Cervical Eval & Treat Flashcards
Cruciform Ligament (Transverse)
-Vertical and Transverse bands
-inhibit excessive translation of C1/C2
-Dens could compress stuff
Alar Ligaments
-attaches to C0 and dens
-can become OA insuficiency
-can cause neuro/vascular compromise
Anterior Column
-vertebral bodies and discs
-Weight bearing and shock absorption
Posterior Column
-articular processes
-Zygapopphhyseal (facet) joints
-Gliding mechanism for movements
Cervical Spinal Segments
-3 joints: 2 vertebral bodies and 1 disc, facet joint of sup and inf
-horizontal surfaces favor rotation
-vertical surfaces favor block rotation
-facets in “ramp” orientation
Amount of Motion Determinants
-Disc height ratio
-fibrocartilage compliance
-shape of end plates
-age
-disease
-gender
Type of Motion Determinants
-shape and orientation of articulations
-ligaments and muscles
-size and location of segment (lumbar biggest)
Intervertebral Discs
-largest avascular structure in body
-Nucleus Pulposus, Annulus Fibrosis, End plate (bone)
-Named for vertebra above
-Cervical & Lumbar: thicker anteriorly
-nutrition diffuses from endplate
-Cervical degenerates early (3rd decade)
Resists:
-compression
-shearing
-bending
-twisting
-combined motions
Spinal Juntions
CV: atlas, axis, head
CT: mobile c spine to stiffer upper t spine
TL: t-spine rotations meet limited L-spine
LS: mobile l spine to stiff SI joints
Mechanical Stability
state of equilibrium when body is still
Dynamic or Controlled Stability
Passive: resist forces at end ranges
Active: muscles coodinated to control body
CNS: feedforward and feedback control to augment stiffness
Zygapophyseal Joint
-synovial joints: articular cartilage, fibroadipose meniscoid
-supported by multifidi and ligamentum flavum
-innervated by medial branch of doral root
-move 5-8mm
Normal disc: 20-25% axial load on facet
Degenerated disc: 70% axial load on facet
Annulus Fibrosis
60-70% of water
-layered
-attaches to endplate
-transmit compression forces
Outer zone: sharpey’s fibers (fibrocarttilage)
Intermediate: fibrocartilage
Inner zone: most fibrocartilage
Nucleus Pulposus
70-90% water
-no nerve oor blood supply
-absorb compression
Disc Pathology Stages
Protrusion: disc bulge w/o rupture
Prolapse: outlayers of AP contain NP
Extrusion: AP perforated into epidural
Sequestration: disc fragments disconnect
End Plate Fx S/s
-trauma or MOI
-Acute pain
-(-) SLR
-(+) compression test
Internal Disc Disruption S/s
-separation of inner layers
-LBP or referred hip pain
-(-) SLR
Disc Protrusion/Prolapse S/s
-contained
-some AF and PLL intact
-LBP or referred hip
-pain with cough or sneeze
-(-) SLR
Disc Extrusion or Sequestration S/s
-uncontained
-LBP
-Pain with cough/sneeze
-True Sciatica (radicular pain)
-(+) SLR
Joint Manipulation Contraindications
-Serious pathology
-fracture*
-lack of skill
-Ligament rupture*
-No working hypothesis
-Worsening neuro function*
-Unremmitting night pain*
-Severe multi directional spasms
-UMN Lesions*
Atlas: C1
Forms atlanto occipital joint (OA).
-Flexion
-lacks spinous process
-Transverse Ligament attaches here
Axis: C2
-Forms atlantoaxial joint (AA).
-Rotation (60%)
-Possesses dens/odontoid process
-Links CV to C-spine
Cervical vertebrae
-Seven, bifid spinous process, flat facet joints.
-C3-C7 have uncunate
Order of cervical muscles from superior to deep
SCM,Trapezius, splenius capitus, splenius cervicis, erector spinae, semispinalis capitis, Rectus capitis (ant/lat), Longus colli
Common carotid
Splits into two at C3 to C4 level. Carotid sinus, contains baroreceptors for pressure and turns into the internal carotid artery.
