Cervical Health Conditions and Clinical Presentations Flashcards
What are risk factors that might signal infection?
- immunosuppression
- diabetes
- cirrhosis
- AIDS
- oral steroid use
- recent/current infection
Signs of meningitis
- fever
- neck stiffness
- Kernig’s sign/Brudzinski’s sign
What is Kernig’s sign?
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees
What is Brudzinski’s sign?
when you flex the child’s neck, they have to flex their knees
- due to tightness/discomfort of meninges
Why are Kernig’s sign and Brudzinski’s sign a sign of meningitis?
- These occur with meningitis because spinal sheath is stretched and since it is irritated the distal segments need to flex to reduce the discomfort
What are signs of a neoplasm?
- prior history of cancer
- fever, night sweats
What is a patient with RA more at risk for? What does this cause?
Basilar invagination - top of the spine pushes into the base of the skull
Atlantoaxial instability – laxity of ligamentous structures between C1 and C2
- Usually causes C2 to shift superiorly
complaints of ankylosing spondylitis
- men 10x > women - most often in 3rd decade (20s)
- back pain that is worse at night and in morning (worst at rest but better with exercise)
- decreased chest wall expansion (barrel chested)
- back stiffness
Physical exam findings of ankylosing spondylitis
- chin on chest position
- multi-directional ROM limitations of the spine/diminished mobility of the spine
- radiographic sacroiliitis on imaging
What is Klippel Feil syndrome?
congenital; failed C-spnine segmentation
- no neck, limited c-spine ROM, low posterior hairline
What is cervical arterial dysfunction (CAD)? What can occur because of it?
Intimal tear with penetration of circulating blood into the vessel wall and formation of intramural hematoma
- stroke (retinal or brain ischemia)
- compression or stretching causes local symptoms
- subarachnoid or intra-cerebral hemorrhage
Consequences of Cervical Arterial Dysfunciton (CAD)
- retinal or brain ischemia (stroke)
- compression or stretching causes local symptoms
- subarachnoid or intra-cerebral hemorrhage
What is the average age for cervical arterial dysfunction (CAD)?
39-45 y/o
cervical arterial dysfunction (CAD) symptoms
- neck pain - 60-80%
- face pain
- Severe headache - worst HA they have ever had
- severe pain - > 70%
- pulsatile tinnitus (comes in bursts)
- bilateral extremity dysesthesia, motor dysfunction, pain
- 5 D’s and N’s
What are the 5 D’s and N’s?
- Dizziness
- Dysarthria - difficulty speaking
- Dysphagia - difficulty swallowing
- Diplopia - double vision
- Drop attacks - beginning of LOC
- Nystagmus
- Nausea
- Numbness - dysesthesia of face/lip/extremities
Physical exam finds of cervical arterial dysfunction (CAD)
- ipsilateral Horner’s syndrome
- CN signs
- HTN
- positional testing (sustained end range, modified sphinx, pre-manipulative positioning)
- Neuro testing (UMN hyperreflexia and LMN hyporeflexia)
- VBI tests
What constitutes Horner’s syndrome?
- ptosis - dropping of upper eyelid
- miosis - constriction of pupil
- enopthalmos - sinking of orbit (shadowing)
- anhydrosis - dry eyes/absence of sweating
What is cervical spine Myelopathy?
Spinal cord compression as a result of impingement from surrounding structures
symptoms of cervical spine myelopathy
- neck pain/stiffness
- shoulder pain
- imbalance/fall Hx
- UE dysesthesia
- may involve LEs first (gait, weakness)
physical exam findings of cervical spine myelopathy
Neurologic signs
- gait impairment
- spasticity
- pathologic reflexes
- hyperreflexia
- dis-coordinated extremity movements
- radicular signs (weakness, sensory impairments)
- balance impairment
5 signs for clinical prediction rule for cervical spine myelopathy
1) gait deviation
2) hoffmann’s sign
3) inverted Supinator sign
4) Babinski sign
5) patient age > 45 y/o
good confirmation is 3 or more + tests
upper cervical instability symptoms
- neck pain
- occipital headache/numbness
- multidirectional ROM at end range
- radicular vs myelopathic symptoms
- reports needing to support head/tires easily w/ prolonged static upright positioning of head
upper cervical instability physical examination findings
- limitation in c-spine ROM multidirectional
- muscle guarding
- potential radicular vs myelopathic signs
special tests for upper cervical instability
- modified/sharp-purser test
- alar ligament stability test
- lateral shear test
- tectorial membrane test
- posterior A-O membrane test
What fractures may occur during traumatic axial loading?
Fractures involving the occipital condyles, C1, C2, traumatic spondylolysthesis
Presentations of fractures involving the occipital condyles, C1, C2, traumatic spondylolysthesis
- limited ROM (multidirectional)
- neck pain
- c-spine spasm
- difficulty swallowing
- radicular pain/radiculopathy
- CAD s&s
- myelopathy s&s
What is a Jefferson fracture? What is the mechanism of injury?
C1 fracture - 4 part burst fracture of atlas
- involves anterior and posterior ring of C1
- Mechanism of injury – compression load like diving
What is spondylolysis?
