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.