Cervical And Thoracic Spine Flashcards
Neck pain with mobility deficits:
Indicators, tests, interventions
Indicators: decreased ROM, unilateral neck pain, referred upper extremity pain; Acute onset Sx Segmental mobility C2-T4 has good intra-rater reliability
Interventions: manipulation cervical/thoracic, stretching, coronation strengthening and endurance exercises
–> thrust + exercise is BETTER than either alone
Neck pain with mobility deficits:
Indicators, tests, interventions
Indicators: decreased ROM, unilateral neck pain, referred upper extremity pain
Tests: pain at END RANGE (A/PROM), restricted mobility, upper extremity pain reproduced with provocation of involved cervical segments
–>Segmental mobility C2-T4 has good intra-rater reliability
Interventions: manipulation cervical/thoracic, stretching, coronation strengthening and endurance exercises
–> thrust + exercise is BETTER than either alone
Neck pain with movement coordination impairments
Symptoms, impairments, interventions
Symptoms: Neck pain associated with preferred upper extremity pain, symptoms linked to trauma/whiplash; pain >12 weeks (chronic)
Impairments: strength endurance coordination deficits of DNF muscles, neck pain with mid range motion increased at end range, neck/upper extremity pain increased with motion testing, cervical instability
Interventions: coordination strengthening endurance exercises, patient education/counseling, stretching
- ->CCF endurance and high level str training with elastic band both shown to be effective
- ->TENS + exercise effective
Cervical spine Canadian fracture rules
Age greater than 65, dangerous mechanism of injury, paresthesias in upper extremity
Simple Rear MVA, sitting, walking, delayed onset, negative cervical midline tenderness
Cervical rotation greater than 45°
Neck pain with radiating pain
Symptoms impairments interventions
Symptoms: neck pain associated with radiating pain in UE, UE paresthesias
Impairments: (NOTE: See Wainner CPR card) radiating pain reproduced with Sperling’s test and upper limb tension tests, relieved with cervical distraction, may have a upper extremity a sensory strength reflex deficits, Decreased rotation (<60) toward involve side, signs of nerve root compression
Intervention: nerve mobilizations, traction, thoracic mobilization
Clinical prediction row for cervical manipulation for neck pain
NDI less than 11.5
Bilateral involvement pattern
Not performing sedentary work more than five hours per day
Feeling better well moving neck
Did not feel worse while extending neck
Diagnosis of spondylosis without radiculopathy
Four or more increased probability of success from 60 to 89%
Cervical spine Canadian fracture rules (stupid canadians)
FIRST: Age greater than 65, dangerous mechanism of injury, paresthesias in upper extremity**if Y to ANY need xray
–>Dangerous MOI: Fall >1 m, MVA >100km/hr, rollover/ejection, bicycle/MVA
SECOND: Low risk criteria: Simple Rear MVA, seated in ER, walking, delayed onset Sx, negative cervical midline tendernessif ANY present, assess c-spine ROM:
–>Cervical rotation greater than 45°if Y no xray if NO xray
Risk factors and level recommendation for neck pain
Recommendation level B: consider age greater than 40, coexisting low back pain, long history of neck pain, cycling as regular activity, loss of strength in hands, worrisome attitude, poor quality of life, and less vitality
Clinical prediction rule for thoracic mobilization with neck pain (Cleland 2007)
Symptom duration less than 30 days No symptoms distal to shoulder Looking up does not aggravate symptoms FABQ less than 12 Diminished thoracic spine kyphosis Cervical extension less than 30°
> 3 variables +LR 5.5
Neck pain intervention recommendation levels
