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Essay: Neck pain

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Neck pain is a very common complaint in most of the people during their lifetime during work and that number may very well rise, due to lack of knowledge about better posture during study and any other work like prolong sitting in front of computer. Neck ache is related to occupation which demand sitting in static posture.
Neck region is the most mobile and the most utilized part and neck pain is common musculoskeletal symptom. Neck problem are not life threatening, but they do cause pain and stiffness, often resulting in utilization of healthcare resources, absenteeism from work, and disability. Mechanical neck pain is not attributable to a specific disease or disorder and is labeled as soft-tissue rheumatism or muscular/mechanical/postural neck pain. In the absence of traumatic injuries, the main cause of mechanical neck pain is poor posture, which in turn result in abnormal forces and strain on musculature that must balance and control the head as the persistent pain may be caused by inadequately addressed compensatory posture.1
The cervical spine is made up of 7 vertebrae. The first 2, C1 and C2, are highly specialized and are given unique names: atlas and axis, respectively. C3-C7 are more classic vertebrae, having a body, pedicles, laminae, spinous processes, and facet joints.2
C1 and C2 form a unique set of articulations that provide a great degree of mobility for the skull. Approximately 50% of flexion extension of the neck happens between the occiput and C1; 50% of the rotation of the neck happens between C1 and C2. Unlike the other parts of the spine, the cervical spine has transverse foramina in each vertebra for the vertebral arteries that supply blood to the brain.
The cervical spine may be divided into 2 parts: upper and lower. The upper cervical spine consists of the atlas (C1) and the axis (C2).3 The atlas articulates superiorly with the occiput (the atlanto-occipital joint) and inferiorly with the axis (the atlantoaxial joint).
The atlas is ring-shaped and does not have a body, unlike the rest of the vertebrae. The apical, alar, and transverse ligaments, by allowing spinal column rotation, provide further stabilization and prevent posterior displacement of the dens in relation to the atlas. On each lateral mass is a superior and inferior facet (zygapophyseal) joint.
The axis has a large vertebral body, which contains the odontoid process (dens). The odontoid process articulates with the anterior arch of the atlas via its anterior articular facet and is held in place by the transverse ligament. The axis is composed of a vertebral body, heavy pedicles, laminae, and transverse processes, which serve as attachment points for muscles.
There is an extensive arterial anastomotic network around the dens, fed by the paired anterior and posterior ascending arteries arising from the vertebral arteries around the C3 level and the carotid arterial arcade from the base of the skull. The anterior and posterior ascending arteries reach the base of the dens via the accessory ligaments and run cephalad at the periphery to reach the tip of the process. The anastomotic arcade also receives tributaries from the ascending pharyngeal arteries that join the arcade after passing through the occipital condyle.
The craniocervical junction and the atlantoaxial joints are secured by the external and internal ligaments. The external ligaments consist of the atlanto-occipital, anterior atlanto-occipital, and anterior longitudinal ligaments. The internal ligaments have 5 components, as follows: The transverse ligament holds the odontoid process in place against the posterior atlas, which prevents anterior subluxation of C1 on C2. The accessory ligaments arise posterior to and in conjunction with the transverse ligament and insert into the lateral aspect of the atlantoaxial joint; the apical ligament lies anterior to the lip of the foramen magnum and inserts into the apex of the odontoid process. The paired alar ligaments secure the apex of the odontoid to the anterior foramen magnum. The tectorial membrane is a continuation of the posterior longitudinal ligament to the anterior margin of the foramen magnum.4
The 5 cervical vertebrae that make up the lower cervical spine, C3-C7, are similar to each other but very different from C1 and C2. Each has a vertebral body that is concave on its superior surface and convex on its inferior surface.
These uncovertebral joints are most noticeable near the pedicles and are usually referred to as the joints of Luschka.5 The spinous processes of C3-C6 are usually bifid, whereas the spinous process of C7 is usually nonbifid and somewhat bulbous at its end.
