAA lq-lw-21@19
In this quotation Sushrut has listed common Vataprapok Hetus as
follows –
1. Balavat vigraha – Fighting with a person stronger than you.
2. Aati vyayama – Excessive Exercise.
3. Aati vyavaya – Excessive Sexual Intercourse.
4. Aati Addhyayana – Excessive Study.
5. Prapatan – Falling down.
6. Pradhavan – Excessive Running.
7. Prapidan – Excessive Pressurising.
8. Abhighat – Trauma.
9. Langhan – Long Jump.
10. Plavan – Excessive Hopping.
11. Prataran – Excessive Swimming.
22
12. Ratri jagaran – Sleeping Late night.
13. Bhara Haran – Lifting Heavy objects.
14. Gaja-Turaga Ratha Aaticharya – Excessive Travelling.
15. Padaticharya – Excessive Walking.
16. Aati Katu, Tikta, Kashaya Rasabbhyasa.
17. Aati Laghu, Ruksha, Sheet Ahara sevan.
18. Shushka Shaka, Mansa sevan.
19. Kudhanya Aati sevan.
20. Kalaya, Nishpav (Mutter, Pavata ) Aati sevan.
21. Anashan – Starvation.
22. Vishamashan.
23. Adhyashan
24. Vegavrodh – Holding Natural Urge.
23
REVIEW FROM MODERN SCIENCE
Anatomy –
Clinically relevant anatomy of the cervical region divides cervical
vertebrae in to two groups that is Typical cervical vertebrae & Atypical
cervical vertebrae.
I) TYPICAL CERVICAL VERTEBRAE :
C3, C4, C5, C6 are defined as typical cervical vertebrae because they
share common structural characteristics. The components of typical cervical
vertebrae include an anterior body & posterior arch formed by lamina &
pedicles. The lamina blends in to the lateral mass which comprises the bony
region between superior articular process & inferior articular process.
The paired superior & inferior articular process form the facet joint. The
intervertebral foramina protects the exiting spinal nerves & are located
behind the vertebral bodies between the pedicles of adjacent vertebra. The
transverse foremen located at the base of the transverse process, permits
passage of the vertebral artery. The spinous process originates in the mid
sagital plane at the junction of the lamina & is bifid.
24
I) ATYPICAL CERVICAL VERTEBRAE :
C1, C2, C7 are defined as atypical cervical vertebrae as they possess
unique structural & functional features.
A) C1 - (Atlas)
The ring like atlas is unique because during the development, its body
fuses with the axis (C2) to form the Odontoid process. Thus the atlas has no
body. It is composed of two thick loadbearing Lateral masses, with concave
Superior & Inferior articular facets. Connecting these facets are a
relatively straight, short Anterior arch & a longer, curved Posterior arch.
The posterior ring has a grove on its posterior-superior surface for the
vertebral artery & first cervical nerve.
B) C2 – ( Axis ) :
25
The Axis receives its name from its Odontoid process (Dens), which
forms the axis of rotation for the motion of Atlantoaxial joint. The Dens is
formed from embryologic body of the atlas. The dens has an Anterior
hyaline articular surface for articulation with the anterior arch of C1 as well
as a Posterior articular surface for articulation with the Transverse
ligament. Hyper flexion or hyper extension injuries may subject the axis to
share stress, resulting in a fracture through the Pars region termed as
Hangman’s fracture.
C) C7 :
The unique anatomic features of C7 vertebra reflect its location as the
Transitional vertebra at the cervicothoracic junction. It has long nonbifid
spinous process. Its Foramen transversarium usually contains vertebral
veins but usually does not contain vertebral artery which generally enters the
cervical spine at the C6 level. The Transverse process of C7 vertebra is
Large in size & possesses only Posterior tubercle. Lateral mass of C7 is the
thinnest lateral mass in the cervical spine. The Inferior articular process of
C7 is in relatively perpendicular direction like thoracic facet joints.
