Cervical and Thoracic Spine Flashcards
What artery passes through the transverse process of the cervical vertebrae?
What is the name of this artery before it enters the C-spine?
What is the name of this artery after it passes through the foramen Magnum?
Vertebral Artery
Arises from Subclavian Artery
Becomes the basilar artery once it enters the foramen magnum
Where does the Alar Ligament attach?
What is the job of the Alar Ligament?
What Ligament helps support the Alar ligament
attaches at the dens and the occipital condyles
keeps the dens in close approximation to the C1 articulation and away from the spinal canal during motion
cruciform ligaments
What ligament attaches the C7 to the external occipital protuberance to increase the depth of the cervical spinous processes allowing for muscular attachment?
What motion does this ligament help limit?
ligamentum nuchae
helps limits excessive flexion of C spine
True or False: Patient’s with neck pain are at a high risk for chronicity of symptoms and neck pain tends to re-occur frequently
True
What are the risk factors described in the neck pain CPG for patient who may develop pain in the C spine?
Females > Males
Prior history of neck pain
old age
smoking
low social or work support
high job stress
Of the stated risk factors in the neck pain CPG which risk factors have the most high quality evidence supporting them?
Female Gender and prior history of neck pain
Of patient who experience acute traumatic neck pain via an MOI such as whiplash, what percentage will likely have mild symptoms and their symptoms will resolve quickly?
What percentage will have moderate disability and their symptoms will take longer to fully resolve or may never resolve?
What percentage will have severe disability and lead to chronic neck pain that doe snot reoslve?
~45% will have mild disability and symptoms resolve quickly
~40% will have mod disability
~15% will have severe disbaility
For patients who have acute traumatic neck pain via whiplash or similar MOIs, what time frame will they have the fastest progress in their recovery?
Within the first 6-12 weeks
The Neck Pain CPG states there are 5 main factors that lead to poor prognosis, what are they?
High Pain Intensity
High Disability
High post-traumatic symptoms
High Pain Catastrophizing
Hyperalgesia
How should you rate a patient’s pain intensity?
What level may be an indicator for poor prognosis?
Numerical Pain Rating Scale (NPRS)
over 6/10
How should you measure a patient’s disability for the C spine?
What level may be an indicator for poor prognosis?
Neck Disability Index
30% or higher=poor prognosis
How can you measure a patient’s post-traumatic symptoms?
What level may be an indicator for poor prognosis?
impact of events scale
over 33%=prognosis
How can you measure a patient’s pain catastrophizing symptoms?
What level may be an indicator for poor prognosis?
catastrophizing scale
over 20-poor prognosis
How can you measure hyperalgesia?
What level may be an indicator for poor prognosis?
cold presser test
it is hard to test but a positive result equals poor prognosis
What is the best way to diagnose cervical Myelopathy?
MRI
What are the five components of the clinical prediction rule for Cervical Myelopathy?
Gait Disturbances
Positive inverted supinator sign
Age over 45 years old
Positive Hoffman’s test
Positive Babinski sign
What is the best clinical course for patients who have 0/5 of the clinical predictors for cervical myelopathy?
1/5?
3/5?
4/5?
0/5- rule out cervical myelopathy
1/5 shows good sensitivity to rule out Cerv Myelopathy
3/5= a positive ratio of 36
4/5= infinite positive ratio and 9% post test probability leads to confidence in ruling in
What are the red flags associated with possibility of upper cervical ligamentous instability?
-any history of traumatic injury
-feelings of instability
-feeling like they need to assist their head with staying up
-myelopathy signs
-limited ROM
What are the red flags associated with carotid or vertebrobasilar artery insufficiency?
signs of a TIA (5 D’s And 3 N’s)
history of TIA
HTN
diabetes
clotting disorders
What are the 5 D’s And 3 N’s?
Dizziness
Diplopia
Dysphasia
Drop Attacks
Dysphagia
Ataxia
Nausea
Numbness
Nystagmus
What is Diplopia?