Carotid body with chemoreceptors for chemicals and turns into the external carotid artery.
Important arteries of the lateral neck
Common carotid, vertebral artery, subclavian artery, brachiocephalic trunk, end of aorta
Upper Cervical Spine Biomechanics: OA Joint
C0-C1
-Lateral flexion: with contralateral rotation coupling (mostly at (CO-C1)
-lots of congruency due to lack of disc
OA joint: convex (C0) on concave (C1) (opposite)
-no disk
-15-25 degrees
-Flexion: rolls ant, slides pos (5 deg)
-Extension: rolls pos, slides ant (10 deg)
-LSB: (5 deg)
Upper Cervical Spine Biomechanics: AA Joint
C1-C2
-Lateral flexion: with contralateral rotation coupling
-Flexion: 5deg
-Extension: 10deg
Rotation: 35-45 deg
AA Joint: Biconvex
-rotation
-Coupled with contralateral lat flexion
-contralateral move of C2 SP
-60% of rotation
-Biconvex (flx lower cerv, ext upp ext)
Lower Cervical Spine
(C2/3-C7/T1)
-uncinate process limit lat flexion
-more mobility
-bifids til C6
Flexion: ant tilt and slide coupled with upward shift of facets (35-70 deg)
Extension: pos tilt and slide coupled with downward shift of facets (55-60 deg)
Lateral Flexion: coupled with ipsilateral rotation (15-40 deg)
-downward slide of ipsilateral facet joints
-upward slide of contralateral facet joints
Rotation: coupled with ipsilateral lateral rotation (30-45 deg)
Vertebral Artery
C1-C6
-most vulnerable at C1/C2 transition
Cervical Nerve Referrals
C1-C3: refers to head and neck
C4-C8: refers to shoulder, ant chest, UE, Scaps
-CN 11
Closing Restriction
Issues with:
-extension, SB, Rotation
-IPSI side of pain
Opening Restriction
Issues with:
-flexion, SB, rotation
-CONTRA side of pain
Cervical Flexion Inclinometer ROM
-Cranium to T1
-80-90
Cervical Flexion Goni ROM
80-90
Stationary: Perp. floor
Axis: Ear hole
Movement: Base of nose
-take resting, subtract from final number
Cervical Extension Goni ROM
50-70
Stationary: Perpendicular to floor
Axis: ear hole
Movement: Base of nose
Cervical Rotation ROM Inclinometer
-PROM
-Supine
-Center of forehead (frontal plane)
Cervical Rotation ROM Goni
-70-90
Stationary: btwn acromion
Axis: Center of cranium
Movement: nose
Cervical AROM Values
Flx: 80-90
Ex: 50-70
LSB: 22
Rot: 70-90
Scanning Cervical Exam Requirement
-VBI
-Alar Ligament
-Transverse Ligament
Patient Hx
Demographics:
-age
-occupation
-Hand Dominance
-Activities
MOI
Pain Behavior (aggs/eas)
Widespread vs Local S/s
-Bilat vs/ Unilat
Neurological S/s
Chief Complaint
5 Ds
-Dizziness
-Dysarthria
-Dysphagia
-Diplopia
-Drop Attacks
3 Ns
-Numbness/tingling
-Nystagmus
-Nausea
Pt Hx Red Flags
-immune
-pigeons
-trauma
-light sensitivity/seizure
-speech/swallowing
Principals of Ortho Exam
- Gather Hx (MOI, description of s/s and pain activity)
- To Scan or Not
- Test Uninvolved First
- AROM>PROM>RROM & Endfeels or Neuro
- Joint Play/Assessment (check for pain)
- Painful tests lasts
- Warn Patient about possible exacerbations
Physical Examination Components
- Pt Hx
- Systems Review
- Screening (VBI/TL/AL)
- Observation
- Scanning Exam (if needed)
- AROM>PROM>RROM & Flexibility
- Muscle
- Joint Play
- Palpation
- Special Tests
Canadian Cervical Spine Rule
-guidlines for immobilization and/or imaging after trauma to neck
-positive= refer
- High risk factor for immobilization (any of these)
->65
- dangerous MOI
