Cervical and Thoracic Spine Flashcards
how does shape of disc allow for its fxn?
- oblique angles: alllow for rotation and integrity of disc
- discs are extremely strong in compression but not in shear force (sliding force)
Where does the spinal cord stop?
- around L1, doesn’t go below L2
Impt rules about nerve root nomenclature of the spine?
- nerve root exits above pedicle w/ same number in cervical spine (C1 exits below occiput and C1)
- C8 root exits above T1 pedicle
- nerve root exits below pedicle w/ same number in thoracic and lumbar spine (T1 below T1 vertebrae)
lumbar disc protrusion at disc L4-L5 affects what nerve?
- lumbar disc protrusion doesn’t usually affect nerve exiting above disc, lateral protrusion at disc level L4-5 affects 5th lumbar nerve, not 4th lumbar nerve. Protrusion at disc L5-S1 affects 1st sacral nerve
Most mobile parts of vertebrae? Orientation of spine?
- cervical and lumbar (see a lot more fracutres and DDD here)
- Cervical: 50% ROM C1-C2, 50% b/t occiput and C1, 10% per subaxial level
- thoracic: rib cage and facet orientation keep it fixed
- becomes more vertical throughout (cervical to lumbar)
How is axial pain generated? Where are these located?
- this is controversial: discogenic pain
- pain fibers located in:
annulus
jt: uncovertebral, facet
ligaments
periosteum
muscle/fascia
How is radicular pain generated? Assoc w/?
- nerve root mediated: compression chemical/inflammatory - dermatomal sharp pain, numbness, parasthesia - assoc w/ weakness, hyporeflexia - diff pathway than pain fibers
Describe referred pain?
- axial or external pain localized to a site remote from location of nocioreceptors
- probably activation of contiguous cerebral cortex
- dull, achy, nondermatomal pain
- assoc w/ axial pain (doesn’t radiate into extremities)
PP of normal aging?
- results in a degenerative cascade that may result in a pathologic state
- intervertebral disc biologic aging triggers the degenerative cascade (degenerative changes don’t always cause pain)
Make up of intervertebral disc - throughout life?
- nucleus is metabolically active, hydrostatic proteoglycans, shock absorber effect
- nucleus is vascular in childhood via annular arteries
- beginning at adolescence nutrition is via diffusion only
- proteoglycans degenerate, lose H2O content (dehydrate)
- alters biomechanical properties of the disc and the motion segment: loss of shock absorber
Normal aging affect on intervertebral discs?
- everyone ages diff (stress, trauma)
- disc dehydration, disc narrowing
- increase strain on annulus:
diffuse bulging annulus, annulur tears, focal disc herniation - stress transfer to uncovertebral and facet jts:
arthrosis (bone spurs), stiffness
instability - most degenerative changes are asx or mildly sx
How common is axial pain? Presentation?
- up to 50% of people have some neck pain: intermittant, mild or occasionally severe
- facet, uncovertebral jt arthritis
- loss of lordosis resulting in muscular pain
- instability
- discogenic pain (hard to track)
How common is neurogenic pain? Diff types?
- 10-15% of people will have at least 1 episode of cervical neurogenic pain
- radiculopathy: pressure related nerve root dysfxn:
- disc herniation,
- uncoverterbal, facet jt spurs
- myelopathy: pressure related spinal cord dysfxn:
large disc herniation
spurs
congenitally narrow canal
Nucleus is bulging out and compressing spinal cord - what should you expect?
- myelopathy
nucleus is bulging out and compressing a nerve root - what should you expect?
- radiculopathy
involved disc space level in relationship of nerve root involved?
- C3-4: C4
- C4-5: C5
- C5-6: C6
- C6-7: C7
- C7-T1: C8
- L4-5: L5 (not where it exits but it does run across L4-5 disc).
Taking a thorough H and P on your pt - How do you diff b/t axial and extremity complaints?
diff b/t axial vs. extremity complaints: structural vs neurogenic
axial pain:
- structural: dull, achy, paraspinal
- referred: sharp, stabbing, intrascapular
ask about constitutional sxs
extremity pain:
- radicular pain: dermatomal, sharp, N/T/W
- appendicular: nondermatomal, jt/bone/muscle localized
- are there signs/sxs of myelopathy?
Other hx ?s to ask?
- previous hx: baseline?