What is dysphasia?
What is dysphagia?
What is ataxia?
What are drop attacks?
double vision
impairment with speech
difficulty swallowing
impaired coordination
sudden fall with or without loss of conciousness
According to the Canadian C-Spine Rules what are the high risk factors for cervical fracture?
How many high risk factors need to be present for a patient to be referred for imaging?
-age over 65
-high speed MVA (over 62mph)
-fall from over 3 feet or 5 steps
-involved in a roll over
-paresthesia in BUEs following traumatic cause of pain
If ANY of these signs are present patient should be referred for imaging
A patient had a traumatic incident and you have started to use the Canadian C spine rules and found no high risk factors. You want to assess ROM of the C spine, what low risk factors do you have to screen for before you do that?
How do you use these factors to determine if ROM is safe?
-no mid-line tenderness
-patient is able to sit upright in ER
-patient is ambulatory
-MVA was a simple rear-end accident
-Delayed pain onset
If any one of these factors is present yo can assess ROM
If a patient has no high risk factors and has at least one low risk factor present you can assess ROM, what findings when assessing ROM would lead you to refer the back for imaging?
patient lacks 45 degrees of rotation on either side
What is the Nexus Criteria for cervical spine imaging?
states imaging should always be performed unless all 5 of the following criteria are met
-no evidence of mid-line tenderness
-no intoxication
-normal cognition
-no facial neuro deficiency
-no painful distracting injury
What are the common symptoms and exam findings for people who fit in the neck pain with mobility deficits classification?
Symptoms
-central and/or unilateral neck pain
-limitations in neck ROM that reproduces symptoms
-Associated shoulder girdle pain
Exam Findings
-restricted cervical ROM
-pain reproduced at end range of AROM and PROM
-restricted cervical ad thoracic segmental mobility
-shoulder girdle referred pain reproduction when stressing segment of musculature
-deficits in strength and motor control in sub-acute and chronic patients
What interventions does the neck pain CPG mention for the acute phase of neck pain with mobility deficits?
B level evidence supporting thoracic manipulation mixed with exercise and stretching
C level evidence supporting cervical manipulation
What interventions does the neck pain CPG mention for the sub-acute phase of neck pain with mobility deficits?
B level evidence supporting neck and shoulder girdle endurance exercise
C level evidence supporting cervical and thoracic manipulation
What interventions does the neck pain CPG mention for the chronic phase of neck pain with mobility deficits?
B level evidence supporting thoracic and cervical manipulation mixed with CTJ strengthening and FDN, traction, and low level laser
C level evidence supporting neck and trunk endurance exercise along with advise
What is the CPR to support the use of cervical manipulation?
-symptoms less than 38 days
-positive beliefs that manipulation will help
-difference of 10deg in rotation side to side
-pain with PA testing of C spine
What are the common symptoms and exam findings for people who fit in the neck pain with headaches classification?
Symptoms
-non-continuous unilateral neck pain with associated headache
-a headache aggravated by neck movement or prolonged positioning
Exam Findings
-positive cervical flexion-rotation test
-provocation of symptoms with provocation of involved upper cervical segments
-limited cervical ROM
-restricted upper cervical mobility
-strength deficits in cervical musculature
What is the procedure for the flexion rotation test?
What is the cut off score for a positive finding?
patient is in supine and therapist flexes their head to end ranges then rotates to the left or right until resistance is felt or symptoms are aggravated
Normal is 39-45 degrees bilaterally
Cut off scores is less than 32 degrees or if there is a 10deg difference side to side
What interventions does the neck pain CPG mention for the acute phase of neck pain with headaches?
B level evidence supporting active mobility
C level evidence supporting C1-2 SNAG exercise
What interventions does the neck pain CPG mention for the sub-acute phase of neck pain with headaches?