The anterior surface is reinforced by the anterior longitudinal ligament and the posterior body by the posterior longitudinal ligament, both of which run from the axis to the sacrum. Articulations include disk-vertebral body articulations, uncovertebral joints, and zygapophyseal (facet) joints. The disk is thicker anteriorly, contributing to normal cervical lordosis, and the uncovertebral joints in the posterior aspect of the body define the lateral extent of most surgical exposures. The facet joints are oriented at a 45º angle to the axial plane, allowing a sliding motion; the joint capsule is weakest posteriorly. Supporting ligamentum flavum, posterior, and interspinous ligaments also strengthen the posterior column.6
The vascular anatomy consists of a larger anterior spinal artery located in the central sulcus of the cord and paired posterior spinal arteries located on the dorsum of the cord. It is generally accepted that the anterior two thirds of the cord is supplied by the anterior spinal artery and that the posterior one third is supplied by the posterior arteries.7
The facet joints in the cervical spine are diarthrodial synovial joints with fibrous capsules. The joint capsules are more lax in the lower cervical spine than in other areas of the spine to allow gliding movements of the facets. The joints are inclined at an angle of 45° from the horizontal plane and 85° from the sagittal plane. This alignment helps prevent excessive anterior translation and is important in weight-bearing.7
Intervertebral discs are located between the vertebral bodies of C2-C7. Intervertebral disks are located between each vertebral body caudad to the axis. These disks are composed of 4 parts. Intervertebral discs are located between the vertebral bodies of C2-C7. Intervertebral disks are located between each vertebral body caudad to the axis
These disks are composed of 4 parts: the nucleus pulposus in the middle, the annulus fibrosis surrounding the nucleus, and 2 end plates that are attached to the adjacent vertebral bodies. They serve as force dissipators, transmitting compressive loads throughout a range of motion. The disks are thicker anteriorly and therefore contribute to normal cervical lordosis. Although the cervical spine consists of 7 cervical vertebrae interspaced by intervertebral disks, the complex ligamentous network keep the individual bony elements behaving as if they were a single unit. As noted, the cervical spine can be viewed as being made up of anterior and posterior columns. It can also be useful to think in terms of a third (middle) column, as follows: The anterior column consists of the anterior longitudinal ligament and the anterior two thirds of the vertebral bodies, the annulus fibrosus, and the intervertebral disks. The middle column is composed of the posterior longitudinal ligament and the posterior one third of the vertebral bodies, the annulus fibrosus, and the intervertebral disks. The posterior column is made up of the posterior arches, including the pedicles, transverse processes, articulating facets, laminae, and spinous processes.8
The muscular system of the spine is complex, with several different muscles playing important roles. The primary function of the muscles is to support and stabilize the spine. Specific muscles are associated with movement of parts of the anatomy. For example, the Sternocleidomastoid muscle (neck area) assists with movement of the head, while the Psoas Major muscle (low back area) is associated with flexion of the thigh. The muscles in the vertebral column serve to flex, rotate, or extend the spine
The longitudinal ligaments are vital for maintaining the integrity of the spinal column. Whereas the anterior and posterior longitudinal ligaments maintain the structural integrity of the anterior and middle columns, the posterior column alignment is stabilized by a complex of ligaments, including the nuchal and capsular ligaments, and the ligamentum flavum.9
Several ligaments of the cervical spine that provide stability and proprioceptive feedback are worth mentioning and are briefly described here. The transverse ligament, the major portion of the cruciate ligament, arises from tubercles on the atlas and stretches across its anterior ring while holding the odontoid process (dens) against the anterior arch. A synovial cavity is located between the dens and the transverse process. This ligament allows rotation of the atlas on the dens and is responsible for stabilizing the cervical spine during flexion, extension, and lateral bending. The transverse ligament is the most important ligament for preventing abnormal anterior translation.10
