C-Spine Common Clinical Presentations Flashcards
PART 1: RARE BUT SERIOUS HEALTH CONDITIONS
PART 1: RARE BUT SERIOUS HEALTH CONDITIONS
What are some infection risk factors?
-Immunosuppression, DM, Cirrhosis, Aids, Steroid Use, recent/current infection
What is meningitis and what are some signs?
- Inflammation of brain and spinal cord membranes, typically caused by an infection.
- Fever, neck stiffness, Kernig’s sign
What is Kernig’s sign?
Stiffness of hamstrings when hip flexed to 90 degrees.
What is neoplasm and what are some signs?
- Abnormal growth of cells (tumor)
- Fever, night sweats
What is the biggest risk factor associated with neoplasm?
Prior Hx of cancer
__________ is the primary cancers responsible for 75% of all bone metastasis.
-Lead Kettle (Pb KTL) = prostate, breast, kidney, thyroid, lung
- In men, _________ is the most common source of musculoskeletal metastasis.
- Kidney neoplasms metastasize to the vertebrae, pelvis, and proximal femur in __% of cases
- Metastases of thyroid effects women _x greater than men
- prostate
- 40%
- 3x
________ is an autoimmune disease, possibly triggered by an infectious antigen in a genetically susceptible patient. It leads to _______ hypertrophy, destruction of ___________ cartilage and bone, synovial cysts, and ligamentous _______.
- Rheumatoid Arthritis (RA)
- synovial
- articular
- laxity
- Are men or women more likely to develop RA?
- RA likely develops prior to the __ decade.
- Women 3x more likely
- 6th
Patients with RA are at a greater risk for developing ____________ instability and ______ invagination.
- atlantoaxial
- basilar
What is ankylosing spondylitis?
Chronic inflammatory spondyloarthropathy in which we see ossification of ligaments of the spine, IV discs/end plates, and facet structures.
- Patients with ankylosing spondylitis are at a ____x risk of a spinal cord injury.
- Is it more common in males or females?
- Risk for osteoporosis increases __-__%.
- Patients with ankylosing spondylitis are at a heightened risk for ___-________ trauma (most common C5-C7)
- 11.4x
- males
- 46%-56%
- low impact
- Men are __x more likely to develop ankylosing spondylitis.
- It is most frequently observed in the ___ decade.
- 10x
- 3rd
What are the complaints patients with ankylosing spondylitis will present with?
- back pain (worse at night and in morning)
- decreased chest wall expansion
- back stiffness
What is the physical presentation of patients with ankylosing spondylitis?
- “chin on chest” (excessive thoracic kyphosis, flattened lumbar curvature)
- multi-directional ROM limitations of spine
What is Klippel Feil syndrome?
Congenital defect in which the C-spine segmentation fails.
What is the clinical presentation of patients with Klippel Feil syndrome?
- 50% short neck
- low posterior hairline
- limited c-spine ROM
- 50% have scoliosis
With Klippel Feil syndrome, fusion of C_ and C_ are the most common.
C2 and C3
What are some complications associated with Klippel Feil syndrome?
- instability
- spinal stenosis
PART 2: CAD (CERVICAL ARTERIAL DYSFUNCTION)
PART 2: CAD (CERVICAL ARTERIAL DYSFUNCTION)
What is the pathophysiology of CAD?
Intimal tear with penetration of circulating blood into the vessel wall and formation of intramural hematoma which can lead to occlusion.
- ) Underlying abnormality of vessel wall
- ) Triggering factor
What are 2 triggering factors for CAD?
- Trauma
- Infection
Where does CAD most often occur?
- Internal Carotid Artery
- Vertebral Artery
- The mean age of patients with CAD is __-__.
- CAD accounts for __-__% of all ischemic strokes, however, it is attributed to = __% of strokes in patients <30yo.
- Carotid dissection is associated with >__% stenosis, occlusion or intracranial obstruction.
- 39-45
- 2-3%, 20%
- 80%
What is the biggest risk factor for CAD?
Hypertension
Other CAD Risk Factors:
- “Past history of trauma to cervical ______/_________
- History of migraine-type headache
- _____tension
- Hypercholesterolemia / hyperlipidemia
- _______ disease, _________ disease, previous cerebrovascular accident or transient ischemic attack
- Diabetes mellitus
- Blood clotting disorders / alterations in blood properties
- Anticoagulant therapy
- Long-term use of steroids
- History of ________
- Recent ___________
- Immediately post partum
- Trivial head or neck trauma
- Absence of a plausible mechanical explanation for the patient’s symptoms”
- spine/vessels
- HYPERtension
- cardiac/vascular
- smoking
- infection
___________ tissue diseases should be on your radar when looking at CAD.
Connective
What symptoms may patients with CAD present with?
