Adv Cervical Spine I: Examination and Evaluation Flashcards
What are risk factors for atraumatic neck pain?
- female sex
- prior hx of neck pain (50-85% experience recurrent neck pain within 1-5 yrs of an episode)
- potentially: older age, higher job demands, hx of smoking, low social support, prior hx of LBP, stress & anxiety
-older age and hx of other MSK disorders predicted greater chronicity
What’s the prognosis for atraumatic neck pain?
- younger people have better prognosis
- poorer health with a modest effect on prognosis
- initial evidence suggests: general exercise at baseline is NOT related to prognosis, but one study suggests regular cycling may WORSEN prognosis
What are WORSE prognoses linked to for for atraumatic neck pain?
worse prognosis linked to:
-poor psychological health
-lower social support and passive coping strategies
-low workplace control decision making
What’s the prognosis for cervical radiculopathy?
favorable outcome usually regardless of intervention
- 75-90% good improvement w/o surgery
- pain, sensory deficit, and OBJECTIVE WEAKNESS used as decision to operate
- no clear evidence of better long-term outcomes with any intervention though specific populations may benefit from surgery
What’s the prognosis for TRAUMATIC neck pain (WAD/whiplash associated disorder)?
- 42% mild problems with rapid recovery
- 40% moderate problems with incomplete recovery
- 17% severe problems without recovery
-trajectory not impacted by collision factors
What’s the prognosis for CHRONICITY of traumatic neck pain?
Within 6 weeks of trauma, 5 factors predict chronicity of pain:
- Pain intensity >6/10 (pain severity)
- NDI >30% (disability/function)
- Pain catastrophizing scale >20 (pain catastrophizing)
- Impact of Events Scale - Revised > 20 (post-traumatic stress response)
- Cold hyperalgesia (multiple ways of assessing)
What’s the prognosis for chronic disability in WAD?
Predictors of chronic disability in WAD are:
- high level of baseline disability
- self reported psychological distress
- passive coping strategies
- predicted recovery >6 months
- 6+ physical symptom complaints (e.g. pain, numbness, head feels heavy, dizziness, etc)
What’s the primary movement of the O-C1 joint?
craniocervical flexion (nod)
What’s the primary movement of the C1-C2 joint?
mainly cervical rotation
What’s the coupled motion in the lower cervical spine?
C/S sidebend and ipsilateral rotation
- this closes the intervertebral foramen and extends (closes) the facet joint
How do you test the facet jt?
with uncoupled motion- this takes away (opens) the intervertebral foramen. will feel stiff b/c it’s not the normal mechanics
ex: sidebending and contralateral rotation
What anatomical variation of the cervical spine are children born with?
Children are born w/o uncinate processes and uncovertebral joints until ~9 years old
uncovertebral jts are distinct by ~33 y/o
What percentage of asymptomatic people age 65+ have cervical DJD?
57%
- evidence of DJD on imaging doesn’t equal pain
If imaging shows DJD/OA in people age <20, is this normal, and what would you suspect?
Abnormal. Suspect trauma (e.g. sports, child abuse, landing on head [gymnastics], sports that involve falling].
Or there could be hypermobility (EDS, Down Syndrome)
Does pathology on imaging equal presence of pain or pain source?
no
what are pathoanatomical diagnoses related to neck pain?
-degenerative disc disease (DDD)
-degenerative joint disease (DJD, arthropathy)
-spinal stenosis (Central/foraminal)
-disc disruption/herniation (HNP)
-sprain/strain (WAD)
-spondylolisthesis
-radiculopathy
-myofascial pain
-instability
-fracture
-myelopathy
-infection
-vascular conditions
-malignancy
-inflammatory spondyloarthropathies
-autoimmune conditions
-more…
2017 Neck CPG Revision categories // ICF classifications include:
- neck pain with mobility deficits
- neck pain with movement coordination impairments (WAD)
- neck pain with radiating pain
- neck pain with cervicogenic headache
What are the steps to a PT exam for neck pain?
- Medical Screening. Treat, Refer & Treat, or Refer?
