C-Spine Pathology Flashcards
Canadian C-Spine rule for stable trauma patients
Patient 65+
Or paresthesias in extremities
Or dangerous mechanism of injury (fall over 1m/5 stairs;MVA.60mph; rollover or ejection; bike collision; motorized recreational vehicle accident)
If no to the above, and if crash was only simple rear end, the patient can sit in ER, the patient has been ambulatory at any time, the patient had delayed onset of pain, they don’t have midline tenderness, and they can rotate head 45 degrees both ways then NO X-RAY
What are symptoms of cervical instability?
Occipital HA
Occipital numbness
Limitations in AROM in all directions
Signs of myelopathy
What are signs of vertebral artery insufficiency?
5D’s And 3 N’s
Diziness, Diploplia/changed acuity, dysarthria, dysphagia, drop attacks
Ataxia or anxiety/panic
Nystagmus, numbness, nausea
Signs of systematic inflammatory process
High temperature bp >160/95
High HR>100
High RR >25
Fatigue
Signs of myelopathy
Hyperreflexia (incl. Hoffman's sign) unsteady gait Bowel and Bladder dysfunction weakness and sensory change Sensory disturbance in the hand
Signs of neoplasm
Pain at night/with rest
weight loss
history of cancer
age (>50)
Inflammatory arthritis of c-spine: symptoms
posterior aching in neck, shoulder, occipital region
symptoms increase with flexion
Structures most commonly involved in inflammatory arthritis of C-spine (e.g. RA)
AA facets, transverse ligament, dens
What % of individuals with RA have c-spine involvement?
50%
Types of headache
Migraine/HA of vascular origin
Organic H/A (can’t reproduce symptoms)
Mechanical/cervicogenic
Which muscles may produce cervicogenic HA?
Likely only muscles innervated by C1, C2, C3 (suboccipitals!)
Trigger points in trapezius, SCM, splenius capitus may refer to head, but likely don’t produce true headache
Where can pain be located in cervicogenic HA?
Neck and occiput
forehead, orbital region, temple, and ears
Primarily unilateral
Potential sources of pain in cervicogenic HA
- referral via spinal trigeminal nucleus
- irritation of DRG of C2 or C2 ventral ramus compression
- WAD
- Occipital neuralgia (compression of greater occipital nerve–likely overdiagnosed)
- Psychological factors?
What is the pain-spasm-pain cycle?
Process whereby irritation of soft tissues–>tension in the muscle–>ischemia, metabolite buildup, and further irritation–>further tension in muscle–>long-term potential for fibrosis and further disability
may play role in cervicogenic HA
Pt presenting with painful neck splinting, occipatal numbness, and neuro signs may have damage to what structures?
C1/C2 vertebrae (fractures)
How much does demand on lower C-spine increase when head is held in forward posture?
Every inch forward adds weight of head
e.g. 10 lb head, 1 inch forward would –>20 lbs load; 2 in forward would–>30lbs load
What is the source of pain in c-spine OA?
LIkely capsular thickening–>decreased motion and pain when stretched
What is the order of symptom onset and motion loss with DJD/DDD/OA/spondylosis?
1) pain in c-spine and/or arm increases in severity and frequency
2)loss of sidebending
3) loss of extension
4) loss of flexion and rotation (Opening)
Morning stiffness is also key symptom
What structure is effected with central stenosis?
Disk material and osteophytes impinge upon spinal cord in spinal canal–>cervical myelopathy
What structure is impacted with lateral stenosis
Nerve roots
Spondylosis/OA structures involved
begins in IVD, progresses to facet and uncovertebral joints; can–>spondylitic myelopathy
Progression of spondylosis
Decreased water in nucleus pulposis in 20’s–>increased load on annulus fibrosis–>cracks in AF–>decreased disk height–>changed arthrokinematics–>osteophytes
4 “classifications” of cervical spondylosis
1) Neck pain
2) Neck pain with proximal referral (e.g trapezius, occiput)
3) radicular pain
3) myelopathy
What signs may indicate that changes resulting from spondylosis are encroaching on intervertebral foramen?
Nerve root signs (radiating pain, dermatomal sensory changes, diminished reflexes…)
What signs may indicate that changes resulting from spondylosis are encroaching on the vertebral canal?
Cord signs (drop attacks, hyperreflexia, etc)
Joints/levels most commonly effected by spondylosis
C5/C6>C6/C7>C3/C4>C7/C8 (C2/C3 possible but rare)
What prevents central disk protrusions in the C-Spine?
Posterior longitudinal ligament
What causes acute cervical spine joint lock/”wry neck”
small piece of synovial membrane entrapped in facet joint or uncovertebral joint
AND/OR
Neurophysiological muscle tightness to protect area (manips are effective)
Synovial membrane inflammation is called and may lead to
Synovitis; persistant inflammation–>cartilage erosion, subchondral bony proliferation, instability of AA joint, muscle aches, fatigue
Exam findings: synovitis
Joint is painful and feels puffy/boggy during manual exam
Whiplash associated disorder classification grades (key differences–see P. 467 course packet for full list)
WAD 0=no signs or symptoms
WAD I=Neck pain or stiffness, no physical signs
WAD IIA= WAD I plus motor impairment/decreased ROM and recruitment and local hyperalgesia
WAD IIB= IIA plus psychological impairment
WAD IIC= IIB plus generalized hypersensitivity (central sensitization) and decreased proprioception
WADIII=IIC plus nerve conduction loss
WAD IV=fracture or dislocation
Cervicocephalic WAD presents with:
neck pain, HA, fatigue, vertigo, decreased concentration/cognitive function, light and noise sensitivity, nervous tissue trauma, barre syndrome
Cervicobrachial WAD presents with:
neck and UE pain, damaged soft tissue, uncovertebral bruising, joint capsule damage
What is the most common cause of disk herniation in the C-Spine
Degeneration (fissures in AF): rare before 30, most commonly at 50
Pain from IVD herniation in C-spine (location)
Broad regions, can be central, unilateral, bilateral
Most common nerve root effected by radiculopathy
C6 and C7 >C8 > C5
Brachial Neuralgia (description)
Pain in nerve root distribution as a result of compression; lasts up to 16 weeks
CPR for cervical radiculopathy
+ULNT 1
Cervical rotation+LR 9.6)
Signs and Symptoms of myelopathy
Leg symptoms/incoordination spasticity weakness paresthesias in multiple segments hyperreflexia balance disturbance visual problem ataxia bowel and bladder change