26
III) NORMAL RANGE OF MOTION ACROSS THE
CERVICAL REGION :
Facet joint orientation, bony architecture, inter vertebral discs,
uncovertebral joints & ligaments all play a role in determining range of
motion at various levels of the cervical spine. Approximately 50% of cervical
flexion-extension occurs at the occiput-C1 level. Approximately 50% of
cervical rotation occurs at the C1-C2 level. Lesser amount of flexion-
extension, rotation & lateral bending occur segmentally between C2 & C7.
IV) KEY ANATOMIC FEATURES OF THE JOINTS IN THE
CERVICAL REGION
A) Atlanto – occipital joint :
The Atlanto – occipital joints are synovial joints comprised of the
convex occipital condyles which articulate with the concave lateral masses of
the atlas. Motion at the Atlanto-occipital joint is restricted primarily to
flexion-extension due to bony & ligamentous constraints & absence of an
Inter vertebral disc.
The most important ligaments are the paired alar ligaments extend from
the tip of the dens to the medial aspect of each occipital condyle & restrict
rotation of the occiput on the dens.
B) The Atlanto – Axial joint :
27
The Atlanto – axial articulation is composed of three synovial joints
i.e. paired lateral mass articulations & a central articulation between dens &
the anterior C1 arch. The primary motion at the Atlanto-axial joint is rotation.
The transverse Atlantal ligament is the major stabilizer at the C1-C2 level,
attaches to the medial aspect of the lateral masses of the atlas. This ligament
has wide middle portion where it articulates with the posterior surface of the
dens. Superior & inferior longitudinal fasciculi extend to insert on the anterior
foramen magnum & the posterior body of the axis respectively. These
structures are collectively named as cruciform ligament. This ligament holds
the dens firmly against the anterior arch of the atlas.
C) Subaxial cervical facet joints :
In the C3 to C7 cervical vertebrae, at each level there are paired
superior & inferior articular processes. The superior articular process is
positioned anterior & inferior to the inferior articular process of the adjacent
cervical vertebra. These articulations are covered with hyaline cartilage &
form synovial zygapophyseal joints. The orientation of the facet joints is a
major factor in the range of motion of the cervical spine. These are the most
horizontally oriented regional facet joints in the spinal column. The
28
orientation of these facets allows flexion & extension, lateral bending &
rotation of the lower cervical spine.
Flexion & extension are greatest at the C5-C6 & C6-C7 levels. This
has been considered to be responsible for the relatively high incidence of
degenerative changes noted at these two cervical levels.
V) IMPORTANT LIGAMENTS OF CERVICAL REGION :
1) Apical ligament – Extends from the tip of the dens to the foramen
magnum.
2) Alar ligament – Extends from the lateral dens & attaché to the medial
border of the occipital condyles.
3) Anterior Atlantoaxial ligament – Continuous with the anterior
longitudinal ligament in the lower cervical region.
4) Posterior Atlantoaxial ligament – Continuous with the ligamentum
flavum in the subaxial spine.
5) Cruciform ligament – Transverse Atlantal ligament & superior &
inferior fascicule combine together to form this ligament.
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6) Anterior longitudinal ligament – This strong ligament extends from
the body of the axis to the sacrum binding the anterior aspect of the
vertebral bodies & intervertebral discs together. It resists hyper
extension of the spine & gives stability to the anterior aspect of the disc
space.
7) Posterior longitudinal ligament – This is the weaker ligament which
extends from the axis to the sacrum. It serves to protect from
hyperflexion injury & reinforces the intervertebral discs from
herniation.
8) Ligamentum flavum – This structure may be considered to be a
segmental ligament which attaches to adjacent lamina. It is continuous
with the facet capsule.
9) Inter spinous & supra spinous ligaments – These ligaments lie
between the spinous processes. The supraspinous ligament is in
continuity with the ligamentum nuchae, which runs from C7 to the
occiput & acts as a posterior tension band to maintain an upright neck
posture.