B level evidence supporting cervical manipulation
C level evidence supporting C1/2 SNAG
What interventions does the neck pain CPG mention for the chronic phase of neck pain with headaches?
B level evidence supporting a combination of cervical/thoracic manipulation and shoulder girdle exercise and strengthening as well as endurance exercise
What are the common symptoms and exam findings for people who fit in the neck pain with movement coordination impairments classification?
Symptoms
-traumatic MOI
-referred shoulder or UE pain
-concussion symptoms
-heightened affected distress
Exam Findings
-positive cranial cervical flexion test
-positive neck flexor endurance test
-positive pressure algometry
-strength and endurance deficits
-neck pain with mid range
-tenderness to palpation
-sensory motor impairments
What is the procedure of the cranial cervical flexion test?
What is considered abnormal or positive?
-patient is supine with a pressure cuff under their neck that is inflated to 20 mmHg
-patient is then asked to perform a chin tuck and to increase the pressure to 22 mmHg and hold for ten seconds and then rest ten seconds
-patient is then asked to repeat this procedure to 24, 26, 28, and 30 mmHg
An abnormal or positive test is if the patient cannot make it to 26 mmHg or cannot hold the position for 10 seconds, abnormal compensatory movements can also elicit a positive result
What is the Neck Flexor Endurance Test procedure?
What are the averages of this test for patients with pain?
Patient is supine hook lying with their head on a pillow
Patient then performs a chin tuck and lift their head once inch off the pillow while therapist has their hands under their head
Patient is instructed to hold this position for as long as possible
30 seconds is cut off score for positive test
Averages for patients with neck pain is 24 seconds
What interventions does the neck pain CPG mention for the acute phase of neck pain with Movement Coordination Impairments?
B level evidence supporting educating patient to return to the prior level of function as soon as possible and educate on postural exercise to improve AROM and decrease pain
What interventions does the neck pain CPG mention for the sub-acute phase of neck pain with Movement Coordination Impairments?
For patients with low risk of chronicity of symptoms there is:
C level evidence to provide one session of advice and all encompassing exercise as well as TENS
For patients who are having moderate to slow recovery there is:
B level evidence for a multi-modal approach of manual therapy and therapeutic exercise as well as modalities such as heat, ice, and TENS
What interventions does the neck pain CPG mention for the chronic phase of neck pain with Movement Coordination Impairments?
C level evidence supporting education and advise; mobilization with exercise; and TENS
What are the common symptoms and exam findings for people who fit in the neck pain with radiating symptoms classification?
Symptoms:
-neck pain with narrow radiating pain
-upper extremity dermatome numbness/tingling or myotome weakness
Exam Findings:
-symptoms brought on with radiculopathy cluster
-Upper extremity strength or sensation loss
What are the components of the CPR for radiculopathy?
-positive upper limb tension test A (median)
-positive Spurling’s test
-positive distraction
-cervical rotation ROM less than 60deg to the involved side
What is the procedure for the Median Nerve Tension Test (ULTT A)?
-depress the shoulder
-abduct shoulder to 90deg
-wrist/finger full extension
-supinate forearm
-ER the shoulder
-Extend the elbow until symptoms come on
What is the procedure for the Ulnar Nerve Tension Test?
-depress the shoulder
-abduct the shoulder
-extend wrist/fingers
-pronate the wrist
-flex the elbow until symptoms provocation
What is the procedure for the Radial Nerve Tension Test?
-depress shoulders
-IR the shoulder
-pronate shoulder
-flex thumb/fingers
-ulnar deviate the wrist
-abduct the should until symptoms are provoked
What constitutes a positive upper limb tension test?
-If familiar symptoms are reproduced
-if there is a 10 degree difference side to side
-if cervical lateral flexion away from the affected limb increases symptoms and towards the limb decreases symptoms
What interventions does the neck pain CPG mention for all phases of neck pain with Headaches?