- sxs: onset, duration, character, location, severity, inciting, relieving events
- axial/extremity
- constitutional/neuro ROS
- tx to date
Physical exam of cervical and thoracic spine?
observation:
- posture: cervical-lordosis, tilt, rotation
thoracic - forward bend, kyphosis, shoulders, pelvis and waist line
- ROM: flexion, extension, lateral bend, rotation
- palpation: bones - occiput, spinous processes, scapula, ribs
muscles: paraspinal, trapezius, scapular elevators, sternocleidomastoid
- neuro exam
- sensory
- DTRs
- long tract signs
- provacative tests
- assoc systems
Motor levels and motor scale (strength) of neuro exam?
- C5: deltoid shoulder, external rotators
- C6: wrist extension, pronator teres
- C7: triceps
- C8: finger flexors
- T1: interosseous
motor scale:
- 5/5 normal
- 4/5 weak
- 3/5 can raise against gravity
- 2/5 can’t raise against gravity but can move parallel w/ it
- 1/5: twitch or trace
- 0/5: absent
Sensory part of physical exam?
- light touch
- pin prick
- vibration
- temp (alcohol swab)
DTRs that we test?
- C5: biceps
- C6: brachioradialis
- C7: triceps
- hyporeflexic: root lesion (radiculopathy)
- hyperreflexic: cord lesions
How do we test C5 to see if it is intact?
- motor: deltoid and biceps fxn
- reflex: biceps
- sensation: (on top of deltoid mucle)
How do we test C6 to see if it is intact?
- motor: wrist extensors - ext carpi rad. longus and brevis, and biceps
- reflex: brachialis
- sensation: first 2 digits and up to elbow
How do we test C7 to see if it is intact?
- motor: wrist flexors, finger extensors, and triceps
- reflex: triceps
- sensation: middle finger
How do we test C8 to see if it is intact?
- motor: interossei muscles (abduction and adduction of the fingers), and finger flexors
- no reflex
- sensation: last 2 digits up to elbow
How do we test T1 to see if it is intact?
- motor: adduction and abduction of interossei muscles
- no reflex
- sensation: medial cubital fossa
What are long tract signs on the PE?
- hyperreflexia
- clonus
- spasticity, increase tone
- gait, coordination, rectal tone
- hoffman (UE), babinski (LE)
Provacative tests on PE?
- spurlings: ipsilateral lateral bending + extension
- reverse spurlings: contralateral bending
(these test impingement on exiting nerve) - L’Hermitte: applying pressure to posterior spine w/ pt’s head flexed: sign for MS, cord compression
What other systems should be tested on PE?
- vascular: adson test (pt turns head and provider posteriorly pulling arm - absent pulse indicates compression of subclavian artery)
- CNs
- shoulder and other UE jts
- peripheral nerves
- lymphatic
- pulmonary
DDx for axial problems?
- spinal:
bone: fracture, instability
disc: DDD, central HNP
jt: arthritis, instability - soft tissue: sprain, fibromyalgia
- tumor/infection: primary, mets
- infammatory: RA
Dx tests for axial disorders?
- spinal: bone - xray, bone scan disc - MRI, myelo/CT, discography jts - bone scan, F/E X-rays, facet injection - soft tissues: MRI, dx of exclusion - tumor/infection: labs, bone scan, MRI - inflammatory: labs
Tx for axial pain/disorders?
- non-op: PT, NSAID, narcotics, MR, education, activity modification, reassurance pain management: injection, RFA, IDET - op: fusion
DDx for extremity pain?
- nerve root:
radiculopathy: HNP, spondylosis, arthritis, instability, tumor, infection, fracture - spinal cord (myelopathy): HNP, stenosis, instability, cord lesions, medical, trauma, tumor, syrinx, CNS
- peripheral nerves: entrapment, neuropathy, plexopathy, RSD
- jts: rotator cuff, tennis elbow
Dx tests for extremity pain?
- nerve root: MRI, myelo/CT, EMG, SNRB
- spinal cord: MRI, myelo/CT, SSEP
- peripheral nerves: NCV
- jts: ortho eval
Tx for extremity pain/disorder?
- non-op: NSAID, narcotics, steroid injection, traction, collar
myelopathy: more urgent W/U - op:
decompression +/- fusion
72 yo male c/o falling and severe neck pain. First step?
- H and P (find out he is hyper-reflexive + rhomberg sign) = myelopathy
- MRI of neck