-Numbness and tingling in extremities - Low risk factor for assessment of ROM
-Complex rearending
-cannot ambulate
-cannot sit in ED
-IMMEDIATE neck pain
-pain at midline of c-spine - Can Ptt voluntarily actively rotate 45deg
-yes: treat
-no: immobilize and image
Cervical Conditions DDx
-Ligamentous instability
-Myelopathy
-Malignancy
-Spinal Fx’s
-Vascular Pathologies
Forward Head/Postural Syndrome
-Cervical hyperlordosis
-Shoulder Protraction
-CT Hyperkyphosis
Cervical Hyperlordosis
-TMJ overcloses
-Posterior Compression
-CV hyperextension
-OA flx hypomobile
-AA rot hypomobile
-OA ext hypermobile
-CV instability
Shoulder Protraction
-GH instability
-AC instability
CT Hyperkyphosis
-T-spine ext hypo
-Shoulder complex hypo
-RC tendinopathy
Mechanical Neck Pain
-non trauma, radic, non-msk
-icnreases with age
-can become chronic
Acute Disc Herniation
-uncommon <30
-common ~50
Disc Degeneration
-after endplate damage
-drop in height
-80% of neuro deficits correspond with disc left
Cervical Radiculopathy
-compression of spinal nerve root
-inflammation or impingement
-common with hyperext
-often in middle age
C2-3 Disc Herniation
-rare
C4 Spinal Root Compression
-posterior neck
-medial scapular border pain
Radiculopathy Diaphragm Involvement
-C3-5
-difficulty breathing
C5 Spinal Root Compression
-numbness on superior shoulder
C6 Involvement
-radiating pain from neck to lateral aspect of upper arm, forearm, and hand
C7 involvement
-radiating pain from posterior neck to scapula, posterior upper arm, forearm, and hand
-MC site for cervical radiculopathy
C8 involvement
-radiating pain from neck to medial aspect of upper arm, forearm and hand
Cervical Spondylosis
-chronic degenerative condition
-related to bony changes causing myelopathy/radiculopathy
-can be asymptomatic
-changes facets and IVD
Facet Joint Dysfunction
-unilateral neck pain (slept wrong)
-2ndary to synovial membrane getting caught in z-joint
-closing/opening restrictions
Facet Joint Dysfunction CPR
CPG:
1. S/s <30 days
2. No s/s distal to shoulder
3. Looking up doesn’t agg s/s
4. FABQ physical activity <12
5. Diminished upper t-spine kyphosis
6. Cervical ext ROM <30deg
(+) > or = 3, successful outcome w/t-spine HVLAP in 86% of Pts
Cervical Spine Instability
-inability of spine under load, to limit displacement so as not to damage structures
-cant control the motion
-2ndary trauma, surgery, disease
S/s:
-Hx of trauma
-catching, locking, giving away
-unpredictable s/s
-altered ROM
-neck weakness and pain
-HAs
Whiplash-Association Disorders
-rapid deceleration or acceleration
-damage to soft tissue structures/joints/nerve issues
Common Mechanism:
-MVAs
-Sport-related
-pulls and thrusts on arm
-falls, landing on trunk or shoulder
Headaches
-Migraine (half of face)
-Tension (band)
-Cluster (behind the eye, focused)
-Cervicogenic (from lateral neck to head)
Migraine HA
-35-45ys
-4h to 3 days
-Mod to severe
-Unilateral/pulsating
Tension HA
-20-40ys
-Mins to hours
-Mild to mod
-Bilateral/pressure
-Treated w/ posture, stress management, MT
Cluster HA
-20-40ys
-1-8 episodes throught the day
-Severe
-Unilateral/congestion/eye watering
Cervicogenic HA
-Any age
-Variable
-Mild
-Unilateral/dec ROM/Rams’s horn
Treatment:
-C2-C3 in neutral
-C2 under C1 in rotation
-C1 under occiput
3 Mandatory Qs for Neck Pain
- Dizziness, blackouts or drop attacks?
