5. WAD & Pathoanatomical Dx of the C/S Flashcards
WAD stands for….
Whiplash Associated Disorders (WAD)
Structures/tissues involved w/ WAD
*usually multiple tissues involved; diff to establish tissue source(s) of sx’s
- Mm’s
- ligs
- discs
- facets
- spinal nerves (CS)
- CNS
- esophagus
- trachea
- TMJ
Whiplash Grades:
How many?
0-4
Whiplash Grades:
all together
see pics
Whiplash Grades:
Grade 0
No complaints about the neck.
No physical signs
Whiplash Grades:
Grade 1
Neck complaint of pain, stiffness, tenderness only
NO physical signs
Whiplash Grades:
Grade 2
Neck complaint AND MSK signs
MSK signs include: dec’d ROM and point of tenderness
Whiplash Grades:
Grade 3
Neck complaint AND MSK signs AND Neurological signs
Neuro signs include: radicular sx’s, change in reflexes, radiating sx’s, +Spurlings, +ULTT
Whiplash Grades:
Grade 4
Neck complaint AND Fx or Dislocation
These patients are MORE vulnerable to WAD
pts w/ underlying DJD
Remember to do this WITH WADs!!!
Check for neuro signs!!!!!
With WADs… in addition to spinal nerves….what else may be involved?
Brachial Plexus
WAD
Mechanism: Acceleration injury
HyperFLEX
what tissues likely to be injured
Post musculature
Discs
WAD
Mechanism: Acceleration injury
HyperEXT
what tissues likely to be injured?
Facet jts
Discs
Anterior musculature
*NOTE: high # tissues involved w/ both→ hard to determine source
General prognosis for WAD
½ recover w/in 3mos; half have chronic sx’s that last years
WAD
Prognosis:
Greater risk of chronic sx’s if:
- rear-ended
- underlying DJD***
- Neuro deficits
- dermatomes
- myotomes
- DTRs
- etc…
Add. prognostic factors for persisting CS sx’s @ 6mos:
*not predictive for everyone
- high baseline neck pain
- HA @ inception
- less educated
- no seatbelt***
- LBP @ inception
- NDI of >14.5/50
- preinjury h/o neck pain
- high catastrophizing
- female
- WAD grade II (neck complaints + MSK sx’s)
- WAD grade III (neck complaints + MSK + neuro signs)
Systematic review of literature
Key Points w/ WADs
- serious phys injury is RARE
- reassurance about good prognosis → start EARLY
- Over-medicalization is detrimental
- Recovery is improved by early return to pre-accident act. lvls
- Self ex, manual tx, positive attitude and beliefs are important in regaining act. lvls
- Collars, rest, neg attitude and beleifs delay recovery and contribute to chronicity***
Emergency and Acute Care Actions for WADs
Use of rigid back board w/ cervical collar IF WHAT:
- abnorm mental status
- spine tenderness
- neuro deficit
- Distraction MOI
- intoxication
*otherwise, just a c/s collar is adequate
Other Emergency and Acute Care Actions
- neuro exam
- exam of spine to r/o fx or SCI
- if NOT classified as LOW RISK→ X-ray or CT
- use NEXUS criteria or Canadian C-spine Rule
- concussion eval→ overlaps w/ s/s whiplash injury
- NSAIDS, pain meds, mm relaxers
Emergency and Acute Care Actions
talk about the first week and active interventions
Active interventions (in the first week from inj.) reduced costs and morbidity
*GET THEM MOVING!!!
Does this pt need a CS X-ray to R/O Fx or Dislocation?
Canadian Cervical Spine Rule in Alert and Stable Trauma Pts
If pt sustained a trauma, X-ray needed if:
- >65yo
- dangerous MOI
- fall from >3’ elevation or 5 stairs
- axial load to head (ex. driving)
- MVA high speed (>100km/hr (65mph)) or rollover or ejection from vehicle
- MVA pushed into oncoming traffic
- MVA hit by bus or truck
- motorized recreational acts (motorcycles, etc.)
- bicycle collision
- parasthesias in extremities***
If NONE of the Canadian C/S Rule factors are present….
what should you do?