The alar ligaments run from the lateral aspects of the dens to the ipsilateral medial occipital condyles and to the ipsilateral atlas. They prevent excessive lateral and rotational motion while allowing flexion and extension. The anterior longitudinal ligament (ALL) and the posterior longitudinal ligament (PLL) are the major stabilizers of the intervertebral joints. Both ligaments are found throughout the entire length of the spine; however, the ALL adheres more closely to the disks than the PLL does, and it is not well developed in the cervical spine. The ALL becomes the anterior atlanto-occipital membrane at the level of the atlas, whereas the PLL merges with the tectorial membrane. Both continue onto the occiput. The PLL prevents excessive flexion and distraction.10
The supraspinous ligament, the interspinous ligaments, and the ligamentum flavum maintain stability between the vertebral arches. The supraspinous ligament runs along the tips of the spinous processes, the interspinous ligaments run between adjacent spinous processes, and the ligamentum flavum runs from the anterior surface of the cephalad vertebra to the posterior surface of the caudad vertebra.9
The interspinous ligament and (especially) the ligamentum flavum control for excessive flexion and anterior translation. The ligamentum flavum also connects to and reinforces the facet joint capsules on the ventral aspect. The ligamentum nuchae is the cephalad continuation of the supraspinous ligament and has a prominent role in stabilizing the cervical spine. 9
Neck has two basic movements first is rotational movement that is the movement of vertebra around an axis. All rotation produce change in orientation of the vertebra. Second movement is translation and it is the movement of whole vertebra by same amount in a given direction. There isno change in the orientation of vertebra. It is the gliding of vertebrae, it rarely occurs by itself but often accompanies other movements. The movements of each spinal segment are limited by anatomical structures such as ligaments, intervertebral discs, and facets. Specifically, anatomical structures cause the coupling of motions of the spine, that is, movements occur simultaneously.
Neck pain is defined as “pain, ache or discomfort” in the anatomical area between occiput and third thoracic vertebra and laterally between the medial margin of the scapulae (see shaded area on the figure).11As shawded area below.
Neck pain can occur anywhere in your neck, from the bottom of your head to the top of your shoulders. It can spread to your upper back or arms. It may limit how much you can move your head and neck. Neck pain is an unpleasant sensory and emotional experience in the neck area associated with actual or potential tissue damage or described in terms of such damage. Neck pain is traditionally viewed as pain symptom in a defined anatomical area. Thus, neck pain is an unspecified pain symptom (or syndrome) not a clinical sign – that covers a variety of specific disorders, for example spinal tumors, spinal infections, and fractures. However, these specific disorders only account for approximately 10% of all cases5 so in most cases NP is non-specific (i.e. no organic or pathological cause of the symptoms can be identified) and is therefore termed a functional (somatic) symptom. Thus, NP covers a range of specific pathological disorders to more somatic conditions and must therefore be seen as a heterogeneous group of pain (or perceived pain) syndromes with anatomical reference to the neck area.12,13
There are many factors associated with neck and upper extremity conditions that contributes: such as individual, physical, and psychosocial factors. Current evidence suggests that risk factors include female gender, older age, having high job demands, low social and work support, being an ex-smoker, and having a history of spinal disorders. Studies have also shown that the prevalence of neck pain is highest during the middle years, after which it begins to reduce. Noticeably, some physical factors are associated with neck pain, including prolonged computer work for undergraduate students and prolonged sitting and neck flexion for office workers.
Posture and workplace ergonomics play important roles to the development of neck and shoulder symptoms associated with computer use.14
Neck pain can be mechanical, overuse, such as too many hours hunched over a steering wheel, often triggers muscle strains. Even such minor things as reading in bed or gritting your teeth can strain neck muscles. Impairments of cervico-cephalic kinaesthesia and habitual forward head posture ave been considered important in the aetiology of postural neck pain. Neck joints tend to undergo wear and tear with age, which can cause osteoarthritis in your neck.
