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MSPT II > 5. WAD & Pathoanatomical Dx of the C/S > Flashcards

5. WAD & Pathoanatomical Dx of the C/S Flashcards

1
Q

WAD stands for….

A

Whiplash Associated Disorders (WAD)

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2
Q

Structures/tissues involved w/ WAD

*usually multiple tissues involved; diff to establish tissue source(s) of sx’s

A
  • Mm’s
  • ligs
  • discs
  • facets
  • spinal nerves (CS)
  • CNS
  • esophagus
  • trachea
  • TMJ
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3
Q

Whiplash Grades:

How many?

A

0-4

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4
Q

Whiplash Grades:

all together

A

see pics

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5
Q

Whiplash Grades:

Grade 0

A

No complaints about the neck.

No physical signs

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6
Q

Whiplash Grades:

Grade 1

A

Neck complaint of pain, stiffness, tenderness only

NO physical signs

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7
Q

Whiplash Grades:

Grade 2

A

Neck complaint AND MSK signs

MSK signs include: dec’d ROM and point of tenderness

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8
Q

Whiplash Grades:

Grade 3

A

Neck complaint AND MSK signs AND Neurological signs

Neuro signs include: radicular sx’s, change in reflexes, radiating sx’s, +Spurlings, +ULTT

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9
Q

Whiplash Grades:

Grade 4

A

Neck complaint AND Fx or Dislocation

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10
Q

These patients are MORE vulnerable to WAD

A

pts w/ underlying DJD

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11
Q

Remember to do this WITH WADs!!!

A

Check for neuro signs!!!!!

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12
Q

With WADs… in addition to spinal nerves….what else may be involved?

A

Brachial Plexus

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13
Q

WAD

Mechanism: Acceleration injury

HyperFLEX

what tissues likely to be injured

A

Post musculature

Discs

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14
Q

WAD

Mechanism: Acceleration injury

HyperEXT

what tissues likely to be injured?

A

Facet jts

Discs

Anterior musculature

*NOTE: high # tissues involved w/ both→ hard to determine source

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15
Q

General prognosis for WAD

A

½ recover w/in 3mos; half have chronic sx’s that last years

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16
Q

WAD

Prognosis:

Greater risk of chronic sx’s if:

A
  • rear-ended
  • underlying DJD***
  • Neuro deficits
    • dermatomes
    • myotomes
    • DTRs
    • etc…
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17
Q

Add. prognostic factors for persisting CS sx’s @ 6mos:

*not predictive for everyone

A
  • 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)
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18
Q

Systematic review of literature

Key Points w/ WADs

A
  • 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***
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19
Q

Emergency and Acute Care Actions for WADs

Use of rigid back board w/ cervical collar IF WHAT:

A
  • abnorm mental status
  • spine tenderness
  • neuro deficit
  • Distraction MOI
  • intoxication

*otherwise, just a c/s collar is adequate

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20
Q

Other Emergency and Acute Care Actions

A
  • 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
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21
Q

Emergency and Acute Care Actions

talk about the first week and active interventions

A

Active interventions (in the first week from inj.) reduced costs and morbidity

*GET THEM MOVING!!!

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22
Q

Does this pt need a CS X-ray to R/O Fx or Dislocation?

Canadian Cervical Spine Rule in Alert and Stable Trauma Pts

A

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***
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23
Q

If NONE of the Canadian C/S Rule factors are present….

what should you do?

A

Assess CS rotation AROM if all risk factors are LOW

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24
Q

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:

A
  • 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

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25
Q

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

A

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

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26
Q

Clinical implication

These interventions are important to prevent occurence of chronic WAD w/ potential permanent fatty atrophy

A
  • EARLY activation of the cervical extensors and deep cervical flexors
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27
Q

Which subgroup is BEST for pts w/ WAD?

A
  • 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)
28
Q

Gen Guidelines for Pts w/ WAD

What are the 3 stages and timelines?

A
  1. Acute Stage → approx. 2 wks
  2. Subacute→ 2-10wks
  3. Chronic→ >10wks
29
Q

Gen Guidelines for pts w/ WAD

Acute Stage (approx 2 wks)

A
  • 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
30
Q

Gen Guidelines pts w/ WAD

Subacute (2-10wks)

A
  • 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
31
Q

Gen Guidelines pts w/ WAD

Chronic Stage (>10wks)

A
  • 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
32
Q

Tissue Sources of Cervical Pain

A

see pics

33
Q

REVIEW MEDICAL RED FLAGS FOR SERIOUS SPINAL PATHO!!

MAGEE TABLE 9-6

A

IN THE L/S UNIT AS WELL!!!