VI) NORMAL CERVICAL CURVATURE i.e. CERVICAL
LORDOSIS:
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This curvature initiated during the late foetal period but do not become
significant until after birth when the spinal column begins to bear the weight
of the body & head. This curvature is caused by differences in the anterior &
posterior dimensions of the intervertebral discs. Cervical curve is a secondary
curve as it does not exist from the embryonic stage.
VII) THE INTERVERTEBRAL DISC :
Each intervertebral disc is composed of a central gel like nucleus
pulposus surrounded by a peripheral fibrocartilaginous annulus fibrosus.
The end plates of the vertebral bodies are lined with hyaline cartilage & bind
the disc to the vertebral body. The nucleus pulposus is composed of
glycosaminoglycans & type – II collagen, which have the capacity to bind a
large amount of water. This mucoid nucleus pulposus functions as a dynamic
shock absorber, moving posterior with flexion of the vertebral column. The
annulus fibrosus is composed of concentric layers of fibrous connective tissue
& fibrocartilage retains the mucoid nucleus.
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VIII) CERVICAL NERVE ROOTS & THEIR RESPECTIVE
AREA OF SENSATION :
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Chart showing nerve roots & their respective area of sensation:
IX) COMMON CONGENITAL ANOMALIES OF CERVICAL
REGION :
Common congenital anomalies of cervical spine are divided in to two
groups according to their location as upper cervical region i.e. (occiput – C2)
& subaxial cervical region i.e. (C3 – C7).
Nerve root level Disc level Area of sensation
C-1 Occiput - C1 No skin supply.
C-2 C1 – C2 Occipital region & posterior neck.
C-3 C2 – C3 Posterior neck &
Supraclavicular region
C-4 C3 – C4
Posterior neck to scapular spine,
Infra clavicular region along the
Anterior chest.
C-5 C4 – C5 Lateral arm i.e. over deltoid & below.
C-6 C5 – C6 Lateral forearm ,
Thumb & index finger.
C-7 C6 – C7 Middle finger.
C-8 C7 – T1 Ulnar aspect of forearm ,
Ring & little finger.
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1) Occiput – C2 region :
A) Basilar impression – Basilar impression is a downward displacement
of the base of the skull in the area of foramen magnum & identified by
the protrusion of the tip of the odontoid through the foramen magnum.
It is the most common congenital anomaly of the upper cervical spine.
B) Congenital cervical stenosis.
C) Arnold – Chiari malformation – The Arnold – chiari malformation is
a developmental anomaly in which the brainstem & cerebellum are
displaced caudally in to the spinal canal.
D) Occipitalisation of C1 – In this type C1 fuses with occipital condyles.
E) Odontoid anomalies – i.e. Aplasia, Hypoplasia
2. Subaxial cervical region :
A) klippel – feil anomaly -
The spinal anomaly associated with the klippel – feil syndrome is
congenital fusion of the cervical spines. The number of fused segments may
vary from two segments to fusion of the entire spine.
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B) Neurofibromatosis
X) CERVICAL SPONDYLOSIS :
Cervical Spondylosis is a nonspecific term that refers to any lesion
of the cervical spine of a degenerative nature. Cervical Spondylosis results
from an imbalance between formation & degeneration of proteoglycans &
collagen in the intervertebral disc. With aging a negative imbalance with
subsequent loss of disc material results in degenerative changes. This disc
degeneration may result in osteophyte formation, ligament hypertrophy &
synovial cyst formation.
In all Cervical Spondylosis is degenerative Osteoarthritis of the
Cervical spine leads to various symptoms.
1) Epidemiology :
A) Herniation most often involves the C5 – C6 disc , followed by the C6 –
C7, C4 – C5 discs.
B) People in the fourth decade of life are affected most often.
C) Men outnumber women by a ratio of 1.4 : 1
2) Causes :
A) Lifting heavy objects.
B) Pushing or pulling heavy objects.
C) Operating vibrating equipments.
D) Some occupational aud postures.
E) Driving automobiles for long distance & spending significant time in
driving.