- neck pain (60-80%)
- face pain
- HA
- severe pain (>70%)
- (Bilateral) neurological symptoms (dysesthesia, motor dysfunction, pain)
- pulsatile tinnitus (ear ringing)
- CN palsies
- 5 D’s and 3 N’s
What are the 5 D’s and 3 N’s of CAD?
D= Dizziness, dysarthria (motor speech), dysphasia (speech comprehension), diplopia, drop attacks N= Nystagmus, nausea, numbness (face/lips)
50% of patients with CAD present with ipsilateral _________ syndrome.
-Horner’s Syndrome
What are the symptoms of Horner’s syndrome?
- miosis (pupil constriction)
- ptosis (drooping eyelid)
- anhydrosis on one side (loss of sweating)
- enophthalmos (sinking of the orbit)
What are some positional tests we can do to check for CAD?
After taking BP to check for HTN
- Sustained end-range rotation (10s)
- “Modified Sphinx”
- VBI Test
- “Pre-manipulative positioning
What are some neurological tests we can do to check for CAD?
- CN (nystagmus, pupil asymmetry, coordination of eye movements)
- UMN (pathological reflexes, coordination, hyper-reflexia)
- LMN (motor, sensory, hypo-reflexia)
Are VBI tests a good way to test for CAD?
No
-More important to look at Hx, interview, BP, and neurological testing
PART 3: C-SPINE MYELOPATHY
PART 3: C-SPINE MYELOPATHY
What is c-spine myelopathy?
Spinal cord compression as a result of impingement from surrounding structures.
C-spine myelopathy is present in __% of individuals by the seventh decade of life. Ossification of ___ is common.
- 90%
- PLL
C-Spine Myelopathy Symptoms:
- Neck ____/ stiffness
- _______ pain
- __________/ fall Hx
- (UE) __________
- May involve ___ first (gait, weakness)
- pain
- shoulder
- imbalance
- dysesthesia
- LEs
C-Spine Myelopathy Neurological Signs:
- _____ impairment
- Spasticity
- _________ Reflexes
- ______-reflexia
- Dis-coordinated extremity movements
- _________ signs (bilateral vs unilateral)
- Weakness
- Sensory impairment
- Balance impairment (dynamic)
- gait
- pathological
- hyper-reflexia
- radicular
- What are the 5 signs (if positive) lead us to think c-spine myelopathy?
- How many need to be positive to have an infinite likelihood ratio of c-spine myelopathy?
- ) Gait Deviation
- ) Hoffman’s Sign
- ) Inverted Supinator sign
- ) Babinski Sign
- ) Patient age >45yo
-4/5 (3/5 still highly likely)
UPPER CERVICAL INSTABILITY
UPPER CERVICAL INSTABILITY
Upper cervical instability can result from what 2 things?
- Ligamentous instability
- Fracture
- Ligamentous instability can be a result of _________ or trauma.
- Fractures can result from _______ fractures or trauma.
- concomitant health condition that affects CT
- fatigue
Risk Factors Associated With Upper Cervical Instability:
- History of ________
- _______ infection
- congenital collagenous compromise such as ___________
- Inflammatory arthritides such as ______
- Recent neck/head/dental _______
- trauma
- throat
- Down’s Syndrome
- RA
- surgery
What are the symptoms of upper cervical instability?
- neck pain
- HA/numbness
- Limitations at end-range c-spine ROM
- radicular vs myelopathic symptoms
- need to support head w/ hands
- tires easily with prolonged upright head positioning
How will a patient with upper cervical instability present during a physical examination?
- limitation in c-spine ROM multidirectional
- muscle guarding
- radicular vs. myelopathic signs
What are some tests to check for upper c-spine instability?
- Modified/ Sharp-Purser
- Alar Ligament Stability Test
- Tectorial Membrane Test
- Posterior AO Membrane Test
If a patient has a history that is suggestive of upper cervical instability, is it safe to perform tests for it?
No because you could hurt the patient more.
Upper cervical instability can result from fractures where?
- occipital condyles
- C1
- C2
- traumatic spondylolysthesis
What are common mechanisms with upper cervical fractures?
axial loading
Presentation of upper cervical instability due to c-spine fractures: -Limited \_\_\_\_ (multidirectional) Neck pain C-Spine \_\_\_\_\_\_ Difficulty \_\_\_\_\_\_\_\_\_\_ Radicular pain/ radiculopathy \_\_\_\_ SxS Myelopathy SxS
- ROM
- spasm
- swallowing
- CAD
What is a Jefferson fracture?
4 part burst fracture at the anterior and posterior arch of C1
What is the difference between spondylolysis and spondylolysthesis?