Cervical mobilization – A Thiracic mobilization – B stretching – C coronation strengthening endurance- A centralization – C nerve mobilization – B Traction – B patient education – A
For indicators to rule out cancer in cervical spine
Less than 50 years old
No history of cancer
Improves over one month
No unexplained weight loss
Sensitivity 1.0
Clinical prediction rule for Cervical spine traction
Peripheralization with C4-7 mobility testing
Positive shoulder abduction sign (Bakody Sign)
Age greater than 55
Positive nerve tension test
Relief with minimal distraction
Three out of five increased likelihood of success from 44 to 79.2%,
4 out of five increased likelihood to 90.2%
Sensitivity and specificity of sharp-purser test
Specificity .96, sensitivity .69
Vertebra basilar vascular insufficiency Symptoms
Vertigo, tinnitus, dizziness, visual perceptual disturbances, fainting, facial numbness, ataxia, diplopia
Craniocervical flexion test guidelines
Five increments: 22, 24, 26, 28, 30 mmHg
Minimize SCM activation and hold tongue on roof of mouth
Abnormal response: – Unable to generate pressure at least six mmHg – Unable to hold pressure for 10 seconds – Superficial neck muscles engage – Sudden movement of chin
Deep neck flexor endurance test norms
Without neck pain – 38.95 seconds, with neck pain– 24.1 seconds
Cervical radiculopathy: Median nerve tension test, Spurling test, distraction test, Valsalva maneuver
And cluster
sensitivity specificity
Median: sensitivity .97, specificity .22
Spurling: sensitivity .50 specificity .90
Distraction: sensitivity .44 specificity .90
Cluster with cervical rotation less than 60°: sensitivity .24, specificity .99
Valsalva: sensitivity .22 specificity .94
C-5 nerve root testing and cervical radiculopathy
If diminished or absent chance of having cervical radiculopathy increases from 23 to 59%
*Biceps DTR: very specific 95%
Cervical radiculopathy: four variables that determine success of treatment
– Ageless and 54 years
– Non-dominant arm affected
– Looking down does not worsen symptoms
– Multimodal treatment
Four out of four increases success to 90.4%
Hoffman 5 item criteria for low probability of cervical injury
No midline tenderness, no focal neurologic deficit, normal alertness, no intoxication, no painful distracting injury
Thoracic outlet syndrome test.
Cluster for Sp and Sn
specificity and sensitivity
Adson’s vascular test – specificity 1.0 for pain, .894 vascular changes, .89 for paresthesias
Costoclavicular test – specificity 1.0 for pain, .89 for vascular changes .85 parehesias
Median nerve tension test – sensitivity .97, specificity .22
Radial nerve tension test – sensitivity .72, specificity .33
Cluster of two provocative test: sensitivity .90
Cluster of five provocative tests: specificity .84
Thoracic spine critical zone and reasoning
T4 through T9
Small diameter spinal canal and reduce blood supply
Subcostal nerve impingement and implications
Impingement in the thoracic/lumbar junction may lead to pain in hip region
Signs and symptoms symptoms of ankylosing spondylitis
Stiffness greater than 30 minutes duration, improvement in back pain with exercise but not with rest, awakening because of back pain during the second half of night only, alternating buttock pain
Signs and symptoms of T4 syndrome
-Intervention:
Headaches, neck pain, upper extremity pain, bilateral stocking glove paresthesias
- Neurovascular Sx NOT a feature
- More women affected than men
- Intervention: mobilization and manipulation of involved segments followed by exercise
First rib test with cervical rotation lateral flexion
Cervical spine maximally rotated away from side being tested
Cervical spine then side bent towards tested side
Positive test: blocking of side bending from elevated first rib on site being tested