- Classify patient according to ICF model
- Determine stage (acute, subacute, chronic)
- Select treatment aligned with ICF classification
what are red flags?
signs and sxs associated with increased likelihood of serious pathology, MSK or non-MSK
-clusters of red flags are more useful than single red flags
Screening tool for red flag
Optimal Screening for Prediction of REferral and Outcome– Review of Systems (OSPRO)
what are yellow flags?
psychosocial risk factors for the dvlpmt of chronic pain (related outcome measure if available)
- Fear avoidance (FABQ)
- myths about condition or activity
- Pain catastrophizing (Pain Catastrophizing Scale)
- Hypervigilance (Impact of Event Scale–Revised)
- Depression (PHQ-2)
- Social withdrawal
- Self-efficacy
yellow flags more strongly assoc. w/ a patient’s outcome than physical factors
validated tool for helping with prognosis of pts with chronic LBP?
OSPRO-yellow flag
-helps assess psychosocial factors
what are orange flags?
psychosocial sxs that are consistent with psychological or psychiatric condition
what are blue flags?
related to those injured on the job- negative perception of work or effect of work on sxs can impair return to work
what are black flags?
the context of the person’s condition
- cultural factors
- economic factors
- healthcare policy in the region
- reimbursement
- professional culture
Urgent/ Emergent conditions
Can mimic mechanical neck pain or common cervical conditions (many of them affect MSK structures or are affected by activity/position)
-to not miss these, cluster red flag sxs and pay attention when a patient is NOT IMPROVING the way you expect
-REFER OUT
Urgent/Emergent Conditions include:
Fracture, vascular pathology, ligamentous instability, malignancy, referred pain from organs, infection
what are screening guidelines for fractures in the neck?
Canadian C-Spine Rules (SN: 99.4%, may be better for elderly population)
Nexus Criteria (SN 99.6%): for acute trauma, alert patients, fx, dislocation, ligamentous instability
What X-ray views should be taken for C/S fracture?
AP, lateral, odontoid (open mouth) views
Flexion/extension radiographs no longer recommended d/t inadequacy of imaging instability
Canadian C-spine rule
know it. can’t get picture on here
Canadian C-spine rule: what are high risk factors? what does it mean if the patient has one?
High risk factors: any of the following
- age 65+
- dangerous mechanism
-paresthesias in extremities
if pt has any of the above, this could mean a possible spine injury
what is a dangerous mechanism from the Canadian C-spine rule?
Dangerous mechanism:
fall from 3+ feet or 5 stairs
- axial load to head
- MVA high speed (>62mph or >100km/hr) rollover, ejection
- bike struck or collision
-motorized recreational vehicles
What are LOW risk factors of canadian c-spine rule?
low risk factors: any of the following
- simple rear-end MVA
-ambulatory at any time
-delayed onset of neck pain
-absence of midline C-spine tenderness
**simple rear-end MVA EXCLUDES:
- pushed into oncoming traffic
-hit by bus/large truck
-rollover
-hit by high speed vehicle
If patient does not have LOW risk factors, this could mean possible spine injury.
If patient DOES have LOW risk factors, move onto C/S rotation AROM
canadian c-spine rule: if patient has low risk factors and cannot rotate their neck actively 45 degrees left or right, what does this mean?
possible spine injury
canadian c-spine rule: if pt has low risk factors, and they can rotate neck actively 45 deg to the left and right, what does this mean?
no spine injury
you can’t apply the canadian c-spine rule if:
-pt is not awake, alert, and reliable
-unstable vital signs
- <16 years old
- acute paralysis
- known vertebral disease
- previous C-spine surgery
Nexus Criteria for Fracture: trauma patients who DON’T require C/S imaging require ALL of the following:
-alert and stable
-NO focal neurologic deficit
-no altered level of consciousness
-not intoxicated
-no midline spinal tenderness
-no distracting injury
what are some vascular pathologies in the neck?
Arterial:
-VBI (vertebrobasilar insufficiency)
-vertebrobasilar artery dissection
- internal carotid artery dissection
- arteritis (inflammation of an artery)
how to neck vascular pathologies present?
-neck pain, headache, often unilateral and/or suboccipital
- ACUTE ONSET, insidious or traumatic
- distinct pain w/o specific features, NOT EXPERIENCED BEFORE, can be severe/sharp
- complains of stiffness w/o loss of motion
- onset of sxs to ischemia can be hours to 2 wks
- may have neuro involvement depending on the affected artery (–> check cranial nerves)
pain presentations associated w/ vertebral artery pathologies:
forehead, right cheek, posterolateral left and posterolateral right neck/suboccipital area
pain presentation with carotid artery pathologies:
forehead, eyes, middle of the cranium (top of head), suboccipital area, posterolateral left and posterolateral right neck
other presentations of vascular pathology (5 D’s, 3 N’s, 1A)
Dizziness
Drop attacks
Dysarthria
Dysphagia
Diplopia
Nausea (often w/o vomit)
Numbness (facial and less often limbs)
Nystagmus
ATAXIA/unsteadiness (most common!)
