(2) Cervical Spine Examination and Evaluation Flashcards by Jocelyn Flores

Provide the most common cervical pathologies for each of the following age groups:

Young (<30 y/o)
Middle Age (30-60 y/o)
Older (>60 y/o)

Young (<30 y/o): Ligament sprain / muscle strain

Middle Age (30-60 y/o): Cervical pathology most prevalent in this age group

Older (>60 y/o): Spondylosis and/or Spinal Stenosis

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Bilateral vs. Unilateral Radiation of Symptoms

Bilateral: Myelopathy (SC) / central dysfunction

Unilateral: Radiculopathy / peripheral dysfunction

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Presence of Cranial Nerve Signs (5 D’s, 3 N’s)

Dizziness / Drop Attacks / Diplopia / Dysarthria / Dysphagia

Nausea / Numbness / Nystagmus

+ Ataxic Gait / Gaze Disturbances

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The presence of neck pain with coughing and / or sneezing may be indicative of ___.

disc pathology

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Patient Health Questionnaire (PHQ-2) Screening Questions

Over the past 2 weeks, how often have you had little interest or pleasure in doing things?

Over the past 2 weeks, how often have you felt down / depressed / hopeless?

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3 Mandatory Questions for Patients w/ Neck Pain

1: Any dizziness (vertigo), blackouts or “drop” attacks? - Vertebral Basilar Artery Insufficiency (VBI) / 5 D’s and 3 N’s

2: Any history of RA, other inflammatory arthritis, or treatment with systemic steroids? - CV instability or ligamentous insufficiency / joint degradation can lead to excess motion

3: Any neurological symptoms in the legs? - Cervical Myelopathy / some form of SC compression

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Canadian C-Spine Rules

Indication: ANY history of trauma and no imaging

Purpose: Determine whether Radiography is necessary prior to initiating PT treatment

Sitting position / ambulatory immediately after accident

Current absence of midline c-spine tenderness

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When are the Canadian C-Spine Rules NOT applicable?

Non-trauma cases

Glasgow Coma Scale <15

Unstable vital signs

Age <16

Acute paralysis

Known vertebral disease

Previous c-spine surgery

Pregnant

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How can you distinguish between a ROM deficit that is related to a muscular issue from that of a joint issue?

PROM > AROM: muscle problem

PROM = AROM: joint problem

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Possible Causes for Decreased Extension and R SB ROM

R extension hypomobility

L flexor muscle tightness

Anterior capsular adhesions

R subluxation

R small disk protrusion

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Possible Causes for Decreased Flexion and R SB ROM

L flexion hypomobility

L extensor muscle tightness

L posterior capsular adhesions

L subluxation

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Possible Causes for A Extension and R SB Deficit > Extension and L SB Deficit

L capsular pattern (arthritis / arthrosis)

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Possible Causes for A Flexion and R SB Deficit = Extension and L SB Deficit

Left Arthrofibrosis (very hard capsular end-feel)

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Possible Causes for SB Deficit in Neutral / Flexion / Extension

Uncovertebral hypomobility or anomaly

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Cervical Spine ROM Norms

C0 - C2 / C2 - 7 / Total

C0-C1:
Flexion - 5 / Extension - 10
Rotation - minimal, conjunct
SB - 5

C1-C2:
Flexion - 5 / Extension - 10
Rotation - 35-45
SB - 0

C2-7:
Flexion - 35-70 / Extension - 55-60
Rotation - 30-45
SB - 15-40

Total C-Spine:
Flexion - 80-90 / Extension - 60-70
Rotation - 75-90
SB - 20-45

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Cervical Radiculopathy CPR (Wainner)

C-Spine rotation to painful side <60 degrees
(+) Spurling Test
(+) ULTT #1
(+) Cervical distraction test (relieves symptoms)

3/4 to 4/4 = 65-90% likelihood of Cervical Radiculopathy

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In which age group is neck / UE pain most common?

Middle Age

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The C-Spine has ___ potential for serious injury.

HIGH

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What should be considered in the examination process if a patient has a history of neck trauma?

Exam may be harmful so examine with caution

Imaging studies may be required to exclude fracture or instability

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What distinguishes symptoms related to Muscle / Ligament pathology vs. Bone?

Muscle / Ligament may be immediate OR delayed several hours or days

Bone pain is usually immediate

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3 Domains of Psychosocial Distress (Yellow Flags)

Negative mood

Fear-avoidance

Negative affect / coping

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What timeframe is considered history of “recent” trauma?

Within last 6 weeks

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UMN Signs and Symptoms (Examples)

B UE symptoms

Intermittent reports of LOB (clumsiness)

Decreased coordination in LEs

Which cervical conditions MUST be ruled out?

Ligamentous instability (Transverse, Alar)

Myelopathy

Malignancy

Spinal fx

Vascular pathology (VBI)

At which spinal level is Cervical Myelopathy most likely to occur? Why?

C5-6 SC is largest and spinal canal is smallest here

Cyriax vs. Mckenzie and Maitland Treatment Models

Cyriax: Identifying *structure* responsible and intervening based on treating that structure (healing timeline) Mckenzie and Maitland: Treating based on *impairments* - loading tissue and evaluating symptom response

What three deficits are associated with Forward Head Posture?