Good intra/interrater reliability
C-Spine motion
C0-1: 10-15 deg F/E, 8 deg SB; minimal rotation
C1-2: 10 deg F/E; 45 deg rotation; minimal/no SB
C3-7: 64 deg F 24 deg E; 40 deg SB and rotation
C-Spine facet orientation, innervation, and % load bearing
45 deg to sagittal
- innervated by dorsal rami
- bear 9-25% load; if spine arthritic facets may bear 50% of load
Functional ROM needed in c-spine
65-70 deg rotation and F/E
- Tying shoes: 67 deg flexion
- turning head while driving: 68 deg
- crossing street 85 deg rotation
C-spine Arthrokinematics:
- upper c-spine: opposite in neutral (type 1) same in non–neutral (type II)
- Lower c-spine: neutral same, flexion same, extension opposite
**Monograph and texts conflicting: say no proven arthrokinematics
Most common c/t spine spondylosis levels
C5-6>C6-7>C3-5>C7-T1
Most common radiculopathy levels in c-spine:
C6 and C7
Cervical stenosis: central vs lateral
- lateral creates radiculopathy type Sx
- central may result in myelopathy: often subtle Sx, may have neck pain; unsteadiness in gait and clumsiness = early Sx; hand intrinsic wasting also common
- *consider surgery (fusion) if myelopathy occured
Predental space (on xray)
atlantodental interval
- space b/t odontoid and anteiror ring of C1
- should be 3, suspect transverse ligament rupture
Basilar invagination (on xray)
McRae’s line: across from foramen magnum: tip of odontoid should be below
Chamberlain’s Line: superior posterior hard palate to foramen magnum: tip of odontoid shouldn’t be >3mm above
McGregor’s line: superior posterior hard palate to most inferior occipital skull; tip of odontoid shouldn’t be >4.5 mm above
Head and Neck Medical Screening Questionnaire
Designed to determine if patient has serious non-musculoskeletal condition (tumor, VBI, stroke, hemorrhage)
**each question has intent to ask about red flag
What to do if patient has high FABQ
Consider active vs passive Tx; use + reinforcement, graded rehabilitation
- refer concurrently if stress, depression, anxiety
- High FABQ associated with high levels of chronic disability
Teardrop fracture:
Often complete disruption of disc and ligaments of injury level
- presents with anterior cord syndrome/complete SCI
- very severe, often requires surgical stabilization
Hangman’s fracture:
AKA traumatic spondylolysthesis of axis
- B C2 pars interarticularis fracture
- typically no neurologic Sx due to canal enlargement
- Need (from least to most invasive): Philadelphia collar > reduction with Halo> posterior stabilization
Jefferson fracture
burst fracture of atlas
- uncommon, often seen with upper cervical fractures
- (B) fracture of both anterior and posterior arch of C1
Vertical compression fracture
- burst fracture
- often ligaments intact, but severe bone injury
- some injuries treated with halo
Distractive-flexion fracture:
Facets sublux 1st, followed by facet dislocation; if dislocated, must be reduced followed by posterior fusion
Compression-extension fracture:
EX: downward blow to forehead
-Most often at C6-7 and stable; halo can treat injuries w/o displacement
Odontoid fracture:
- waist fractures (type II) healy poorly
- Type II fractures may union
- often halo immobilization trialed but if severely displaced need operative management
Natural Hx whiplash and Tx
- Often Sx onset 2 days s/p
- 57% complete recovery in 3 months
- 8% remain severely affected and loss of work
- 35% recover partially
- Max improvement in 1 year typically
TX: goal to reengage normal activities as soon as possible; if mild return to work immediately
- if more severe 3 weeks rest with NSAIDS (NOT muscle relaxants)
- collar first few days only, then short arc AROM and PROM first 48 hrs
- Progress to AROM after 48 hrs
- after acute pain, progress to isometric strength