-limb weakness: less common
Vascular pathology: common neuro features
-ipsilateral Horner’s syndrome
-ipsi limb ataxia
-gait ataxia
-ipsi sensory abnormalities (CN V); most commony loss of pain/temp; diminished/absent corneal reflex
-ipsi CN IX-XII abnormalities
-nystagmus (cerebellar/vestibular)
-possible CN VII deficit
-possible pyramidal signs
-most clinical features are related to Wallenberg Syndrome (posterior inferior cerebellar artery)
signs of VBA dissection
**unsteadiness, ataxia (most frequent)
dysphagia, dysarthria, aphasia
lower limb weakness
upper limb weakness
nausea, vomiting
facial palsy
dizziness, loss of equilibrium
loss of consciousness
signs of internal carotid artery dissection
**ptosis (eyelid droop)- most common
**upper limb weakness
**facial palsy (entire half of face)
lower limb weakness
dysphagia, dysarthria, aphasia
unsteadiness, ataxia
nausea, vomiting
loss of consciousness
individual risk factors for vascular pathology include:
HLD, hx of smoking, HTN, recent trauma or infection of the head/neck (including respiratory), CAD/atherosclerosis
look for clusters of these risk factors
physical exam components for vascular pathology?
-blood pressure
-palpate internal carotid artery
-auscultate ICA
-no longer recommended to do positional/provocative testing (e.g. vertebral artery test) due to poor validity
-neuro screen (CN, gait/balance)
causes of C/S Ligamentous Instability
-insufficiency or injury to the cervical ligaments, particularly upper cervical
- trauma (collisions, concern for transverse and posterior AO ligaments)
-repetitive microtrauma
-congenital (Down Syndrome, EDS type III)
-related to disease process (RA, SLE, Reiter’s, ankylosing spondylitis, Grisel’s syndrome) or prolonged corticosteroid use
Signs/sxs of C/S ligamentous instability
-Headaches
-Severe suboccipital or other muscle spasm
-Fear/anxiety/apprehension with head motion
-Neuro signs related to the spinal cord or brain stem. Can be constant, absent, or transient
C/S ligamentous instability tests:
-sharp-purser
-alar ligament test
-anterior shear test
-distraction test
-neuro screen including UMN testing (Babinski, Hoffman)
- caution w/ segmental mobility assessment and PROM
Malignancy screen: another urgent/emergent condition
-previous hx of cancer
-unexplained weight loss
-failure to improve after 1 month
- age>50 y/o
- no relief with bed-rest
note: neck pain is the MOST common sx assoc. w/ cancers of the head and neck. can also see sore throat, dysphagia, tinnitus
Referred pain from organs to the neck
Neck pain referred from: lung, diaphragm, spleen, liver conditions
Lower neck/upper back pain referred from thymus gland issues
neck pain referred from: lymph node inflammation, thyroid, esophageal conditions
Anterior C/S pain are sometimes referred from the heart and ascending aorta
Infections causing neck pain include:
-Meningitis (septic or aseptic); it presents as neck pain and stiffness [worse w/ flexion and rotation]. assoc w/ signs of infection and neuro involvement
- tests for meningitis: Kernig’s and Brudzinski’s signs
-osteomyelitis
-Abscess
-more. screen for red flags assoc w/ infection + patient not improving
Zorse conditions: refer and (maybe) treat
Concussion, Myelopathy, Rhematological conditions (RA, SLE, fibromyalgia, polymyalgia rheumatica, more)
What’s the most common cause of myelopathy?
spondylosis. myelopathy is a spinal cord pathology
what are signs and sxs of myelopathy?
-bowel /bladder urgency, incontinence
-balance issues/ataxia
-fine motor/coordination deficits
-bilateral presentation in limbs. if cervical, may affect all 4 limbs
what’s the recommended diagnostic cluster for myelopathy?