- Spondylolysis refers to a defect of the pars interarticularis (degeneration), can progress to spondylolysthesis.
- Spondylolysthesis refers to the anterior displacement of a vertebral body (most common at (C3/4 and C4/5)
How is a spondylolysthesis graded?
Graded by the % of vertebral body slippage.
- I: 0–25%
- II: 25–50%
- III: 50–75%
- IV: >75%
Spondylolysthesis can be both ___________ and __________.
- degenerative
- traumatic
What is a screening tool used to be more confident that a patient doesn’t have a c-spine fracture?
Canadian C-Spine Rules
- What question is Step 1 in the Canadian C-Spine Rules?
- What are some examples?
- Any high risk factors that mandates radiography?
- Age >65, dangerous mechanism, paresthesias in extremities
- What question is Step 2 in the Canadian C-Spine Rules?
- What are some examples?
- Any low-risk factors that allows safe assessment of ROM?
- Simple rear-end motor vehicle collision, sitting position in the emergency department, delayed onset of neck pain
-What question is Step 3 in the Canadian C-Spine Rules?
Able to rotate neck actively? (45 degrees L and R)
What is the NEXUS Low Risk Rule?
5 criteria in order to be classified as having a low probability of cervical injury.
What are the 5 criteria of the NEXUS Low Risk Rule?
- no midline cervical tenderness
- no focal neurological deficit
- normal alertness
- no intoxication
- no painful, distracting injury
“The physical therapist must accept that the clinical decision is made in the absence of _______ and a decision based on a balance of __________ is the aim of assessment.”
- certainty
- probabilities
“An_______-________ _______-______ process is an opportunity for the therapist to consider the likelihood that such a condition is present.”
evidence-informed history-taking
“Many testing procedures lack the diagnostic utility required to confidently _______ or _______ pathologies when used in isolation. However, use of procedures is indicated based on evidence related to best practice, pathomechanisms, and the on-going accumulation of clinical data to support or refute a hypothesis”
rule-in or rule-out
CERVICAL SPINE ARTHROPATHY
CERVICAL SPINE ARTHROPATHY
What is arthropothy?
Disease of joints
Can c-spine arthropothy be acute?
Yes, it can be acute or degenerative.
What are 4 examples of degenerative arthropathy?
- Spondylosis
- Osteoarthrosis
- Central Canal Stenosis
- Lateral Canal Stenosis
Spondylosis affects the vertebral _______ and _______.
bodies and discs
Osteoarthrosis occurs at the _________ joints and ____ joints.
zygopophyseal and A-A
Central Canal Stenosis is a narrowing of the _________ canal and is likely insidious with a progressive onset of symptoms.
vertebral
What are some things that can cause Central Canal Stenosis?
- Z-joint hypertrophy
- Bulging disc
- Thickening/ossification of ligamentous structures
- Spondylolysthesis
Can Central Canal Stenosis cause Cervical Spine Myelopathy?
Yes
Lateral Canal Stenosis is an encroachment on spinal nerve in _______ foramen/lateral recess of spinal canal and may cause _________ pain.
- lateral
- radicular pain/ radiculopathy
What are some things that can cause Lateral Canal Stenosis?
- Loss of disc height with degenerative processes
- Z-joint and uncovertebral joint hypertrophy
- Spondylolysthesis
Acute Zygapophyseal Joint Arthropathy is commonly associated with _______ mechanism.
extension
Acute Zygapophyseal Joint Arthropathy Physical Examination:
- Painful with joint ____________ ROM
- Painful with segmental ___________
- Cervical Compression and Spurling’s Tests likely provoke concordant pain, though differences are…
- Pain observed in segmental distribution
- Pain observed, not paresthesia/ anesthesia
- compression
- provocation
What is the difference between somatic referred pain, radicular pain, and radiculopathy?
Somatic Referred Pain= Altered pain perception in CNS, that will present as a dull ache pain in a fixed location. It is usually deep but generally presents more proximal.
Radicular Pain= Pain related to nerve root irritation that will present as a narrow band of sharp shooting. It can be both deep and superficial but generally presents more distally.
Radiculopathy= Conduction block of motor and sensory axons. Results in neurological defects.
Radiculopathy is technically not painful, but is commonly associated with what?
Radicular Pain
C_ and C_ are most commonly affected by c-spine radiculopathy.
C6 and C7
Radiculopathy can be both ________ and _____________.
traumatic/acute and degenerative
With c-spine radiculopathy, pain and limited ROM with motions that _______ foramen or place tensile load on nerve root.
compress
What is Wainner’s Cluster?
Tests for the presence of cervical radiculopathy
What are the 4 items in Wainner’s Cluster?