- Modalities: traction, US, manipulation, heat, ice
CCF test:
Inflate to 20mmHg, increase to 22-30mmHg in 2mmHg increments, holding 10 sec each without superficial contraction; 10 sec rest b/t
NORMAL is 26-30mmHg
DNF endurance test
supine, lift head 1 in, 40 sec normal in healthy aducts
24 sec in adults with Sx
Common VBI Sx and what to do if present
VBI Sx: U/L HA/neck pain often suboccipital
- if hugh suspicion of VBI, don’t passively end range test and refer back to MD
- Qualities of VBI include “Sharp” pain, neck stiffness but no loss of ROM
Cervical spine manipulation CPR: (Tseng et al)
- (B) Sx
- No Sx looking up (cervical ext)
- No Sx looking past shoulder
- C-Spine extension <14 degrees
* *3/6 or more increases success to 86%
Wainner CPR for Neck pain with Radiating pain
- C-spine rotation <60 deg involved side
- Spurling test: (Sen 50% Spec 90%)
- ULTTA (Sen 97% Spec 22%)
- Distraction test (can ONLY perform if UE/Scapular Sx at rest) Sen 44% Spec 90%
–4/4 Spec 99%
–3/4 Spec 94%
(3+ useful, Spec drops 50% if less than 3/4)
- Distraction test (can ONLY perform if UE/Scapular Sx at rest) Sen 44% Spec 90%
UMN/Myelopathy Characteristics: (Cook 2010)
- Gait deviation
- Hoffmans
- Inverted supinator sign
- babinski’s
- Age >45
- -4/5 +LR: infinite; -LR .91
- -3/5 +LR 30.9, -LR .81
- -1/5 +LR 1.4 -LR .18
If + UMN Testing (Hoffmans, Babinski) refer back to MD
Interventions for neck pain with radiating pain: Short term prognostic factors for response to Tx (cleland et al):
- Age t increase Sx
- Multimodal tx 50%+ of time
4/4 characteristics, success 90.5% of time 3/4 present success 85.4%
Cervical Manipulation for Mechanical Neck Pain (Puentedura 2012)
- Sx duration <38 days
- expectation for manipulation
- side to side difference in cervical rotation ROM of 10 deg +
- Pain with PA testing in middle c-spine
3/4: +LR 13.5 post test probability 90%
4/4: +LR infinite, posttest probability 100%
Sharps-Purser test:
Assess transverse ligament of C1-2; pt sitting try to translate C2 on C1
(+) if excessive translation of C1 without C2 moving
Alar ligament test:
patient supine, PT stabilizes C2 with pinch grip SB to C/L side, should feel SP move into thumb
**Test of immediacy, if doesn’t move laxity of alar ligament suspected
t-spine referral pattern: facet vs costovertebral/TP vs disc
- Sx typically >1/2 segment above or up to 2.5 segments below
- Facets: C7-T3: superior angle or interscapular C5-7 also refer here so must differentiate
- T11-12: I/L iliac crest
- Costovertebral/TP: directly over joint
- Disc: no current research: 37% herniated in t-spine asymptomatic
t spine flexion impairment causes
- decreased superior facet translation
- anterior rib rotation
- vertebral segment motion
- Most often T3-7
- may have decreased T-spine kyphosis
- MOI: may be whiplash (EX: muscle spasm)
t spine extension impairment causes
Most often C7-T2 and T8-12 due to increased kyphosis
-Degenerative vs traumatic; disc lesions, decreased inferior facet glide
Rib impairments and treatment
Upper ribs: Cranially subluxed, decreased caudal glide; due to trauma or overuse
Middle/lower ribs: Anterior or posterior subluxation
- -Correct anterior with SA contraction
- -Correct posterior with pec major contraction
Differential Dx: Descending AAA vs MI vs Angina Vs CAD
AAA: unrelenting sudden pain, no change with position
MI: Chest pain, heaviness, nausea
Angina:
- Stable: increase with exertion, decrease with rest
- Unstable: unpredictable
CAD CPR: (3/5+ 80% sens/spec): Female 65+/male 55+, known vascular disease, increased Sx with exertion, Sx not reproduced with palpation, Pt assured pain is cardiac in nature
- *PT secrets:
- myocarditis and endocarditis don’t produce chest pain but breathlessness with chest tightness
