Cervical Flashcards
What decade of life produces greatest prevalence of neck pain?
50s
What ligament attaches to the dens and the occipital condyles?
Alar ligament
What ligament covers the dens, attaches horizontally at C1, arises medially from the transverse ligament and attaches superiorly to occiput/inferiorly at C2?
Transverse ligament
What are the attachment sites for the alar ligament?
Dens and occipital condyles
The transverse ligament composes what greater ligamentous structure with superior and inferior longitudinal fibers of this ligament?
Cruciform ligament
What is the broad expansive ligament that extends from the spinous processes started at C7 to the external occipital protuberance?
Ligamentum nuchae
What motion does ligamentum nuchae limit in the cervical spine?
Flexion/ hyperflexion
What nerve innervates the suboccipital muscles?
Suboccipital nerve
What muscles comprise the neck flexors? (assist in rotation)
Longus capitis and longus colli
What two portions of the scalene group attach to the 1st rib?
Anterior and middle
Where does the posterior scalene have attachments to in the rib cage?
2nd rib
What are the 4 main neck extensors?
1) splenius capitis
2) splenius cervicis
3) semispinalis capitis
4) semispinalis cervicis
In terms of arthrokinematics: what occurs in the upper cervical spine? (One theory)
While in neutral - SB and rotation will occur in opposite directions // while flexed/extended will occur in the same direction
In terms of arthrokinematics: what occurs in the lower cervical spine? (Two theories)
1) Rotation and SB to the same side, no matter if flex/extension
2) Rotation and SB while flexed will be the same direction - rotation and SB while extended will be the opposite direction
What are subjective red flags for cervical fracture/ligamentous instability?
1) major trauma (MVA, fall from height)
2) RA
3) Down’s syndrome
What are objective red flags for cervical fracture/ligamentous instability?
Midline tenderness,
Positive ligamentous testing (Sharp purser - Alar)
Apprehension with/inability to rotation > 45 deg
What are subjective red flags for central cord lesions in the cervical spine?
1) older age
2) hx of trauma (MVA/fall)
3) incontinence
What are objective red flags for central cord lesions in the cervical spine?
Gait disturbance
Hyperreflexia LEs
UE (hand) sensory/motor deficits & atrophy
What are subjective red flags for a Pancoast tumor?
1) men over 50 y.o. with hx of smoking
2) “nagging” shoulder pain along vertebral border of scapula
3) burning pain down arm in ulnar nerve distribution (C8-T1)
What are objective red flags for a Pancoast tumor?
Wheezing with auscultation
Horner’s syndrome (ptosis, constricted pupil, sweating disturbance)
What are subjective red flags for septic arthritis for the SC joint?
1) insidious onset of chest pain (localized to SC joint)
2) hx of IV drug use, diabetes, trauma, infection
What are objective red flags for septic arthritis for the SC joint?
Tender SC joint
Limited shoulder movement
Swelling over the SC joint
Fever
What are the high risk factors for radiography with the Canadian C Spine rules?
1) age > 65
2) paresthesia in extremities
3) dangerous MOI (fall, MVA)
What are the low risk factors for radiography with the Canadian C Spine rules?
1) Ability to sit / ambulate
2) Delayed onset of neck pain
3) Absence of midline tenderness
4) lower impact MVA
What ROM in the neck is necessary to demonstrate bilaterally for the Canadian C Spine rules?
> 45 deg of rotation
What is the MCD (minimal change detected)?
The amount of change needed before the change can be considered to exceed measurement error
What is the MCID (minimal clinically important difference)?
The smallest difference patients perceive as beneficial
What is the MCD/ MCID for the numeric pain rating scale?
MCD 2.1
MCID 1.3
What is the MCD/ MCID for the NDI?
MCD 5 points / 10%
MCID 5 points / 10%
What are the most common activities listed for the Patient Specific Functional Scale? (3)
1) backing up car
2) sleeping
3) computer use
What is the MCD /MCID for the PSFS?
MCD 2.1
MCID 2 points
What outcome measure’s work subscale is sensitive in identifying those who may develop prolong work incapacity?
FABQ - work subscale
Who developed the inorganic signs for the cervical spine?
