C-Spine Common Presentations Flashcards
Rare, but serious health conditions at the c-spine
- Neoplasm
- Infection
- Ankylosing Spondylitis
- Rheumatoid Arthritis (RA)
- Klippel Feil Syndrome
- Cervical Arterial Dysfunction (CAD)
You are treating a patient for cervical spine stiffness. When assessing for the cervical flexion ROM you passively move the patients neck into flexion when they are supine and you note their LE’s retract. The pt states they did not purposefully do this.
This is a sign of what?
Meningitis
Kernig’s sign
What is the greatest risk factor for cancer?
A history of cancer
What types of cancer commonly metastasize to the spine?
Prostate, breast, kidney, thyroid, lung (PB KTL)
Rheumatoid arthritis is more likely to affect women and puts a patient at risk for…
- Atlantoaxial instability
- Basilar invagination (present with more advanced RA)
Ankylosing Spondylitis increases the risk of…
- Spinal cord injury
- Epidural hematoma
- Low-impact trauma (most common C5-C7)
- Osteoporosis
- Fracture at transitional regions of spine
What is ankylosing spondylitis?
ossification of the ligaments of spine, IV discs, end-plates, facet structures
Ankylosing spondylitis is most frequent observed in…
MEN in the 3rd decade (20-30s)
Symptoms of ankylosing spondylitis include…
- back pain worse in am/pm
- Pain improves with exercise
- Pain worse with rest
- ↓ chest wall expansion
- Back stiffness (esp. upper/lower)
Physical Exam findings for ankylosing spondylitis
- “chin on chest” (excessive thoracic kyphosis, decreased lumbar lordosis)
- Multi-directional, progressive ROM limitations of spine
- AROM = PROM
- Hard end-feel
What joint is used to diagnose ankylosing spondylitis with imaging?
the SIJ
Klippel Feil Syndrome
congenital failed c-spine segmentation
Fusion of what vertebrae is most common with Klippel Feil Syndrome?
C2/3
Complications associated with Klippel Feil Syndrome
Instability, spinal stenosis
Cervical arterial dysfunction occurs most commonly in what arteries?
vertebral and internal carotid arteries
Triggering factors of Cervical arterial dysfunction
Trauma or infection (often occurring together)
Cervical arterial dysfunction can lead to…
- retinal or brain ischemia
- compression or stretching causes local symptoms
- Subarachnoid or intracerebral hemorrhage
Cervical arterial dysfunction occurs most commonly in those who are ____ years old. It has a ____ yearly incidence, and is associated with…
39-45 YO, low yearly incidence, associated with ischemic strokes.
Cervical Arterial Dysfunction Risk Factors
- Hx of trauma to c-spine or vessels
- Hx of migraine HA
- HTN
- Hypercholesterolemia/ hyperlipidemia
- Cardiac disease, vascular disease, previous CVA/TIA
- DM
- Blood clotting disorders/alterations in blood properties
- Anticoagulant therapy
- Long-term use of PO steroids
- Hx of smoking
- Recent infections
- Immediately post-partum/peri-partum
- Trivial head or neck trauma
- Absence of plausible mechanical explanation for the pt’s symptoms
Symptoms of cervical arterial dysfunction
- Neck pain, SEVERE
- Facial pain
- HA (hemi-or bilateral, pain in face, neck, head simultaneously)
- Uni-or bilateral extremity dysesthesia, motor dysfunction, pain (UE > LE)
- Pulsatile tinnitus
- CN palsies
- D’s and N’s
Physical exam findings for cervical arterial dysfunction
- Ips horners syndrome
- CN signs
- HTN
- Positional testing (sustained end-range rotation, Modified Sphinx, VBI Test, Pre-manipulative positioning)
- Neurological testing
- UMN: pathological reflexes, coordination, hyper-reflexia
- LMN: motor, sensory, hypo-reflexia
Cervical spine myelopathy
spinal cord compression due to impingement from surrounding structures
Cervical spine myelopathy occurs in 90% of individuals by what age?
70’s
Ossification of what ligament is common with cervical spine myelopathy?
PLL
Symptoms of cervical spine myelopathy include
- neck pain/stiffness
- shoulder pain
- imbalance/fall Hx
- UE Dysesthesia
- LE before UE’s
Physical Exam of cervical myelopathy
*Neurological signs:
- Gait impairment
- Spasticity
- Pathological reflexes
- Hyper-reflexia
- Dis-coordinated extremity movements
- Radicular signs (BI > UNI): motor + sensory impairments
- Balance impairment (dynamic)
Clinical Prediction Rule for Cervical Myelopathy
- Gait deviation
- Hoffmann’s Sign
- Inverted Supinator Sign
- Babinski Sign
- Patient age >45 YO
A patient presents to your clinic and you are suspecting cervical myelopathy (CM), how many signs in the clinical prediction rule indicate you can RULE OUT CM? How many indicate you can RULE IN CM?