Cervical hyperlordosis Shoulder protraction CT hyperkyphosis

What impairments are associated with Cervical Hyperlordosis?

TMJ overcloses Posterior compression CV hyperextension / instability OA flexion hypomobile / OA extension hypermobile AA rotation hypomobile Mid-cervical hyperextension

What impairments are associated with Shoulder Protraction?

GH / AC instability

What impairments are associated with CT Hyperkyphosis?

Hypomobility with t-spine extension and at the shoulder complex RC tendinopathy (decreasing space between Acromion and Humerus, squashing RC)

Facet Joints are overloaded specifically at which spinal levels in relation to Forward Head Posture?

C5/6 and C6/7 This often results in osteophyte formation

Mechanical Neck Pain is pain that changes with ___.

position

When are a patient's symptoms in the neck area labeled as "Mechanical Neck Pain"?

When they are NOT caused by trauma (MVA) / cervical radiculopathy / non-MSK cause

In which age group is Mechanical Neck Pain the MOST prevalent?

30's and 40's

What can Mechanical Neck Pain transition to?

Chronic Neck Pain if symptoms are severe and /or debilitating enough No specific MOI responsible for symptoms here

What spinal level could be responsible if a patient refers to their pain as occurring "inside the shoulder blade?"

Acute Disc Herniations are uncommon in those aged __ years old or younger. They are most commonly seen in ___ -year-olds.

30, 50

T or F: The IVD has a limited ability to self-repair due to a restricted blood supply.

What MOI commonly results in Cervical Radiculopathy?

Hyperextension injuries - especially when combined with rotation and SB

*Disk Level: C4-5* Nerve Root Motor Deficit Sensory Deficit Reflex Compromise

Nerve Root: C5 Motor Deficit: Deltoid / Biceps Sensory Deficit: Anterolateral shoulder and arm Reflex Compromise: Biceps

*Disk Level: C5-6* Nerve Root Motor Deficit Sensory Deficit Reflex Compromise

Nerve Root: C6 Motor Deficit: Biceps / wrist extensors Sensory Deficit: Lateral forearm and hand / thumb Reflex Compromise: Brachioradialis / Pronator Teres

*Disk Level: C6-7* Nerve Root Motor Deficit Sensory Deficit Reflex Compromise

Nerve Root: C7 Motor Deficit: Wrist flexors / Triceps / finger extensors Sensory Deficit: Middle finger Reflex Compromise: Triceps

*Disk Level: C7-T1* Nerve Root Motor Deficit Sensory Deficit Reflex Compromise

Nerve Root: C8 Motor Deficit: Finger flexors / hand intrinsics Sensory Deficit: Medial forearm and hand / ring and little fingers Reflex Compromise: None

*Disk Level: T1-T2* Nerve Root Motor Deficit Sensory Deficit Reflex Compromise

Nerve Root: T1 Motor Deficit: Hand intrinsics Sensory Deficit: Medial forearm Reflex Compromise: None

T or F: C2-3 disc herniations are common.

F They are rare!

Pain Patterns Related to C4 and C5 Nerve Root Compression

C4: Posterior neck / medial scapular border C5: Numbness on superior aspects of shoulders

Difficulty breathing with physical activity may indicate ___ involvement. What spinal levels are associated with this structure?

Diaphragm C3-5

C6 Involvement Pain Pattern

Radiating pain from neck to lateral aspect of upper arm, forearm and hand

Pain Pattern (C7 and C8 Involvement)

C7: Radiating pain from posterior neck to scapula, posterior upper arm, forearm, and hand (MOST COMMON SITE FOR CERVICAL RADICULOPATHY) C8: Radiating pain from neck to medial aspect of upper arm, forearm, and hand

Do patients typically report unilateral or bilateral neck pain in the case of Facet Joint Dysfunction?

Unilateral Reports "crick in the neck" or that they "slept wrong"

What contributes to Facet Joint Dysfunction?

Small piece of synovial membrane getting caught in Z-Joint

T or F: Imaging is typically unremarkable in Facet Joint Dysfunction.

CPR Facet Joint Dysfunction

1. Symptoms < 30 days 2. No symptoms distal to shoulder 3. Looking up does not aggravate symptoms 4. FABQ PA score <12 (pretty active) 5. Diminished upper t-spine kyphosis 6. Cervical extension ROM <30 degrees > or = 3 (+) out of 6 indicate successful outcome with t-spine HVLAT in 86% of patients

What is the *gold standard* for diagnosing Mild C-Spine Instability?

There is none!

What signs and symptoms are associated with Mild C-Spine Instability?

Hx of major trauma Reports of catching / locking / giving way *Unpredictability of symptoms* Subjective reports of neck weakness (head feels heavy) Altered ROM Neck pain with or without muscle spasms Reports of HAs

What are some common MOIs related to Whiplash-Associated Disorders (WAD)?

MVAs Sport-related injuries (concussions) Pulls and thrusts on arms Falls, landing on trunk or shoulder

What are the 4 types of HAs that PT focuses on?

Tension Cervicogenic Cluster Migraine