Sobel - higher presentation with inorganic signs, higher risk for prolong disability
Name the special test: pt seated, passive flex cervical spine 20-30 deg, one hand on forehead/opposite hand on C2 vertebra -> press forehead posteriorly (Name, positive outcome, spec/sens)
Sharp Purser test
Positive test: cranial movement with force without axis moving, myelopathic sxs during flexion, decrease of sxs with posterior movement
Spec: 0.96 - Sens: 0.69
Name the special test: pt supine, pinch grip on C2 spinous process, SB neck and feel spinous process move into index finger/thumb (Name, positive outcome, spec/sens)
Alar ligament
Positive test: delay in movement of spinous process
Spec 0.96 - Sens 0.70
What are the Hoffman criteria for instability? (5)
1) no midline tenderness
2) no focal neurological deficit
3) normal alertness
4) no intoxication
5) no painful, distracting injury
99% sensitivity to screen
What are three key assessments done for identifying VBI in screening?
1) subjective complaints
2) head and neck pain <90% of time> most often unilateral and suboccipital
3) MOI - most commonly trauma, whiplash with flexion-distraction and rotational force - with ACUTE onset
What are clinical features of VBI?
Dizziness, vertigo, giddiness, light headedness, nausea with vomitting, numbness (unilateral facial - not so much limbs), ataxia (most common), diploplia, limb weakness (uncommon)
What are neurological signs for VBI?
ipsilateral Horner’s syndrome (ptosis, sweating, constricted pupil)
ipsilateral limb ataxia
gait ataxia
ipsilateral sensory abnormalities of face (CN V)
diminished/absent corneal reflex
nystagmus, cerebellar or vestibular
facial expressions/CN VII deficits
CN IX-XII abnormalities (taste disturbed, slurred speech, dysarthria, dysphagia, dysphonia, trap reflex, tongue protrusion with deviation to involved side, tongue atrophy)
What landmark is used for inclinometry for the cervical spine?
External auditory meatus
What percent of patients with neck pain may suffer with facet or synovial fold/meniscoid entrapment?
50%
Overall, is manual therapy (mob vs manip) isolated or better in combination with exercise?
Isolated = weak evidence Combination = relatively strong
Is the mechanism of pain relief for spinal manipulation thought to be mechanical or neurophysiological?
Neurophysiological - central pain control by stimulating descending inhibitory pain mechanisms, like dPAG
Mob vs. manip in the cervical spine? Difference in pain, disability or patient satisfaction
Gross et al (systematic review) found moderate to low quality evidence that HVLA produced no difference
What two authors found significant improvement in pain and disability for cervical HVLA?
Puentedura & Dunning - greater reduction in pain, disability, improvement in rotation
What are the six factors that inc probability of success with cervical manipulation?
1) initial NDI score <11.5
2) bilateral involvement pattern
3) not performing sedentary work more than 5 hr/day
4) feel better while moving
5) did not feel worse with neck extension
6) dx of spondylolysis without radiculopathy
4 or more factors inc probability of success from 60 to 89%
What are the 4 factors identified by Puentedura as a CPR that pts with neck pain will benefit from thrust manip?
1) sxs duration <38 days
2) positive expectation that manip will help
3) side to side differences >/= to 10 deg rotation
4) pain with posteroanterior spring test of mid cervical spine
3 of 4 attributes had +LR 13.5
Fernandez-de-las-Penas found what implications with performance of C5-6 manipulation for elbow pain?
Increased pain pressure threshold (PPT) over lateral epicondyle - reduced number of treatments
Cleland established a CPR for patients who would benefit from thoracic manipulation for neck pain: 6 factors
1) sxs duration <30 days
2) no sxs distal to shoulder
3) looking up did not aggravate sxs
4) FABQ- physical <12
5) diminished upper thoracic kyphosis (T3-5)
6)cervical extension <30 deg
3 variables with 54 to 86% improvement, more than 3 even greater
What produced greater reduction in pain, reduced disability score and perceived improvement in GRoC scale: manipulation of t-spine or non-thrust mobilization
Manipulation - versus sham had had 15.5 improvement on VAS
What are descriptors for cervicogenic headache?
- unilateral headache, associated pain in neck/suboccipital area
- sxs aggravated by neck movement/posture
- restricted cervical ROM
- restricted cervical segmental mobility
- abnormal/substandard performance of CCFT
What percentage of rotation occurs at C1-2?
50%
What articulation has been found to have high frequency of sxs involved in neck pain with headaches?
C1-2
If active ROM is limited to less than 45 deg, what articulation may be restricted?
C1-2; produces 40-45 deg of rotation - 4-8 degrees from each level C3-7
Name the special test: pt supine; maximal passive flexion, actively rotate neck (positive test indicates)
Flexion rotation test - less than 45 deg = positive test
Less than 32 deg Ogince
High sens/spec 91/90
What is the MDC (beyond scope of error) with change for the FRT in the cervical spine?