34
Q

S/S assoc’d w/ C/S Dysfunction

A
  • 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
35
Q

Cervical Myelopathy

Defined:

A

Functional or pathologic changes in the SC

36
Q

Cervical Myelopathy is a consequence of WHAT?

A

Consequence of CS DJD, spondylosis, and/or central stenosis

37
Q

Cervical Myelopathy may also be secondary to _________

A

Secondary to congenital or dev. cond’s or diseases

Ex’s: CP, tumor, infections, UMN dis., HIV, syph.

38
Q

Cervical Myelopathy

Dx?

A

MRI

Correlation w/ clinical exam

39
Q

S/S Cervical Myelopathy

A

see pics

40
Q

Course of Pathology for Cervical Myelopathy

A
  • Prolonged, long pds of non-progressive disability COMMON
    • phase of disability for awhile then more progressive loss
  • RARE instances of progressive deterioration
41
Q

Course of Patho for Cervical Myelopathy

Interventions??

A
  • Conservative Tx (meds, PT)
    • interventions depend on sx response
  • Sx

**AVOID EXTENSION!!!

42
Q

What interventions should be AVOIDED w/ Cervical Myelopathy

A

EXTENSION!!!

43
Q

DJD (OA) in C/S

Will affect what?

A

Atlanto-occipital jt

Facet jts @ C2-3 and lvls below

44
Q

Assoc’d w/ DJD (OA)

Spondylosis (OA of spine):

A

term typ NOT used specifically for facet jts, but more for global degen changes b/w vertebrae and IVF

45
Q

2 other characteristics of DJD (OA) in C/S

*NOTE: both will limit ROM

A

*widening of vertebral end plates

*osteophytes may be present

46
Q

AKA painful facet joints

A

Facet syndrome

47
Q

2 types of Stenosis:

A
  1. Central (think Cord)
  2. Lateral (think nerves)
48
Q

Central stenosis

A
  • watch for s/s of myelopathy
    • think cord
49
Q

Lateral stenosis

A
  • watch for s/s of radiculopathy
    • think nerves
50
Q

3 things assoc’d w/ Disc Patho:

A
  1. DDD (think disc hts)
  2. Bulging*
  3. Herniations*

NOTE: *→ by age 40, the nucleus’s fluid content has diminished greatly and the nucleus now mostly a “ligamentous/fibrocartilaginous dry core”

51
Q

Nerve root impingement aka

A

radiculopathy

“pinched nerve”

52
Q

Nerve root impingement

Can occur due to…..

A
  • disc bulge
  • disc herniation
  • DDD
  • spondylosis
  • lateral stenosis
53
Q

Terms/jargon assoc’d w/ disc patho:

Protrusion/degen

THINK “BULGING”

A

post or post/lat bulge w/out any sig. tearing of annulus

54
Q

Terms/jargon assoc’d w/ disc patho:

Herniations: 3 phases

A
  1. Prolapse→ outermost rings of annulus still intact
  2. Extrusion→ just moving→ annulus completely perforated; disc mat. moves into epidural space
  3. Sequestration→ disc fragments “escape” and may migrate into epidural space; may put pressure on:
    1. SC
    2. nerve roots
55
Q

Terms/jargon assoc’d w/ disc patho:

A

see pics

56
Q

C/S disc disease (DDD, herniation)

May req. sx intervention IF:

A
  • 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
57
Q

Dx tests used to confirm patho detected upon clinical exam:

A
  • 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
58
Q

Most common procedure for C/S Disc Patho

A

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
59
Q

Pot. Comps of Sx or Post-Sx Pd.

A
  • 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
60
Q

Rehab of Pts who have undergone ACDF Sx

A
  • 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)
61
Q

ACDF Sx:

Phase I

A
  • 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
62
Q

ACDF Sx: Phase II

A
  • 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

63
Q

ACDF Sx: Phase III

Consolidation and Maturation Phase→ from post of Wk 4 to 24wks

Weeks 4-8

A
  • 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
64
Q

ACDF Sx: Phase III

Consolidation and Maturation Phase→ from post of Wk 4 to 24wks

Weeks 9-12

A
  • Continue prior exercises (4-8wks), progressing UE PREs to above 90degs
  • ADD CS isometrics and strengthening of TS paraspinals and scapular mm’s
65
Q

ACDF Sx: Phase III

Consolidation and Maturation Phase→ from post of Wk 4 to 24wks

Weeks 13-24

A
  • progress resistance and reps of above ex’s
  • ADD functional retraining (work; sports) IF approved by surgeon

MSPT II (20 decks)

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