C-spine Flashcards
What are the bones of the vertebral column
C: 7 vertebrae, 8 spinal nerves T: 12 vertebrae and nerves L: 5 vertebrae and nerves, cauda equina S: 5 fused, SI joints C: 5 fused
Briefly describe the anatomy of a vertebrae
Vertebral body and arch pedicle, lamina Vertebral foramen (spinal cord passes through here) Spinous process Transverse processes Articular facets (T have costal facets)
How does the vertebral column move
lateral flexion
rotation
flexion extension
How are C1 and C different
There is no intervertebral disc between C1 and C2
Dens (C2) extends upwards to allow C1 to rotate
What are the intervertebral discs
between adjacent vertebrae from C2-Lumbosacral junction
Numbered as vertebral body above it
Has a fibrous ring around it (fibrocartilage), and a Pulpous nucleus in the center (high water content, slightly posterior, shape altered by movement)
What are examples of disc problems
Degeneration (+/- w/ osteophyte formation)
Bulging (prolapse)
Herniated (extrusion)
Sequestration (herniated and leaking away)
Thinning
What are the layers of the spinal column (SF to Deep)
Epidural space Dura mater Subdural space Arachnoid mater Subarachnoid space Pia mater
What do different spinal nerve roots innervate
Ventral root: Myotomes
Dorsal root: Dermatomes
(C7 dermatome is the middle finger)
(S#-5 is perineal/genital area)
Briefly explain the brachial plexus
C5-T1 nerve roots lead into;
Superior, Middle, and Inferior trunks lead into;
3 anterior and 3 posterior divisions lead into;
Lateral, Posterior, and Medial cords lead into;
Musculocutaneous, Axillary, Radial, Median, and Ulnar nerves
What is the difference between a sprain and a strain
Sprain: Ligament injury (bone to bone)
Strain: Tendon injury (muscle to bone)
What is a cervical strain/sprain
Usually a combined injury of ligamentous structures and cervical musculature
Causes of a cervical strain/sprain are
forced movement past end range
sudden contraction
violent high velocity movement
How does a C-sprain/strain present
Non-radicular, non-focal neck pain anywhere from base of skull to cervicothoracic junction
Neck stiffness, limited ROM
+/- Cervicogenic HA pattern
On C-sprain/strain PE you may find
ttp over involved muscle, facet joint, or transverse process
NO pain w/ axial loading
usually normal neuro exam
In what non-trauma case would you order a C spine XR
50+ w/ new onset Sx
Constitutional Sx (fever, wt loss, chills)
mod-severe neck pain >6 wks
progressive neuro findings
infectious risk (IVDU, immunosuppressed)
Hx of malignancy
In what trauma cases would you order a C spine XR
can use Nexus low risk criteria, but Canadian C spine rules are preferred (for alert and stable trauma patients where C spine injury is a concern) 3 qualifying questions:
- High risk factors that mandate XR?
- No low risk factors that allow safe assessment of ROM?
- able to actively rotate neck 45” L&R?
Describe high risk factors present that would rule in C spine XR
65+
Dangerous mechanism of injury
Paresthesias in extremities
Describe low risk factors that would allow ROM testing and exclude need for XR
Simple rear end MVC Sitting position in ED Walking at ay time Delayed onset neck pain NO midline C spine ttp (if they can rotate neck actively, do not need XR)
Why is delayed onset neck pain not a worry
BC s/p MVC, pain will be worse on Day 2 and 3 than Day of accident if the MOI is musculoskeletal
Fractures hurt the same day!
When viewing a C spine XR that shows the dens, what must you look out for
A straight line through the dens! This is normal, the bottom of the two front teeth, but most mistake it for a Fx
There are never straight lines in anatomy!