- Ipsilateral C-spine rotation AROM <60 deg
- Spurling’s Test +
- Cervical Distraction Test +
- ULTT +
WHIPLASH ASSOCIATED DISORDERS (WAD)
WHIPLASH ASSOCIATED DISORDERS (WAD)
Whiplash causes the trunk to thrust ________ causing an _______ moment on the lower c-spine segments.
- upward
- extension
With whiplash the _______ annulus is distracted, and results in the impact of ______ joints.
- anterior
- facet
With whiplash, what structures are strained?
- Anterior annulus
- ALL
- facet capsule
- Whiplash can cause a __________ contusion.
- It can cause intra-articular ________ of facets.
- It can also cause fractures of ______ pillars, _____, laminae C2, and occipital condyles.
- meniscoid
- hemorrhage
- articular, dens
With whiplash we get ________ on the posterior component and ________ on the anterior component.
- compression
- tensile loading
What symptoms are associated with WAD?
- Neck, shoulder, UE pain
- Radicular vs Referred symptoms
- Glove-like distribution paresthesia
- Weakness (myotomal vs pain inhibition)
- Dizziness
- Difficulty focusing vision
- Tinnitus
WAD Physical Examination:
- _________ signs possible
- C-spine motion limited ________ planes
- Weakness
- Muscle ________ (UT, Lev Trap, paraspinals, anterior c-spine musculature)
- Tinnitus
- radicular
- multiple
- guarding
CERVICOGENIC HEADACHES
CERVICOGENIC HEADACHES
What is cervicogenic headaches?
referred pain perceived in the head from a source in the c-spine
The prevalence of cervicogenic headaches is generally ___ in the general population, but increases to __% following whiplash.
- low
- 53%
The main diagnosis for cervicogenic headaches includes _______ headaches without side-shift, pain starting in the ______ and spreading to oculo-fronto-temporal areas.
- unilateral
- neck
What are some other differential diagnosis we should be thinking about when considering cervicogenic headache?
- Migraine
- Dissecting aneurysms (VA or ICA)
- Posterior Cranial Fossa Lesions
- Greater Occipital Neuralgia
- Neck-tongue syndrome
- C2 Neuralgia
CERVICOGENIC DIZZINESS
CERVICOGENIC DIZZINESS
What are the 3 pathophysiologic mechanisms that have been proposed for cervicogenic dizziness?
- ) “Ischemic process affecting the vertibrobasilar system”
- ) “Vasomotor changes caused by irritation of the cervical sympathetic nervous system”
- ) “Altered proprioceptive input from the upper cervical region” **
What is common history associated with cervicogenic dizziness?
- concomitant neck pain
- Hx of whiplash may increase suspicion
How will a patient with cervicogenic dizziness present?
- dizziness with neck motion (especially rot. and ext)
- dizziness with deep palpation
- dizziness with joint mobility testing
- Head-Neck Differentiation Test
C-SPINE SURGICAL PROCEDURES
C-SPINE SURGICAL PROCEDURES
What is discectomy/microdiscectomy?
Taking out part of the disc
What is laminoforaminotomy?
Removing parts of c-spine that might be impinging structures in lateral canal.
What is laminoplasty?
Surgical procedure to enlarge the spinal canal (“open the door”)
What is a laminectomy?
Removal of spinous process and bilateral laminae with <25% of z-joint removal
What is arthrodesis (Anterior Cervical Discectomy and Fusion (ACDF))?
Removal of structures causing compression on nerve tissue, prevents motion at disc level to improve stability via bone graft to ensure adequate space.
What is arthroplasty?
Reconstruction/replacement of joint.
Anterior Cervical Arthrodesis:
- With an anterior cervical arthrodesis, the adjacent vertebral levels require increased ______ requirements.
- Gradual increase in LE/UE __________ training (per toleration) without ______ resistance training and _____ progression.
- ROM
- resistance, overhead, UBE (bike)
What is the process of a cervical disc arthroplasty?
- cervical discectomy
- the disc space is distracted to “typical” disc height
- prosthetic implanted into disc space
- d/c 24-48 hours typically, minimal restrictions
What are the risk factors of cervical procedures?
- Surgical site infection: 0.7% and 12% of spinal surgery
- Myositis ossificans
- DVT
- Spinal Cord/ nerve Injury
- Muscular dysfunction
- Hardware failure (if applicable)
- Pseudoarthrosis (if applicable)
Post-op Considerations:
- Communication with surgeon
- Pt Education
- Monitor for SxS of complications
- Pain modulation
- Restoration of functional movement
- Progression to coordination/ strengthening as appropriate (pt status, procedure, impairments, etc)
