Approach to Cervical Spine

Question 1

What is the top cause of neck pain?

Answer 1

atraumatic MSK (followed by neurologic and non-spinal systemic or referred pain)

Question 2

Traumatic neck pain DDX

Answer 2

myofascial injury (muscle strain)
cervical fracture
ligament injury
disc injury
cord or nerve root injury

Question 3

Myofascial neck pain

Answer 3

may or may not be traumatic

symptoms: pain, spasm, loss of ROM in neck & headache (persistent pain w/ nothing on imaging)

Question 4

Cervical fractures

Answer 4

3% of blunt trauma pts

MUST determine if stable or unstable (w/ imaging)

MUST document (initial presence & level of sensory & motor loss)

Question 5

Spinal Cord Injury (w/o radiographic abnormality)

Answer 5

PT w/ normal CT of cervical spine but continues to have symptoms

MUST keep spine immobilized until MRI eval & consult w/ neurosurgeon

Question 6

Nexus Criteria

Answer 6

determine if pt w/ neck pain needs imaging

if meet all then do NOT need imaging

Question 7

What are the nexus criteria?

Answer 7

absence of posterior midline cervical tenderness
normal level of alterness
no evidence of intoxication
no abnormal neurologic findings
no painful distracting injuries

Question 8

For atraumatic neck pain due to MSK, what should be on your mind?

Answer 8

Cervical spondylosis (degenerative changes)

Question 9

For atraumatic neck pain due to non-spinal causes, what should be on your mind?

Answer 9

systemic disease or referred pain (need context, history & PE to eliminate DDX)

Question 10

Cervical Spondylosis

Answer 10

degenerative changes in the spine (degenerative discs & osteophytes)

the MOST COMMON cause of acute & chronic neck pain in adults (general neck pain, radiculopathy & myelopathy)

Question 11

Cervical Myelopathy

Answer 11

EMERGENT situation

any neuro deficit related to spinal cord

signs & SXs: bilateral or distal weakness/numbness, complain of clumsy hands, gait disturbances, bowel or bladder dysfunction

Question 12

Cervical Radiculopathy

Answer 12

any neuro deficit occurring @ or near the nerve root

signs & SXs: sharp & burning pain radiating to shoulder or down arm, weakness or paresthesias develop weeks after pain onset

most common is C5-C6 followed by C6-C7

Question 13

Meningitis

Answer 13

emergent situation

signs & SXs: fever, malaise, headache, neck pain & stiffness (nuchal rigidity, Kernigs & Brudzinki signs of meningeal inflammation)

diagnosed by lumbar puncture

Question 14

Thoracic Outlet Syndrome

Answer 14

confined space between clavicle & 1st rib

compression of neurovascular bundle by various structures in area just above 1st rib & behind clavicle

Question 15

TOS symptoms & management

Answer 15

Symptoms: arm pain, numbness & weakness (when hold up arms), reproducibly aggravated by any activity requiring elevation or sustained use of arms/hands above head

Vasculogenic (5%) & neurogenic (95%)

Question 16

Imaging for atraumatic complaint

Answer 16

most pts w/ atraumatic neck pain w/o red flags do NOT require imaging

if pain for more than 6 weeks, use cervical spine radiography, CT or mRI

Question 17

When to image for atraumatic pt?

Answer 17

w/ progressive neuro findings & pts w/ moderate to severe neck pain who do not respond to conservative management over 6 weeks

Question 18

What are red flags in pts w/ neck pain?

Answer 18

recent major neck trauma
neuro symptoms indicating spinal cord issue
shock like paresthesia w/ neck flexion
fever or chills
history of IV drug use
immunosuppression
chronic glucocorticoid use
unexplained weight loss
history of cancer
headache
anterior neck pain (cardiac issue)

Question 19

What do you palpate in cervical region?

Answer 19

LNs, thyroid gland, muscle, bone, CT, spinous processes, disc spaces

Question 20

What is super important to document from PE of cervical neck region?

Answer 20

ROM (active v passive)

need to document + & - (no nuchal rigidity, no meningismus, negative NEXUS criteria)

Question 21

Cervical sensory dermatomes

Answer 21

C6-lateral forearm & thumb
T4-nipples
T10-umbilicus

Question 22

What will happen from spinal cord injury above C5?

Answer 22

respiratory paralysis b/c diaphragm innervated by C3-C5

Question 23

What does the cervical spine PE look for?

Answer 23

carotid pulse

jugular venous distension

Question 24

Special tests for cervical radiculopathy

Answer 24

Spurlings

Manual Distraction Test

Question 25

Special tests for meningeal irritation

Answer 25

Kernigs Sign

Brudzinki’s sign

Question 26

Special tests for Thoracic Outlet

Answer 26

Roos or East test

Question 27

Physical Exam Pearls from Cervical Spine region

Answer 27

ROM (never check ROM in trauma pt unless cleared of cervical fracture or spinal cord injury)

Never force ROM

Neck stiffness (inability or unwillingness) to move neck is concerning

Question 28

HVLA contraindications for cervical spine

Answer 28

RA (weak odontoid ligament)
Down Syndrome (weak odontoid ligament or missing odontoid process)
Carotid disease or PVD
Osteoporosis
Local metastases
PT on anticoagulants
Fracture or ligament disruption