What type of pain points you to different C spine injury
Sharp pain: Muscle or ligament sprain
Tightness followed by pain: Muscle spasm
What type of pain points you to different C spine injury
Sharp pain: Muscle or ligament sprain
Tightness followed by pain: Muscle spasm
What levels are usually tested when assessing C sprain/strain
C5-T1 myotomes, dermatomes, and reflexes
What is Spurling’s test
ROM test used to r/o neurologic involvement in a C spine injury (C strain/sprain, will be negative)
Helps Dx cervical herniation or spondylosis
How do you preform Spurling’s test
Pt: Rotate and laterally flex neck to affected side
PA: apply light downward (axial) pressure. If tolerated, apply cervical extension (tilt back) and reapply light axial compression
What do the moves in Spurling’s test do
Narrow neural foramen and compress the nerve root
If pain is reproduced or there is an increase in radicular arm pain, the test is positive
How does whiplash occur
When vehicle gets struck from behind, head tilts back, torso rises up
After impact, head snaps forward, and torso rebounds (forwards)
Cause of whiplash is
MC: stopped vehicle is rear ended
Acceleration-Deceleration of neck with rapid flexion/extension
Classic whiplash presentation is
Delayed onset C spine ttp and stiffness over 12-24 hours
Pain peaks on day 3-5
Pain and stiffness w/ flexion/extension
PE findings for whiplash are
Limited ROM in all directions, mostly flexion extension
NO pain w axial loading
Neuro exam is usually normal
How do you treat whiplash
Soft C-collar
NSAIDs
Muscle relaxers (Flexaril, Skelaxin, Valium if bad)
Cervical pillow to sleep (take C collar off)
heat/ice
PT if no improvement by day 5-7, or if improvement plateaus > day 10
What is cervical facet dysfunction
Shift in vertebral alignment leads to locking of facet joint
Caused by prolonged positional stress or traumatic injury
How does cervical facet dysfunction present
Insidious onset (when i woke up, I couldnt turn my head)
Unilateral pain (sharp in C spine, achey in referral zone)
Focal facet ttp
ROM limitations: ipsilateral sharp pain w/ extension- contralateral tightness
How do you treat cervical facet dysfunction
Anti-inflammatories
Muscle relaxers
Early PT (stretch and strength), DC (adjustment), and DO (joint manipulations)
What are complications of cervical facet dysfunction
Cerebral artery occlusion/dissection
-cervical/suboccipital pain, dizzy, n/v, vision loss
What is cervical radiculopathy
neurogenic pain in distribution of cervical roots, w/ or w/o numbness, weakness, or loss of reflexes
Causes of cervical radiculopathy are
Traumatic stretching of nerve root/brachial plexus (birth, football)
Cervical disc bulge/herniation
Cervical foramen narrowing (old)
How does cervical radiculopathy present
Abrupt onset (if disc injury from trauma) or gradual onset (mostly older pts) *Cervical pain increased with extension, lateral flexion, and rotation to involved side* AKA spurling test is positive!
Neurologic deficits associated with Cervical radic. are
Burner-stinger syndrome (resolve in minutes)
Bulge/hernia (gradual onset, need serial exams)
Foraminal narrowing (increased risk for potential deficit)
What XR view lets you look at the foramen
Oblique
How do you grade muscle strength
0-5
0: no contraction
1: flicker of contraction
2. Moves w/o gravity (supine)
3: Moves against gravity
4: Moves against gravity and some resistance
5: Full, wo fatigue
How do you grade reflexes
0-4+ 0: no response 1+: low normal 2+: normal 3+: brisker than average, can still be normal 4+: Hyperactive, clonus
What radiographs are good for evaluating cervical radiculopathy
5 views!
AP, lateral, odontoid, R & L obliques
How do you treat cervical radiculopathy
#1: Oral prednisone for 5-7 days, then mvoe to NSAIDs PT (cervical traction)
Why is slouching bad
It increases extension to C-spine
When would cervical radiculopathy require Neuro/PMR consult
Persistent/progressing neuro deficit
Persistent pain despite conservative Tx
What is in an epidural injection (can be used to Tx cervical radiculopathy)
Lidocaine and a steroid
This is to decrease inflammation
What is cervical spondylosis
Degenerative disease MC to C5-6 and C6-7
Characterized by osteophyte formation, Ligamentum flavum thickening, Disc space narrowing, and Vertebral subluxation (misalignment)
What happens to the vertebrae in C spondylosis
Degeneration due to arthritis
How does C spondylosis present
Progressive ROM loss/stiffness
Intermittent pain at onset (can become chronic)
Uni/bilat, deep aching neck, shoulder, and upper back pain
Cervical crepitus
focal/diffuse ttp along spinous processes and facet joints
Loss of natural curve of C spine
Facet joint arthrosis
How does C spondylosis present
Progressive ROM loss/stiffness
Intermittent pain at onset (can become chronic)
Uni/bilat, deep aching neck, shoulder, and upper back pain
Cervical crepitus
focal/diffuse ttp along spinous processes and facet joints
Loss of natural curve of C spine
Facet joint arthrosis
What is myelopathy (caused by osteophyte compressing spinal cord in C spondylosis)
Essentially, compression of spinal cord causing: Weak hands/muscle atrophy Leg weakness Unsteady gait Loss of bladder control Hyper-reflexia L'Hermitte's sign
What is L’Hermitte’s sign
Electric shock sensation down centr of back following flexion of neck
How do you treat cervical spondylosis
NSAIDs (not steroids, bc this is chronic)
Duloxetine (SNRI)- taper off VERY slowly
Amitriptyline (SNRI)- for sleep, slow taper
Gabapentin (neuropathic pain)
cervical pillow
PT
+/- surgical fixation
What do you stay away from in C spondylosis
Opioids or narcotics
Steroids
-This is a chronic dz, you dont want them on those for a long time!