-gait deviation
- (+) Hoffman’s sign
- (+) inverted supinator sign
- (+) Babinski’s sign
- Age >45 yrs
having >3/5 variables = 94-99% post-test probability
what are red flags for rheumatological conditions?
-Insidious onset,
-no relief with rest,
-improvement with
-activity/exercise,
-waking up due to pain -during 2nd half of the night,
-morning stiffness >30 min
-age <40
what are common conditions seen in the clinic (horses)?
DDD, DJD, Spondylolisthesis, spinal stenosis, disc disruptions and herniations, radiculopathy, TOS, sprain/strain (includes whiplash), myofascial pain, cervical dystonia, referred pain from other joints
what is degenerative disc disease (DDD)?
-anatomic/structural changes within an intervertebral disc (IVD) causing a loss of function
-occurs naturally with aging, not always assoc. w/ pain
-loss of H2O content in nucleus and decreased disc height –> decreased space at intervertebral foramen + increased stress at facet jts –> higher potential for DJD and radiculopathy
what is DJD?
facet osteoarthritis (DJD)
-involves facet arthropathy and osteophytosis, can develop due to DDD
-pain is thought to be d/t cartilage destruction and decreased joint space
-pain can be local or referred to the proximal upper quarter
OA pattern: stiff in AM and after a period of immobility; worse pain in AM -> better midday-> worse by end of day
what is spondylolisthesis
slippage of one vertebra on another
-degenerative: most common type, due to DDD/DJD
-often presents with sxs of spinal stenosis/radicular or myelopathic sxs
-slippage can be anterolisthesis or retrolisthesis
other types: traumatic, iatrogenic, congenital
what is the grading for spondylolisthesis?
Grade 1: -25% slippage
Grade 2: 25-50%
Grade 3: 50-75%
Grade 4: 75-100%
Over 100% is Spondyloptosis, when the vertebra completely falls off the supporting vertebra
what is spinal stenosis? what is it typically caused by?
spinal stenosis= clinical diagnosis (Vs. only radiological finding) involving symptomatic narrowing of the spinal canal or intervertebral foramen causing pain and/or neuro sxs in the extremities
-typically caused by spondylosis (DDD/DJD with ligamentum flavum hypertrophy) or spondylolisthesis
-some ppl are born with narrow spinal canals
what is the incidence for disc herniations (asymptomatic, protrusion, and extrusion)
asymptomatic bulge 61.3%
protrusion 46.3%
extrusion 31/7%
imaging evidence of healing from disc disruption and herniation occurs within :
2-40 months
does a more severe disc injury (sequestration and extrusion vs. protrusion and bulge) have a greater or lesser likelihood of healing?
greater likelihood of healing with a more severe injury
imaging does or does not always correlate with clinical outcome
does not
what is radiculopathy?
nerve root compression leading to RADICULAR sxs – pain/paresthesia in a dermatomal pattern, myotomal (fatiguable), weakness, hyporeflexia, usually unilateral
what are potential causes of radiculopathy?
disc herniation, foraminal stenosis
what is thoracic outlet syndrome (TOS)?
Lateral neck pain radiating into the distal UE particularly medially (C8/T1/ ulnar nerve distribution)
-can be neurogenic TOS or vascular TOS (rare)
what can TOS be caused by?
- 1st rib elevation
- scalene tightness/spasm
- pec minor tightness
- anterior shoulder laxity/instability
- possible weakness in intrinsic hand muscles
what is the clinical presentation of a cervical sprain (ligament) or strain (muscle), including whiplash?
pain, muscle spasm, edema, increased temperature of local tissue
-can have pain radiating into the proximal upper quarter
-pain increase w/ muscle contraction or stretch of the affected tissue
what is cervical myofascial pain?
Persistent regional neck pain w/ trigger points.
-think of common muscles w/ trigger points
-often limited in ROM
-trigger pts can refer pain to the upper quarter
what is cervical dystonia?
SCM causing pain due to spasm or spasticity
-presents as anterior/lateral neck pain, often with rotated/tilted position of the head
-painful form of torticollis
what other joints can refer pain into the neck?
TMJ, shoulder, thoracic spine
what are some recommended patient recorded outcome measures for neck pain?