Rule out: 1/5
Rule in: 3 or 4 out of 5
Two main categories of upper cervical instability include:
- Ligamentous
- Fracture
T/F upper cervical instability often occurs because of either ligamentous instability or fracture, but not both?
False
Often occur together due to the intensity of force to cause trauma.
Increased risk for cervical instability includes:
- History of trauma (whiplash, sports)
- Throat infection
- Congenital collagenous compromise (Down’s, Ehler’s Danlos)
- Inflammatory arthritides
- Recent neck/head/dental surgery
Symptoms of upper cervical instability
- Neck pain
- Occipital headache/numbess
- Multidirectional limitation at end-range c-spine ROM
- Radicular vs myelopathic symptoms
- “Needing to support head with hands”
- Tires easily with prolonged static upright posture of head”
Physical Exam with upper cervical instability
- Multi-directional limitation ROM (painful)
- Muscle guarding (likely related to ROM limits, esp paraspinals)
- Neuro exam: Potential radicular vs. myelopathic symptoms
Special tests to assess for upper cervical instability
- Modified/Sharp-Purser
- Alar ligament stability
- Lateral shear test
- Tectorial Membrane test
- Peterior A-O membrane test
C-spine fractures common MOI
Axial loading
MVC, diving, head on collision in sport, fall landing head 1st, etc.
Presentation of upper cervical fracture
- Multidirectional limited ROM
- Neck pain
- C-spine spasm
- Difficulty swallowing
- Radicular v myelopathic S&S
- CAD S&S
Jefferson Fracture
4-part burst of Atlas (C1)
Requires HIGH forces! Consider other trauma
Spondylolysis
defect of pars interarticularis
“stress fracture”
Spondylolithesis
displacement of vertebral body
Anterior spondylolithesis: anterior displacement of vertebral body compared to inferior segment.
Retro-spondylolithesis: posterior displacement of vertebral body compared to inferior segment.
Degenerative spondylolysthesis is most common at
C3/4 and C4/5
Describe the grading of spondylolysthesis
Graded by the % of displacement of the superior vertebral body compared to the inferior body.
I: 0-25%
II: 25-50%
III: 50-75%
IV: >75%
Canadian C-Spine Rules
Used to rule in/out need for radiography in suspected c-spine complaints.
HIGH-risk factors in Canadian C-spine rules
- Age >65
or - Dangerous Mechanism
or - paresthesia in extremities
Indicates radiography is required!!
LOW-risk factors that allow safe assessment of ROM in Canadian C-spine Rules
- Simple rear-end MVC
or - Sitting in ED
or - Ambulatory at any point
or - Delayed neck pain
**or ** - No midline C-spine tenderness
If NOT present - indicates need for radiography!!
Canadian C-spine rules assesses what kind of ROM?
Active rotation to 45º left and right.
Yes - no radiography needed; No - radiography needed
Are Canadian C-spine rules used to RULE IN or OUT?
Rule Out
-LR 0.01
NEXUS Low Risk Rules
- No midline cervical tenderness
- No focual neurological deficit
- Normal alertness
- No intoxication
- No painful, distracting injury
5 present = low probabiltiy of injury
When determining appropriateness of manual therapy interventions for the c-spine - a PT must
Balance probabilities from assessment to determine a clinical decision
Cervical Spine arthropathy symptoms
Facet Joints*
- Referred spinal segment distributions
- Headache
- Anterior chest pain
C2-3 Facet Joint Referral Area
Suboccipital, upper neck
C3-4 Facet Joint Referral Area
Lower occipital area, entire neck
C4-5 Facet Joint Referral Area
Below occiput, superior upper trap
C5-6 Facet Joint Referral Area
Upper trap area, lower neck
C6-7 Facet Joint Referral Area
Upper trap, periscapular area
Degenerative Arthropathy can occur due to…
- Spondylosis
- Osteoarthrosis
- Stenosis
Spondylosis
osteophyte complexes form around margin of bodies and body of disc.
Osteoarthrosis
osteophytes that form in facet or A-A joints and cause narrowing
Stenosis
Narrowing of a vertebral canal
Impingement on neurological structures in the vertebral canal can occur with central canal stenosis. What are some potential causes?
- Z-joint hypertrophy
- Bulging disc
- Thickening/ossification of ligamentous structures
- Spondylolysthesis
Lateral Canal stenosis
encroachment on spinal nerve in lateral foramen/lateral recess of spinal canal.
Causes of lateral canal stenosis
- Loss of disc height w/degenerative processes
- Z-joint and uncovertebral joint hypertrophy
- Spondylolysthesis
Central or Lateral canal stenosis often present with sudden or insidious onset?
insidious, progressive onset
Acute Z-joint arthropathy is most commonly associated with what mechanism?
Extension
Physical exam of acute Z-joint arthropathy
What ROM is symptomatic?