7 deg
In CGH vs migraine: which has more restriction in flexion and extension?
CGH
In CGH vs migraine: which has significantly higher instances of painful upper cervical joint dysfunction?
CGH
How is muscle strength and endurance assessed in the cervical spine?
Cranial cervical flexion test - started at 20 mm Hg - graded manner at 5 increments (22, 24, 26, 28, 30); goal to hold 10 seconds with 10 seconds rest between stages
What headache presentation has significant forward head posture/position?
Chronic tension type headache
How is endurance assessed for upper cervical flexion?
Timed test of upper cervical flexion (without SCM activation) and lift head 1 inch off table
What are mean times for neck flexor endurance testing for subjects without pain and with neck pain?
Without 39 seconds
With pain 24.1 seconds
10 second difference between men and women
What was the comparison in those with CGH vs controls?
Deficits in peak torque 16%
Deficits in endurance 35%
As well as deficits in precise contraction level
In those diagnosed with whiplash type disorders, isometric strength was reduced 90% - if no neurologic disorder/atrophy - what accounts for strength loss?
Learned pain avoidance behavior - looking at isometric strength in cardinal planes
In the O’Leary study for those diagnosed with whiplash type disorders, what was better focus of strengthening? (CCFT strengthening or neck flexor endurance strengthening)
Craniocervical flexion coordination - better pain pressure thresholds, mechanical hyperalgesia, perceived pain relief
What motion is suggested for regular performance in those diagnosed with whiplash type disorders?
Cervical rotation - coupled wtih reassurance, encouragement for regular movement
What three areas are specific exercises for cervical spine targeting for strength?
1) craniocervical flexion/ head nods
2) cervical flexor endurance progression - lifted off table /returned
3) lower cervical extensor training - quadriped or prone - while maintaining neutral craniocervical flexion
What are the 4 factors to identify cervical radiculopathy? CPR
1) cervical rotation < 60 deg to involved side
2) ULTT 1/A positive
3) distraction test relieves sxs
4) Spurlings positive on involved side
4 variables - 99% specificity/24% sensitivity (+LR 30.3)
3 variables - 94% specificity/ 39% sensitivity (+LR 6.1)
What are clinical indications of upper motor neuron pathology?
- hyperreflexia
- diffuse sensory changes/not dermatomal
- clonus ankle
- pos Hoffman’s or Babinski
- clumsiness/ataxic gait
- weakness below compression
What is a positive Babinksi sign?
Fan sign = abduction of small toes and great toe extension
Specificity 99%, sensitivity 51%
What is a positive Hoffman reflex?
Flick distal phalanx of middle finger; flexion of IP joint of thumb and adduction of index finger
94% sensitive
What are clinical indicators for lower motor neuron pathology?
- hyporeflexia
- absent DTRs
- decreased sensation to light touch following dermatomal pattern
- muscle weakness in myotomal pattern
Muscle for myotomal testing C5
Deltoid
Muscle for myomtomal testing C6
Biceps - ECRL/brevis (wrist extended, radially deviated, forearm pronation)
Muscle for myotomal testing C7
Triceps - flexor carpi radialis (wrist flexed, radially deviated, forearm supinated)
Muscle for myotomal testing C8
Abductor pollics brevis
Muscle for myotomal testing T1
First dorsal interossei
Dermatomal testing C5
Lateral forearm
Dermatomal testing C6
Distal thumb
Dermatomal testing C7
Distal middle finger
Dermatomoal testing C8
Distal fifth finger
Dermatomal testing T1
Medial forearm
DTR testing C5
Biceps (5-6)
DTR testing C6
Brachioradialis (5-6)
DTR testing C7
Triceps (7)
What reflex is commonly absent in cervical radiculopathy?
Biceps - inc from 23% to 59% inc chance
What two muscle groups are commonly associated with nerves around the cervical spine that inc radicular or radiating pain?
Scalenes and pectoralis minor
What ULTT is an excellent screening tool for cervical radiculopathy?
ULTT 1/A - median nerve
Is Spurlings more sensitive or specific in detection of cervical radiculopathy?
Specific - 90% with +LR 3.5
Does the systematic review regarding traction favor intermittent or continuous traction?
Favored intermittent - no support for continuous
What is the CPR for intermittent cervical traction? (5 factors)
1) peripheralization with lower cervical mobility testing (c4-7)
2) positive shoulder abduction sign
3) age >55 years
4) pos ULTT 1/A
5) relief of sxs with manual distraction test
4 or more variables = 98% probability of success, +LR 23.1
3 variables = 53.2% probability of success, +LR1.44