B level evidence supporting upper extremity neural mobilization
B level evidence combining intermittent traction with exercise and manual therapy
C level evidence that centralizing is not beneficial in reducing disability compared to approaches
What interventions does the neck pain CPG mention for the acute phase of neck pain with Movement Coordination Impairments?
C level evidence supporting mobilizing and stabilization exercises
What interventions does the neck pain CPG mention for the chronic phase of neck pain with Movement Coordination Impairments?
B level evidence for intermittent traction and cervical mobilization, stabilization, and cerv/thoracic manipulation
B level evidence supporting education encouraging exercise and resuming work tasks
What are the 5 components of the CPR for deciding if intermittent traction would be beneficial on top of exercise for a patient?
How many positive findings should be present to increase the positive ratio to 5? how many for a 20 positive ratio?
-age over 55
-positive shoulder abduction test
-positive ULTT A
-positive distraction
-peripheralization with PA of lower C-spine
3/5= positive ratio of 5
4/5=positive ratio of 20 or post-test probability of 90%
What is a cervicogenic headache?
a headache caused by cervical spine structures, usually at the C1-3 level
A Patient is curious why they have pain in their TMJ and has fullness in their ear when they have been told their issue is with their C1-3 segments. What might you educate them on to address their confusion?
the trigeminal nerve and auriculotemporal nerve all merge in the same nucleus with the nerves from C1-3 and so when pathology at the nucleus is present it can present at any one area that branches from the nucleus
What evaluation findings would support a diagnosis of cervicogenic headache?
-positive cervical flexion rotation test
-poor cervical ROM
-strength, endurance, or motor control loss of cervical musculature
-C1-2 spring testing brings on headache
-restricted upper cervical segmental mobility
As well as Hx and S/Sx that reflect cervicogenic headache
What intervention are supported for patient in the acute phase who have cervicogenic headache symptoms?
B level evidence supporting supervised instruction and mobility exercise
C level evidence supporting C1-2 SNAG
What intervention are supported for patient in the sub-acute phase who have cervicogenic headache symptoms?
B level evidence for cervical manipulation and mobilization
C level evidence for C1-2 SNAG
What intervention are supported for patient in the chronic phase who have cervicogenic headache symptoms?
B level evidence supporting cervical/CTJ manipulation and mobilization with shoulder girdle exercise
What symptoms would suggest a patient is experiencing tension type headaches?
-headaches that are usually accompanied with TTP in the facial/cranial and neck musculature
-headache is bilateral and can last minute to days with mild to moderate intensity
-headaches are usually episodic
-headaches usually do not have nausea associated with them and do not get worse with activity
-patient can have sensitivity to sight OR sound, but not both
How many headache episodes are needed for a diagnosis of tension type headaches?
10
What is the treatment in the acute phase of tension type headaches?
NSAIDs, FDN, and STM
What are common symptoms associated with migraines whether they have an aura or not?
prodromal symptoms such as fatigue, poor concentration, neck stiffness, sensitivity to light and sound, nausea, blurred vision, yawning, and pallor
If a patient’s headache symptoms are made worse with routine physical activity what type of headache is ruled higher for likelihood?
Migraine since tension type and cervicogenic headaches are not usually affected by physical activity
What is a migraine aura?
CNS symptoms such as visual, sensory, or auditory deficits that are fully reversible and come about gradually and usually followed by a headache
these symptoms are connected to decreased blood flow to the brain and brain stem
How many migraine episodes are required to receive a diagnosis?
5
How does PT intervention treat migraines?
Modulates symptoms but poor evidence is present for PT intervention
What are Cluster headaches?
severe to extremely severe, strictly unilateral pain that is orbital, supra-orbital, temporal, or any combination of those that lasts for 15-180 minutes and occur once ever other day or up to 8x a day
Attacks can last weeks or months with rest periods of months to years
Men are 3x more likely and age of onset is usually between 20-40 years
What are the non-ischemic signs and symptoms of a vertebral artery dissection?