- Cardiac red flags: chest pain >30 min, SOB, pallor, perspiration, N/V, nonproductive cough, nocturia, skin color changes, early AM pain
Differential Dx: Acute pleuritis
sharp stabbing pain with exertion, pleural rub on ascultation; can refer to upper traps and interscapular
DD: pneumothorax
Malaise, sharp chest pain, diminished and rapid pulse, decreased BP, dry cough
DD: gallbladder:
R upper quadrant, infrascapular, Cholesystitis
- often fever N/V
- Sx increase 1-2 hrs after eating
- Murphy’s sign: palpate R subcostal angle and inhale + if sx increased
DD: pancreas
Sx at TL junction
DD: kidneys
Bruising. itching, hyperpigmentation, palness, anemia, eye redness, SOB, tremor, foot drop, weakness, decreased concentration, lethargy, irritability, impaired judgement
- Costovertebral and flank region
- Fever, NV, renal colic (ab pain that radiates to genitals)
- @ risk: patients with prior or current UTI
Tumor in t-spine
metastatic: primary bone cancers 25:1 ratio
- thoracic level MOST affected by metastatic spinal tumors (breast most common; also prostate, lung, thyroid, kidney, rectum, uterine, cervix
- Characteristics: (Deyo) Age >50, Hx CA (98% specific), unexplained weight loss, failure conservative Tx
Ankylosing Spondylosis:
3:1 maile to female
onset 15-40 y/o
90% of patients with AS have +HLA-B27 but only 10-20% with HLA-B27 will develop AS (high false +)
S/Sx: Stiffness >30 min in AM, decreased back pain with exercise, not with rest, awakening with back pain during 2nd 1/2 of night, alternating buttock pain
Exam: chest expansion <2.5cm
Rib mobilization for Anterior subluxation:
Seated AP; I/L arm is across chest with towel on I/L side and fisted hand over towel-diagonal slump (flexion with C/L SB and rotation) cue with SA activation
Rib mobilization for posterior subluxation:
seated PA; I/L arm across chest, T-spine extension with I/L SB, C/L rotation, pull elbow down and in to activate pectoralis major
TE to increase mid thoracic flexion
Barrel hug T3-7 cue patient for flexion, C/L SB (weight on I/L hip)
TE to increase general mobility of chest wall, t-spine and ribs
shoulder circles
Mintken CPR-response to CTJ mobilization (thrust/non-thrust) for patients with shoulder pain
- Painfree shoulder flexion <90 days
- no medications used for pain
- (-) neer impingement
Structural Scoliosis
Curves 20 deg: 7x more likely females, typically onset in adolsecence 11-14 y/o
- Have (+) adam’s forward bend test (rib hump present on convex side)
- progression depends on iliac epiphysis ossification for grading (Risser classification)
- The greater the curve at low levels of ossification, generally more chance for progression
Scoliosis intervention:
-Bracing: only for >20 deg that progress 5 deg over 12 months or any curve >30 deg; NOT for skeletally mature (EX: Risser Type 4); Work 23 hrs/day until skeletally mature
Surgery Indications:
- Curves progressed >40 deg in skeletally mature
- Curves >30 deg with marked rotation
- Double curves >30 deg (Ex: l and t spines)
Sympathetic Chain: where is it and S/Sx if dysfunction
Lies anteriorly along rib heads and costovertebral joints
- Tensioned by flexion, C/L rotation and C/L SB
- Sx and ROM associated with (+) slump test altered after spinal manip tx in mid thoracic spine due to increased segmental mobility
What if t-spine AROM side bending is only painful and limited movement?
ALWAYS indicates severe extra-articular impairment such as pulmonary or abdominal tumor or spinal neurofibroma
Cervical Rotation lateral flexion test:
Assesses for presence of elevated first rib in patients with brachialgia
-pt sitting, C/spine rotated passively and maximally away from I/L side and SB maximally (ear towards chest_
(+) when S/B limited–Due to T1 TP being blocked by superiorly subluxed rib