- defect of pars interarticularis
- stress fracture forming at the pars interarticularis (uni or bilateral)
What is spondylolysthesis? Where is it most common?
- anterior displacement of vertebral body
- degenerative spondylolysthesis - most common at C3/4 and C4/5
Grades of spndylolysthesis
1 - 0-25%
2 - 25-50%
3 - 50-75%
4 - 75-100%
Canadian c-spine rules
- When to send patient for radiography
- Have high-risk factor (age >= 65, dangerous mechanism, or paresthesias in extremities
- not able to rotate neck actively 45 deg L or R
5 criteria for NEXUS Low Risk Rule (low probability of injury)
- no midline cervical tenderness
- no focal neurologic deficit
- normal alertness
- no intoxication
- no painful, distracting injury
What is the difference between radicular and referred pain?
radicular pain - Pain from irritation to spinal nerve or root(s) (nociception)
referred pain - pain felt in one part of a body that comes from another but does not follow a dermatomal or myotome pattern
What affects vertebral bodies and discs by the formation of osteophytes around the margin of bodies?
spondylosis
What affects zygapophysial joints and AA joints by the formation of osteophytes that cause joint narrowing?
osteoarthrosis
What is lateral canal stenosis?
encroachment on spinal nerve in lateral foramen/lateral recess of spinal canal
What does lateral canal stenosis result in?
- loss of disc height w. degenerative processes (as disc height shrinks, lamina on both vertebra become smaller)
- z-joint and uncovertebral joint hypertrophy
- spondylolisthesis
- radicular symptoms
Which motion is commonly assoicated with acute z-joint arthropathy?
extension
physical exam findings of acute z-joint arthropathy
- painful with joint compression ROM
- painful with segmental provocation
- concordant pain with cervical compression and spurlings test
- pain observed in segmental distribution, not paresthesia/anesthesia
somatic referred pain vs radicular pain vs radiculopathy
somatic referred pain - altered pain preception in CNS
radicular pain - pain related to nerve root irritation (dermatomal pathway)
radiculopathy - conduction block of motor and sensory axons
T/F: Radiculopathy is painful
false - technically it is not painful but it is commonly associated with radicular pain
What cervical spine is most commonly affected by radiculopathy?
C6 and C7
Hx of cervical radiculopathy
traumatic/acute
- local neck injury involved
- traumatic event associated with onset of radicular sign/symptoms
Degenerative
- recurrent episodes - worsening in length and intensity throughout episode progressions
- trauma in initial episode
cervical radiculopathy symptoms
- unilateral > bilateral
- radicular symptoms
- aggravation with activities that compress the neuroforaminal space
cervical radiculopathy physical exam
- natural bakody’s sign possible
- painful/limited ROM w/ motions that compress foramen or place tensile load on nerve root
- relief with opening of neuroforament
- valsalva test
- Wainner’s test item cluster
What is Bakody sign?
hand on top of the head with palm up and it reduces pain
Wainner’s Test Item Cluster
used to confirm radiculopathy - more positive items the better confirmation
- ipsilateral C-spine rotation AROM < 60 deg
- spurlings test
- cervical distraction test
- upper limb tension test - median nerve bias
pathomechanics of whiplash
- trunk thrust upward
- lower c-spine segment rotation into extension
- anterior annulus distracted, impaction on facet joints, meniscoid contusion
What ligaments are stretched and what is injured during whiplash?
- anterior annulus, ALL, and facet capsule strain
- meniscoid contusion
- intra-articular hemorrhage of facets
- fractures of articular pillars/subchondral plates, dens, laminae C2, occipital condyles
symptoms of whiplash
- neck, shoulder, UE pain
- radicular vs referred symptoms
- Glove-like distribution paresthesia
- weakness
- dizziness
- difficulty focusing vision
- tinnitus
physical exam findings of whiplash
- radicular signs possible
- multidirectional limitations
- weakness
- muscle guarding
- tinnitus
What is a key sign of cervicogenic headache?
Retroocular pain – pain referring to behind the eye from cervicogenic headaches
Hx of cervicogenic dizziness
- concomitant neck pain
- hx whiplash may increase suspicion
physical exam of cervicogenic dizziness
- dizziness with neck motion (especially rotation and extension)
- dizziness with deep palpation
- dizziness with joint mobility testing
- head-neck differentiation test
discectomy
removal of disc or part of it
microdiscectomy
arthroscopic removal of little part of disc
laminoforaminotomy
shave off part of lamina to open up foramen
laminoplasty
portion of lamina are removed
arthrodesis
surgical immobilization of a joint by fusion of the adjacent bones
- stabilized by halo
- prevents motion at disc level to improve stability
arthroplasty
surgical procedure to restore the function of a joint
Laminectomy
removal of spinous process and bilateral laminae
- posterior approach
Anterior cervical arthrodesis
- removal of structures causing compression on nerve tissue
- fusion of a joint
What does anterior cervical arthrodesis cause?
increased ROM requirements on adjacent vertebral levels
at 4-6 weeks post-op of anterior cervical arthrodesis what to work on
Still have external protection (collar)
- AROM of the c-spine and UE
- c-spine isometrics
- increase tolerance to sitting
- walking/stationary cycling
- limited UE activity