Neck pain may be classified according to the duration of symptoms as acute (less than 4 weeks), sub-acute (4–12 weeks), chronic (more than 12 weeks).15
Risk factors for neck pain are, workplace-associated risks: poor workplace design, awkward neck postures, neck flexion, arm posture, duration of sitting, twisting or bending of the body, hand or arm vibration. Excessive use of pillows and psychosocial factors that may indicate increased risk for chronicity and work or family problem.
Sign and symptoms of neck pain are, headache, numbness, tingling or weakness in the arm. Pain intensity of neck can be measured by pain scale. Pain scales are based on self- report, observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible.
The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders describes neck pain as pain located in the anatomical region of the neck with or without radiation to the head, trunk, and upper limbs. It defines the posterior neck region from the superior nuchal line to the spine of the scapula and the side region down to the superior border of the clavicle and the suprasternal notch. The IASP definition limits the pain symptoms down to T1 vertebra and does not include the various regions that neck pain can be referred to, whereas the Neck Pain Task Force includes in its definition the areas of referral destination. Chronic neck pain is described as an often widespread sensation with hyperalgesia in the skin, ligaments, and muscles on palpation and in both passive and active movements in neck and shoulder area.16
Nevein M M Gharib et.al in 2013 conducted a survey in Taif University, Saudia Arabia and found that the female students had a high prevalence of mechanical neck pain. It is most common in clinical students and its prevalence increased with higher level of study. Fifty-four percent (162 students) of the undergraduate university students reported experiencing neck pain that persists for more than 24 hours. The prevalence of neck pain increased substantially between the first and second years and continued at this higher level during the third and fourth year. Further clinical attention is needed for the neck pain among university students. There was association between neck pain status and the length of the study as greater percent of participants who had studied in the university for more than 1 year (second-fourth year students) reported neck pain compared with first-year students and they were at risk of developing neck problems. Postural bad habits should be prevented through proper guidelines. Results of the study revealed that there is significant association between degree of neck disability and neck pain.1
The International Association for the Study of Pain (IASP) describes cervical spinal pain as pain perceived anywhere in the posterior region of the cervical spine, from the superior nuchal line to the first thoracic spinous process. This is consistent with patients’ notions of neck pain. Bogduk and McGuirk also suggest that neck pain may be subdivided into upper cervical spinal pain and lower cervical spinal pain, above or below an imaginary transverse line through C4. From upper cervical segments, pain can usually be referred to the head, whereas from lower cervical segments, pain can be referred to the scapular region, anterior chest wall, shoulder, or upper limb. They also define suboccipital pain as the pain located between the superior nuchal line and C2, an area that appears to be the source of cervicogenic headache. In that aspect, the division of neck pain into suboccipital and upper and lower cervical pain may be important for clinicians and researchers in recognizing the area of the source of pain and trying to determine the possible causes.16
L. Smith et.al in 2009 conducted a study in South Africa and observed that there is a relationship between high hours of computing and neck pain in school students. There is an association between neck pain and high hours of computing for school students, sitting for long periods in fixed position such as using laptops may result in adolescent neck pain. It has confirmed the need to educate new computer users (school students) about appropriate ergonomics and postural health..17
Antonio-Jose Diaz-Caballero et.al in 2010 found that dentistry students are more prone to neck pain. There is also a positive association between presence of pain and specific forced postures: torsion of the trunk, moving the shoulders towards the side, elevating thsse elbows, operating light too far away from the line of vision when working on the maxillary arch, working with the hands close to the patient´s face and working for long periods of time. Muscular pain was reported in 80% of students due to clinical practice. The result of the study show that neck pain is caused by adopting inadequate posture to gain better vision of the oral cavity, performing exaggerated flexion or cervical torsions could produce muscular pain. And female population is at higher risk of neck pain. A large majority of students performed torsions or cervical flexion to improve vision when working, adopting an inclined posture of the neck and maintaining a seating position in the middle of the stool. Only 13% of students did stretching exercises. Adequate posture adoption in work environment can reduce the frequency of musculoskeletal lesion. 18