-ipsilateral posterior neck pain as well as occipital headache
-C2-6 cervical root impairments are rare
What are the ischemic signs and symptoms of a vertebral artery dissection?
-Hind Brain TIA symptoms (5D’s And 3 N’s)
-Hind Brain Stroke (Wallenberger’s syndrome and Locked-in syndrome)
What are the signs and symptoms of a Carotid Artery Dissection? (ischemic and non-ischemic)
Non-Ischemic
-Horner’s syndrome
-Pulsatile Tinnitus
-Cranial Nerve Palsies
Ischemic
-TIA
-Ischemic stroke
-Retinal infarction
When measuring a Patient’s cervical ROM where should the goniometer fulcrum, stationary arm, and movement arm be aligned?
Fulcrum: top of the head
Stationary Arm: in line with the acromion process
Moving Arm: middle of patient’s nose
During Cervical ROM assessment you decide the patient has an “closing” problem to the right side, what findings would lead to this decision?
a limitations from right to left during segmental assessment in extension which denotes a limitations with extension, right side bending, and right rotation
During Cervical ROM assessment you decide the patient has an “opening” problem to the right side, what findings would lead to this decision?
a limitations from right to left during segmental assessment in flexion which denotes a limitations with flexion, right side bending, and right rotation
What are the six components of the CPR which would indicate if a patient is likely to benefit from thoracic spine manipulation?
-symptom duration less than 30 days
-no symptoms distal to the shoulder
-looking up does not aggravate symptoms
-FAB-Q physical activity scale less than 12
-diminished upper thoracic kyphosis (T3-5)
-cervical extension less than 30 degrees
3/5 positive findings increase chance of successful outcomes by 54-83%
If you suspect a C5 nerve root issue what are the key muscles to test?
What is the dermatomal area you might suspect neural symptoms?
What are the deep tendon reflexes you should test?
Deltoid for MMTs
Lateral Forearm dermatome
Biceps Brachii DTR
If you suspect a C6 nerve root issue what are the key muscles to test?
What is the dermatomal area you might suspect neural symptoms?
What are the deep tendon reflexes you should test?
Biceps Brachii and extensor carpi radialis longus/brevis MMTs
Distal Thumb Dermatome
brachioradialis DTR
If you suspect a C7 nerve root issue what are the key muscles to test?
What is the dermatomal area you might suspect neural symptoms?
What are the deep tendon reflexes you should test?
Triceps and flexor carpi radialis MMTs
Distal Middle Finger dermatome
Triceps DTR
If you suspect a C8 nerve root issue what are the key muscles to test?
What is the dermatomal area you might suspect neural symptoms?
What are the deep tendon reflexes you should test?
Abductor Pollicis Brevis
Distal Fifth finger
No applicable DTR
If you suspect a T1 nerve root issue what are the key muscles to test?
What is the dermatomal area you might suspect neural symptoms?
What are the deep tendon reflexes you should test?
First Dorsal Interossei MMT
Medial Forearm dermatome
No applicable DTR
What is the thoracic rule of 3’s?
Spinous process of T1-3 are at the same level as the transverse processes
T4-T6 are one half vertebral level below the transverse processes
T7-T9 are one full vertebral level below
T10-T12 are at the same vertebral level to which they are attached
Which thoracic segments have the most lateral flexion ROM?
Most Rotation ROM?
the lower thoracic spine has the most lateral flexion while the upper thoracic spine has the most rotation
What is the rib movement of the true ribs during breathing?
What is the movement of the “false” ribs?
Floating ribs?
anterior/superior or “pump-handle”
lateral/superior or “Bucket Handle”
Caliper like movement due to no anterior attachment
What is T4 syndrome?
a rare occurrence of symptoms involving upper limb paresthesia, weakness with reduced thoracic movement and TTP of the T4 vertebra
This is a rare diagnosis of exclusion with very little research on it