Assess CS rotation AROM if all risk factors are LOW
If NONE of the Canadian C/S Rule factors are present….
assess CS rotation ROM if all risk factors listed below are LOW
Low-risk factors included:
-
simple rear-end MVA (low speed)
- IF high speed, rollover, ejection, get x-ray and do NOT assess ROM
-
pt able to sit in ER waiting room
- IF pt unable to sit, get x-ray and DO NOT assess ROM
-
Pt able to ambulate after accident
- IF unable to ambulate, get x-ray and DO NOT assess ROM
-
delayed onset of neck pain
- IF immediate, get X-ray and DO NOT assess ROM
-
absence of midline CS tenderness
- IF midline tenderness, get x-ray and DO NOT assess ROM
*IF all above low-risk factors present→ assess pts ability to do CS AROM for rotation (L&R)
*IF <45deg to L and R→ get x-ray
*IF >45deg rot to L and R→ NO X-ray
Pts w/ persistent WAD demo. fibrosis of facet-jt meniscoids and fatty infiltration of the DCEMs and deep cervical multifidi and deep cervical flexor mm’s
see pics
T1 axial MRI @ C2-3 lvl demo’ing fatty infiltration (atrophy) in the longus capitis/colli mm’s in Fig A on the L vs healthy control Fig B
Clinical implication
These interventions are important to prevent occurence of chronic WAD w/ potential permanent fatty atrophy
- EARLY activation of the cervical extensors and deep cervical flexors
Which subgroup is BEST for pts w/ WAD?
- IF recent (<30d) and relatively HIGH initial pain ratings/disability→ PAIN CONTROL
- move into any other subgroups after short pd of pain control****
- IF recent (>30d), BUT relatively LOW pain/disability→ ANY other sugroup(s)
Gen Guidelines for Pts w/ WAD
What are the 3 stages and timelines?
- Acute Stage → approx. 2 wks
- Subacute→ 2-10wks
- Chronic→ >10wks
Gen Guidelines for pts w/ WAD
Acute Stage (approx 2 wks)
-
Exam findings:
- swelling, spasm, soreness, stiff
- Spasm of SCM can cause FHP and flattening of CS lordosis
-
Goals:
- protect against further injury, reduce/control pain
-
Interventions:
- gentle mobs
- STM
- modals
- UE mvmt (scap)
- walking
Gen Guidelines pts w/ WAD
Subacute (2-10wks)
- Wean off/min. use of acute stage intervents (get away from modals)
- progress gradually into chronic stage intervents
- DCFMs early on→ think back to early intervention of multifidi in L/S
Gen Guidelines pts w/ WAD
Chronic Stage (>10wks)
-
Goals:
- restoration of C/S lordosis and normal posture
- restore CS ROM and strength
- restore function
- control/elim. pain
- Pathoanatomics of injury (if known) and repro. of pain upon exam are key guides to tx
-
Interventions:
- strength/cond.
- functional retraining
- aerobic
Tissue Sources of Cervical Pain
see pics
REVIEW MEDICAL RED FLAGS FOR SERIOUS SPINAL PATHO!!
MAGEE TABLE 9-6
IN THE L/S UNIT AS WELL!!!
S/S assoc’d w/ C/S Dysfunction
- cervical pain
- HAs
- T/S and scapular pain
- TMJ/craniofacial pain
- UE pain
- UE neuro signs
- P&N, numbness, reflex changes, motor weakness)
- balance, auditory, visual disturbs
- cervical myelopathy
- vertebral aa s/s
Cervical Myelopathy
Defined:
Functional or pathologic changes in the SC
Cervical Myelopathy is a consequence of WHAT?
Consequence of CS DJD, spondylosis, and/or central stenosis
Cervical Myelopathy may also be secondary to _________
Secondary to congenital or dev. cond’s or diseases
Ex’s: CP, tumor, infections, UMN dis., HIV, syph.
Cervical Myelopathy
Dx?
MRI
Correlation w/ clinical exam
S/S Cervical Myelopathy
see pics
Course of Pathology for Cervical Myelopathy
- Prolonged, long pds of non-progressive disability COMMON
- phase of disability for awhile then more progressive loss
- RARE instances of progressive deterioration
Course of Patho for Cervical Myelopathy
Interventions??
- Conservative Tx (meds, PT)
- interventions depend on sx response
- Sx
**AVOID EXTENSION!!!
What interventions should be AVOIDED w/ Cervical Myelopathy
EXTENSION!!!
DJD (OA) in C/S
Will affect what?
Atlanto-occipital jt
Facet jts @ C2-3 and lvls below
Assoc’d w/ DJD (OA)
Spondylosis (OA of spine):
term typ NOT used specifically for facet jts, but more for global degen changes b/w vertebrae and IVF
2 other characteristics of DJD (OA) in C/S
*NOTE: both will limit ROM
*widening of vertebral end plates
*osteophytes may be present
AKA painful facet joints
Facet syndrome
2 types of Stenosis:
- Central (think Cord)
- Lateral (think nerves)
Central stenosis
- watch for s/s of myelopathy
- think cord
Lateral stenosis
- watch for s/s of radiculopathy
- think nerves
3 things assoc’d w/ Disc Patho:
- DDD (think disc hts)
- Bulging*
- Herniations*
NOTE: *→ by age 40, the nucleus’s fluid content has diminished greatly and the nucleus now mostly a “ligamentous/fibrocartilaginous dry core”
Nerve root impingement aka
radiculopathy
“pinched nerve”
Nerve root impingement
Can occur due to…..