-Ds and Ns
-VBI - Hx of RA/arthritis or steroids?
- Any neuro in legs?
Optional: Down Syndrome
-ligamentous laxity
Arthritis and Steroid Affects
-ligamentous instability
Closing Restriction
Issues with:
-extension, SB, Rotation
-IPSI side of pain
Opening Restriction
Issues with:
-flexion, SB, rotation
-CONTRA side of pain
Cervical Radiculopathy CPR
- C-spine rot to painful side <60deg
- (+) Spurling test
- (+) ULLT#1
- (+) Cervical Distraction (relieves)
4/5: 90%
3/5: 65%
ICF Model: Neck Pain w/ Mobility Deficits
-hypomobility
S/s:
-Pain in central (older stenosis) or Unilateral (younger foramena)
-limited ROM that constantly reproduces s/s
-possible referred pain
Exam:
-Dec ROM
-Neck pain at end ranges
-Restricted mobility in c and t-spine
-referred pain reproduced w/ provocation
-deficits in cervico-scapulo-thoracic strength
Treatment:
-T-spine manips
-C-spine manual
-Cervical ROM
-Strengthening
ICF Model: Neck Pain w/ Movement Coordination Impairments
-Instability
S/s:
-MOI linked to trauma/whiplash or hypermobility
-referred shoulder pain
-HA, concussion, confusion, hypersensitivity
Exam:
-(+): cranial cervical flexion test
-(+): Neck flexor muscle endurance test
-(+): Pressure algometry
-Neck pain at midposition to end
-Dec strength
-Point tenderness
Treatment:
-Pt education and prognosis
-Increase ROM
-Manual or exercise
-Pain science
ICF Model: Neck Pain w/ Headaches
S/s:
-non-continuous, unilateral neck pain (facet joint) and referred HA
-HA precipitated or aggravated by neck movements or positions
Exam:
-(+): Cervical flexion rotation test
-HA reproduced w/ provocation
-Limited ROM
-Strength and endurance deficits
Treatment:
-Mobility
-Self SNAGs to AA joint
-Manual therapy c and t-spine
ICF Model: Neck Pain w/ Radiating Pain
-Radiculopathy
S/s:
-neck pain w/ UE radiating pain
-UE neruological signs
Exam:
-(+): Cervical radiculopathy CPR
-UE sensory, strength deficits
Treatment:
-Exercise and MT
-Cervical collar for short term
-Intermittent traction
-Pt education
Neck Pain and use of Thoracic HVLAT CPR
- S/s <30 days
2.No s/s distal to shoulder - Looking up dec s/s
- FABQ <12
- Diminished thoracic kyphosis
- Cervical extension ROM <30deg
> 3/6: inc chance of helping
C0-C1 Joint Referral
-back of neck to mid skull
C1-C2 Joint Referral
-Occiput
C2-C3 Joint Referral
-Occiput to mid skull
Anterior Cervical Discectomy and Fusion
-anterior approach of cervical disc removal
Anterior Corpectomy and Fusion
-anterior approach
-removal of bone and fusion
Laminoplasty
-widen lamina space w/o removal
-done for multi-level myelopathy
-preserves spinal motion
Contraindications for Manual Therapy
-infection
-Fever
-Cancer
-Acute Circulatory Condition
-Open Wound
-Fracture
-Hematoma
-Advanced DM
-Hypersensitivity
-Abnormal Endfeel
-RA
-Cellulitis
-Constant, Severe pain
-Extensive radiation of pain
-Condition not evaluated
Precautions for Manual Therapy
-Joint effusion or inflammation
-RA (non-exacerbation)
-Osteoporosis
-Pregnancy (over spine)
-Dizziness
-Steroid or anti-coagulant