Therese N. Hanvold ET. Al in 2010 and observed neck pain among 173 technical school students. Students were found to have high prevalence of neck in students. There were few students reporting severe pain. Neck, shoulder, and upper back pain are common among adolescents and may persist into working life. 19
Harutunian Karmen ET. Al in 2011 performed a cross-sectional study among students and faculty members of dentistry students. The results shows that most of the dentist had experienced some kind of musculoskeletal pain in last 6 months, neck was found to be the most commonly affected site. Women showed a higher frequency of intense pain involving the cervical, lumbar, and wrist areas. Pain is more prevalent in cervical region. 20
Betina et.al in 2015 concluded that there is a weak association between musculoskeletal disorders and computer use, including tension neck syndrome. Some researcher found that keying with a more extended elbow, greater downward head tilt, and use of arm rests could reduce risks of developing neck and shoulder symptoms and disorders. Since computer use often involves maintaining the same posture for prolonged periods of time, the muscles of the neck and shoulder may become overworked to maintain the static posture and supporting the head in improper postures. Several studies have supported a relationship between trapezium muscle load and the development of musculoskeletal discomfort in the upper part of the body. There is a high incidence of persistent neck pain in undergraduate students.14
A study was performed by Mohd Azuan ET. Al in 2010 on Malaysian school children declared that neck pain was most common musculoskeletal disorder among school children. It was associated with backrest shape and desk height. The presence of neck pain implied that there was a high level of neck flexion as well as static and awkward postures during sitting. Sitting with flexed trunk increases spinal load, compared to standing and prolonged static sitting increases intradiscal pressure resulting in decrease nutrition to disc and also causing pain. Female experienced more pain than males. This could be due to the gender difference, and male and females differ in their strength as females tend to have lower muscular strength particularly in upper limb. Females also have a greater body awareness and lower pain threshold so complaint more than males. 21
Neck and shoulder symptoms are associated with static working postures. It has also been suggested that dynamic load reveals neck and shoulder symptoms. The purpose of this study was to describe the occurrence of neck and shoulder pain and its association with static and dynamic load in various types of leisure time activity in high school students. Seven hundred eighteen students filled out a question.22
The neck (82%) and lower back (64%) were reported to have the highest prevalence of work related musculoskeletal diseases. Discomfort in the neck region was found to be associated with self-reported frequency of bending of the neck. Neck and lower back are more injury prone areas and are at increased risk of developing musculoskeletal disorder in students. Risk factors for students’ neck symptoms aggravate with working with a bent neck.23
Musculoskeletal pain (MSP) among medical students was relatively high, thus, further clinical assessment is needed in depth study of ergonomics. The study results indicate that medical school authorities should take measures to prevent MSP due to factors related to medical school. Students should make aware of importance of weight reduction to reduce MSP.23
420 medical secretaries took part in a cross-sectional study at examining the prevalence of musculoskeletal disorders as well as the relationship between neck and shoulder pain and possible risk factors. Sixty-three percent had experienced neck pain sometime during the previous year and while 15% had suffered almost constant pain 32% had experienced neck pain only occasionally.24
Many studies concluded that there is an increase in neck pain with increased computer usage. Students are therefore more prone to have neck and upper back pain because of many hours spent reading, studying, working on computer and playing video games. These activities are performed sitting in a static position with the forward head posture, often in poorly designed chairs in classrooms or apartments. Neck pain can result from laptop usage as the keyboard and monitor are kept together that result in slouched posture.
Poor posture that results in neck pain can be describes as: Spinal vertebrae supports the head in upright position. While using laptop head is flexed forward, so the weight of the head is not supported by the vertebrae as much. Due to excessive workload muscles and other soft tissue become tight over time. There is weakness of anterior neck muscle due to excessive stretching and neural structures are kept in less optimal positions. This soft tissue tightness leads to decreased blood flow and oxygen to tissues. The person may maintain a slouched posture due to pain in neck and it continues the pain cycle.
Not all neck pain is posture related. Other reasons are joint stiffness, muscle strain, lifting, sudden neck movement and trauma from falls or accidents.25

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