F) Cigarette smoking.
G) Trauma in the neck region.
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H) Some chronic metabolic disorders.
3) Symptoms :
A) Neck pain.
B) Neck stiffness.
C) Shoulder, Arm or hand pain.
D) Tingling , numbness in the hand.
E) Muscle weakness.
F) Vertigo with sudden neck movement.
4) Differential diagnosis between cervical spondylosis
& Cervical disc herniation
Condition Cervical
Spondylosis
Cervical disc
Herniation
Age >50 yrs. <50 yrs.
Sex Male > Female Male = Female
Onset Insidious Acute
Pain location Neck & Arm Arm
Neck stiffness Yes No
Weakness Yes Yes or no
Mylopathy More common Less common
Dermatomes
affected One or multiple One
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5) Imaging :
A) X – Ray :
The cervical spine series includes an AP view , a lateral view & oblique view
in the x-ray
AP – view : Gives an idea about cervical rib or cervical stump.
Lateral view : Evaluate overall alignment. Those with Cervical
Spondylosis will often have loss of normal lordosis. This view also
evaluate the narrowing of intervertebral disc spaces, cervical
osteophytes & lysthesis of the cervical spine.
Oblique view : This view revel the foramen & they should be
evaluated for spinal canal stenosis.
B) Magnetic Resonance Imaging :
M.R.I. is the best modality for imaging the cervical spine. It gives clear
cut idea about herniated disc, degenerative disc, facet arthritis, nerve root
compression, cord compression & tumor.
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Radiological spinal abnormality or herniation of a disc is not
necessarily a symptomatic event in the Radiograph of a patient suffering from
Cervical Spondylosis.
(Ref. Core knowledge in orthopedics, by Mc Covin )
B) CT Myelography :
Modality of choice for those who cannot undergo an MRI.
Good for postoperative imaging if any hardware was placed.
Advantages – Good patient tolerance, Excellent imaging of the
cervical spine, Can be performed in conditions in which MRI is
contraindicated.
Disadvantages – Invasive requires a dye load, anaphylactic reaction to
the injected dye may occur, requires radiation, Difficult for patients with
claustrophobia.
6) Treatment options in the management :
A) Nonsurgical management :
Non surgical management includes Pharmacological management,
Physiotherapy & use of cervical orthoses.
i) Pharmacological management :
Use of NSAID (CENTRALLY & PERIPHERALLY acting) &
Celecoxib cyclooxygenase-2 inhibitors are useful for decreasing the
inflammation around the entrapped nerve root.
Muscle relaxants have been shown to have some benefit when there is
cervical muscle spasm.
Narcotics & sedatives may be useful in acute flare-ups. However
prolong use of these drugs should be avoided because of their high risk
of developing dependency.
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Antidepressants may be necessary for emotionally depressed patients
with chronic cervical pain.
Opioid analgesics shows great efficacy even after prolong use, without
any organ toxicity or addiction.
ii) Physiotherapy :
Advice regarding Postural changes.
Specific exercise according to the pathology & its level at the cervical
spine.
Gentle massage & hot fomentation.
Progressive resistance training.
iii) Cervical orthoses :
Soft Cervical Collar
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Rigid Cervical Collar
CervicaCervical orthosis is an apparatus that provides support or
attempts to improve function of the cervical spine. Cervical collar is most
commonly used in patients with Cervical Spondylosis. Soft or rigid collar is
advised according to the level of movement restriction & force desired.
B) Surgical management :
Anterior cervical discectomy and fusion with or without
instrumentation.
Anterior cervical corpectomy and fusion with instrumentation.
Laminaplasty.
Laminectomy.
Laminectomy and fusion with or without instrumentation.
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The choice of surgical technique to be preferred depends upon the level
or levels involved, the number of levels involved, the presence of central
canal stenosis, the presence of foraminal stenosis & other associated factors
such as spondylolisthesis, kyphosis, ossification of the posterior longitudinal
ligament etc.