NDI (validated in many languages);
PSFS;
McGill Pain Questionnaire; Oswestry for axial pain;
outcome measures for yellow flags;
consider using Radar plot for pain domains
characteristics of Neck Pain with Mobility Deficits
-primarily motion limitations in cervicothoracic spine related to joint or muscle stiffness
-NO radiating pain or trauma, likely cntral or unilateral cervical pain that pay or may not refer to shoulder and upper quarter but NOT into the distal UE. should have (-) neuro screen.
-sxs usually elicited by A/PROM and/or segmental testing (PAIVMs, PPIVMs, up/downglides, lateral glides)
-may have weak neck and scapular muscles if condition is subacute or chronic
what’s a helpful special test for neck pain with mobility deficits?
cervical rotation lateral flexion (CRLF)
(if 1st rib is elevated, it’ll feel stiffer/blocked)
-The test is performed with the patient in a sitting.
-The cervical spine is passively and maximally rotated away from the side being tested.
-While maintaining this position, the spine is gently flexed as far as possible moving the ear toward the chest.
-A test is considered positive when the lateral flexion movement is blocked.
what are characeristics of Neck pain with movement coordination impairments?
-whiplash or traumatic onset
-pain primarily related to motor control issues
-neck pain, shoulder girdle pain or referred UE pain, dizziness, nausea, concussive sxs, HA, difficulty concentrating, light sensitivity, heightened affective distress, general hypersensitivity to stimuli
-reduced mm recruitment in C/S and shoulder girdle, degeneration of posterior cervical mm; proprioceptive deficits, sensory hypersensitivity or reduced pain thresholds, psychosocial disturbances– depression, anxiety, fear of mvmt
What are helpful special tests for neck pain with movement coordination impairments?
- craniocervical flexion test (the one with the BP cuff),
- neck flexor muscle endurance test (chin tuck + lifting head up an inch, then holding),
- pressure pain threshold (uses a digital pressure algometer)
–use for allodynia or hyperalgesia, central sensitization
–lower thresholds locally -> local mechanical sensitivity
–widespread lower thresholds -> suggest central nociceptive processing disorder [central sensitization]
What is the norm for the neck flexor muscle endurance test for people with neck pain, and people without neck pain?
Norm for ppl w/ neck pain: 24.1 sec
Norm for ppl w/o neck pain: 38.95 sec
What are characteristics of neck pain with cervicogenic headache?
-Intermittent, UNILATERAL “ram’s horn” presentation from occiput to temporal region
-related to changes in mvmt of the neck and jaw
-Present with ROM DEFICITS, painful/ HYPOMOBILE segmental mobility of UPPER 3 cervical segments, weakness or impaired coordination of DNF’s
What’s the diagnostic cluster for neck pain with cervicogenic HA?
-Decreased cervical AROM
-Impaired craniocervical flexion test
-Provocative and/or hypomobile PAs Occiput-C3
What’s a helpful special test for diagnosing neck pain with cervicogenic headache?
cervical flexion-rotation test (highest specificity)
-pt is supine
-you flex their neck (hold with your hands & belly)
-rotate to one side, then the other
-inclinometer/goni to measure
What’s a positive cervical flexion rotation test?
either < 32 deg of rotation, or a 10 degree reduction when comparing side to side
-note: if ROM >45, pt likely came out of flexion or started to sidebend
What are characteristics of neck pain with radiating pain?
Pain or parethesias that radiate to DISTAL UE or medial scapular border
-neuro screen (DTRs, myotomes, dermatomes C5-T1): not great at determining location of disc herniation, but tells us if there’s generally a nerve root compromise
-Valsalva maneuver (increased sxs with cough/sneeze)
what’s the diagnostic cluster for neck pain with radiating pain?
-Cervical rotation <60 deg on affected side (specific)
- (+) ULTTa (most sensitive)
- Positive Spurling’s (specific)
- Positive distraction (specific)
- 4 of 4 = 90% post-test probability
- 3 of 4 = 65% post-test probability
describe/practice the ULTTa. what is a positive test?
- prevent scapular elevation (block it)
- shoulder ABD 90 deg + elbow flexion
- forearm supination, wrist and fingers extension
- shoulder ER
- elbow extension
- contralateral and then ipsilateral sidebending of neck
Positive test:
1. reproduce sxs
2. side to side difference >or = 10 deg in elbow or wrist
3. contralateral SBing increases sxs
4. ipsi SBing decreases sxs