- disc bulge
- disc herniation
- DDD
- spondylosis
- lateral stenosis
Terms/jargon assoc’d w/ disc patho:
Protrusion/degen
THINK “BULGING”
post or post/lat bulge w/out any sig. tearing of annulus
Terms/jargon assoc’d w/ disc patho:
Herniations: 3 phases
- Prolapse→ outermost rings of annulus still intact
- Extrusion→ just moving→ annulus completely perforated; disc mat. moves into epidural space
-
Sequestration→ disc fragments “escape” and may migrate into epidural space; may put pressure on:
- SC
- nerve roots
Terms/jargon assoc’d w/ disc patho:
see pics
C/S disc disease (DDD, herniation)
May req. sx intervention IF:
- progressive myelopathy
- worsening of hard neuro s/s over time, OR impairments related to SC involvement
- CS radic. that is recalcitrant (not resp.) to conservative Tx for @ least 6-8wks
- Recurrent radic.
- Progressive neuro deficits (gradual worsening of DTRs, myotomes, derms, and/or peripheralization of sx’s)
- Severe incapacitating neck pain recalcitrant to conservative tx that correlates w/ clinical exam and dx studies
Dx tests used to confirm patho detected upon clinical exam:
- EMG/NCV
- distinguishes bw nerve root compression vs. peripheral neuropathy
- radiographs
- MRI (most Sn img to detect SC patho.)
- Cervical myelogram/CT scan
- good for foraminal stenosis and cortical bony margins
- Provocative discography
- confirms that pain is of discogenic origin and/or determine which disc lvls involved
Most common procedure for C/S Disc Patho
Anterior Cervical Discectomy and Fusion
ACDF
- req’s retraction of midline structures including trachea and esophagus
- ANT. approach req’s disruption of longus coli/longus capitis
- so train them!!!
- Discectomy and resection of foraminal exostosis
- Bone graft inserted into tractioned disc space; fusion plate screwed into ANT. VB’s
Pot. Comps of Sx or Post-Sx Pd.
- Inf.
- dysphagia
- esophageal injury
-
Nerve injury
- laryngeal nerve; SCI; nerve root inj.
- Vascular comps
- vert aa.
- skin breakdown and/or mm atrophy and/or swallowing dysf due to long term collar use
- graft failure
- graft displacement; nonunion; instrumentation failure
- chronic pain
Rehab of Pts who have undergone ACDF Sx
-
Post-op:
- HOB elevated to dec swelling
- sore throat and pain w/ swallowing first few days
- Avoid overactivity before fusion “takes”; avoid strenuous ex’s in 1st 12wks post-op
- *OK to gently mob. nerves, but AVOID tension/stretching of nerves
- *Cervical collar for up to 12wks (typically LESS or NOT AT ALL)
ACDF Sx:
Phase I
- Acute Inflamm Phase→ 0-14days
- Use CS collar to protect sx site
- ADLs w/ correct body mechs and neutral CS
- DAILY walking 5-15min
- UE mvmts below 90degs
ACDF Sx: Phase II
- Reparative Phase→ 3rd week post-op
- Start gentle chest stretch in corner
- Gentle UE AROM ex’s
- AROM, pulleys, finger ladder
- Gentle trunk stabilization ex’s (Neutral CS)
- DAILY walking 15-20mins
- UE mvmts below 90degs
*NOTE: Aerobic ex’s correlated w/ healing post-sx
ACDF Sx: Phase III
Consolidation and Maturation Phase→ from post of Wk 4 to 24wks
Weeks 4-8
- PROM shoulder above 90degs
- active still BELOW 90
- Begin gentle CS AROM
- Begin gentle UE neural glides/mobs/flossing
- Begin strengthening of DCFMs
- Begin UE PREs w/ shoulders below 90degs
- Progress trunk stabilization ex’s (neutral CS)
- Mobs to MID and LOWER T/S segments
- INC WALKING TO 30mins
ACDF Sx: Phase III
Consolidation and Maturation Phase→ from post of Wk 4 to 24wks
Weeks 9-12
- Continue prior exercises (4-8wks), progressing UE PREs to above 90degs
- ADD CS isometrics and strengthening of TS paraspinals and scapular mm’s
ACDF Sx: Phase III
Consolidation and Maturation Phase→ from post of Wk 4 to 24wks
Weeks 13-24
- progress resistance and reps of above ex’s
- ADD functional retraining (work; sports) IF approved by surgeon