What about joint assessment?
What about special tests?
- Painful joint compression ROM (ips. lateral flex/rotation + extension, though acutely multidirectional end ROM)
- Painful with segmental provocation (CPA/UPA)
- Concordant Cervical compression + Spurling’s in facet referral pattern (NO radicular symptoms)
Somatic Referred Pain
Altered pain perception in CNS, pain perceived in an anatomic location innervated by nerves other than that which innervates the source of pain.
Radicular Pain
Pain related to spinal nerve root irritation/inflammation
May occur with or without radiculopathy.
Radiculopathy
conduction block of motor + sensory axons.
Symptoms of Radicular Pain
- Shooting/lancing pain in dermatomal distrubution
- “Band-like”
- Pain with activities that close the neuroforamen or place tension on spinal nerve (extension, ips. rotation/lateral flex)
Physical Exam with radicular pain
- Visual: Shifting to open neuroforamen
- Painful/limited ROM with motions that compress foramen or place tensile load on nerve root.
- Relief with opening of neuroforamen.
Cause of radiculopathy
Compression or ischemia
Foraminal stenosis, impingement by disc herniation, epidural, meningeal , or neurological disorder
What cervical spinal segments are most commonly invovled with radiculopathy.
C6/C7
Prognosis in c-spine radiculopathy worsens with _______________.
workman’s compensation claim
Symptoms of c-spine radiculopathy
- Unilateral > bilateral
- Radicular symptoms in dermatomal pattern
- Aggravation with activities that compress the neuroforaminal space.
People who have c-spine radiculopathy will often show what sign?
Natural Bakody’s sign (hand on head)
Physical Exam of c-spine radiculopathy includes
- Painful/limited ROM with motions that compress foramen or place tensile load on nerve root.
- Relief with opening of neuroforamen
- Valsava’s test
- Wainner’s Test Item Cluster
Wainner’s Test Item Cluster
- Ipsilateral C-spine rotation AROM <60º
- Spurling’s Test +
- Cervical Distraction Test +
- ULTT +
Pathomechanics of whiplash associated disorders
- Trunk thrust upward
- Lower c-spine segment rotation into extension
- Anterior annulus distracted, impaction on facet joints.
Secondary damage occurs where with whiplash associated disorders (WAD)?
- Anterior annulus, ALL
- Meniscoid contusion
- Facet: capsule strain, intra-articular bleeding
- Fractures of articular pillars/subchondral plates, dens, laminae C2, occipital condyles
Symptomology of Whiplash Associated Disorders (WAD)
- Neck, shoulder, UE pain
- Radicular vs. referred symptoms
- Glove-like distribution paresthesia (NON-dermatomal)
- Weakness (myotomal vs. pain inhibition)
- Dizziness
- Difficulty focusing vision
- Tinnitus
Physical examination of whiplash associated disorders (WAD)
- Radicular signs possible
- Multidirectional ROM limitations
- Weakness
- Muscle guarding
Cervicogenic Headache
trigeminocervical nucleus - convergence of nociceptive input between trigeminal nerve and C1-C3
Cervicogenic Headaches are frequently associated with
Whiplash associated disorder
What two clinical criteria must be present for cervicogenic headache dianosis?
- Unilateral HA without side-shift
- Pain starting in neck, spreading to oculo-fronto-temporal area
What are additional, but not required, clinical criteria to diagnose cervicogenic headaches?
- S&S of neck involvement: pain triggered by neck movement or sustained awkward posture +/- external pressure of posterior neck or occipital region; ipsilateral neck, shoulder, and arm pain; reduced ROM
- Pain episodes of varying duration and fluctuating continuous pain
- Moderate, non-excruciating pain, usually of a non-throbbing nature
- Anaesthetic blockades abolish the pain transietnly provided complete anaesthesia is obtained, or occurrence of sustained neck traumma shortly before onset.
- Various attack-related events: autonomic symptoms and signs of N/V, ipsilateral oedema and flushing in the peri-ocular area, dizziness, photophobia, phonophibia, or blurred vission in the ipsilateral eye.
What should be included in your differential when considering cervicogenic headache?
- Migraine
- Dissecting aneurysms (VA or ICA)
- Posterior Cranial Fossa Lesions
- Greater Occipital Neuralgia
- C2 neuralgia
Cervicogenic dizziness is caused from
Altered proprioceptive input +/- ischemic process/vasomotor changes of the vertibrobasilar system.
Cervicogenic Dizziness Diagnosis
Exclusion of other likley sources of dizziness.
Cervicogenic dizziness history
- Concomitant neck pain
- Hx whiplash can increase suspicion
Physical exam of cervicogenic dizziness
- Dizziness with neck motion (esp rotation and extension)
- Dizziness with deep palpation
- Dizziness with joint mobility testing
- (+) Head-Neck Differentiation Test
