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MSK > Cervical Spine > Flashcards

Cervical Spine Flashcards

1
Q

Applied Anatomy: Nerve Roots

A

8 Nerve Roots (C1-8)

In c-spine nerve roots exit ABOVE the corresponding vertebrae

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2
Q

Applied Anatomy: Intervertebral Discs

(4)

A
  • NO disc between C0-1 & C1-2
  • Discs at C2-C3 & below
  • Slightly thicker anteriorly, contributes to lordosis
  • Discs are relatively thin in C-spine allowing for greater mobility
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3
Q

Cervical Rediculopathy

A

A condition describing a group of signs & symptoms related to a compressed or irritated nerve root

MIDDLE = cervical Myelopathy
- S/S of an UMNL
POSTERIOR/LATERAL = nerve root

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4
Q

Cervical Rediculopathy: Etiology

(3)

A
  1. Disc Herniaton
    Dynamic Disk Theory = material inside the disk is dynamic - can move (nucleus pulpous) from HIGH > LOW pressure - & goes for the path of least resistance
  2. Stenosis
    - Osteophytes
    - Spondylosis - degeneration of the spine - disc (less hydrated - thinner) = IVF narrows = less space for nerve roots
    - Ligament Thickening - ligamentim flavum- leads to CENTRAL stenosis
  3. Swelling & inflammation (from local trauma)
    Messy & unclear
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5
Q

Physical Examination: Neuro Scan

A

Performed when there are S/S present that are neurological OR you want to rule out C/S (unsure what is occuring)

  1. Dermatomes: any area of the skin supplied by a single nerve root
  2. Myotomes: a group of mm supplied by a single nerve root
  3. Reflexes: an involuntary & almost instant response to a stimuli
  4. Special Tests
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6
Q

What direction do you test dermatomes in?

A

Proximal > Distal

Start w/ light touch, if impaired > may test area with crude touch (sharp/dull) or temperature (hot/cold)

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7
Q

Reflexes: What to do if unable to elicit a response?

(2)

A
  1. Use Jendrassik Manuever
    L/E - cross legs & pull ankles apart
    U/E - clasp ahnds & try to pull them apart

Ask patient to close their eyes & count backwards

** Distract pt so they will relax

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8
Q

UMN Reflexes: Positive Findings

(2)

A

Positive findings indicates a possible lesion of the spinal cord, brainstem, or brain

Clonus: quickly & forcefully DF the ankle AND HOLD in the fully DF’ed position
Abnormal response: Sustained clonus of 5 beats or more

Babinski Reflex: run a pointed objected along the lateral aspect of the foot, from the heel & across the ball of the foot
Abnormal Response: splaying of toes &/or extension of big toe

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9
Q

Special Test: Cervical Distratction

A

Test is used when a patient is currently experiencing radicular symptoms

PT places one hand under the chin & the other hand around the occiput, lifts upward to apply a traction to the c-spine

(+): Radicular symptoms decreased or abolished

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10
Q

Special Test: Spurling’s (Foraminal Compression Test)

A

Therapist applies a axial load by pressing straight down on patient’s head

If no symptoms occur whille head is in neutral progress to:
1. Extension + rotation to unaffected side, then extension + rotation to affected side
Closing the IVF down even more
2. Side flexion to affected side - contralateral (may alleviated S/S slightly)

(+) = reproduction of radicular symptoms (towrds the side of side flexion)

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11
Q

Special Test: Spurling’s (Foraminal Compression Test)

A

Therapist applies a axial load by pressing straight down on patient’s head

If no symptoms occur whille head is in neutral progress to:
1. Extension + rotation to unaffected side, then extension + rotation to affected side
Closing the IVF down even more
2. Side flexion to affected side - contralateral (may alleviated S/S slightly)

(+) = reproduction of radicular symptoms (towrds the side of side flexion)

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12
Q

Upper Limb Tension (Neurodynamic) Tests

A

Test unaffected side first - compare both sides
1. Shows pt what they should expect to feel - avoid getting false (+)

Order of limb positioning shoulder > forearm > wrist > fingers > elbow (< easy joint to calculate angle - objective measure)

Neurolgoical tissue is differentiated by adding sensitizing test (contralateral C-spine side flexion). Alternatively, relieving test may be used (ipsilateral side flexion)

(+) = productiion of radicular symptoms

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13
Q

ULTT 1:

Nerves & Positions

A

Median, anterior interossesous nerve, C5-6-7

  1. Shoulder depression & abduction (110)
  2. Forearm supination
  3. Wrist extension
  4. Finger & thumb extension
  5. Elbow extension
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14
Q

ULTT 2

Nerves & Position

A

Median nerve, musculocutaneous nerve, axillary nerve

  1. Shoulder depression & abduction (~10)
  2. Forearm supination
  3. Wrist extension
  4. Fingers & thumb extenson
  5. Elbow extension
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15
Q

ULTT 3:

Nerve & Position

A

Radial Nerve

  1. Shoulder depression & abduction (~10)
  2. Forarm pronation
  3. Wrist flexion & UD (tensioning nerve)
  4. Fingers & thumb flxion
  5. Elbow extension
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16
Q

ULTT 4:

Nerve & Position

A

Ulnar nerve, C8 & T1 nerve roots

  1. Shoulder depression & abduction (10-90)
  2. Forarm pronation (or supination)
  3. Wrist extension & radial deviation
  4. Finger & thumb extension
  5. Elbow flexion
17
Q

Cervical Radiculopathy: Interventions

A

Stenosis: open up intervertebral foramen (ie. traction, flexion, etc)
- Offload nerve initially & then gradually return to neutral
- FLEX = open, EXT = closed, CONTRA SB (May not work if it stretches the nerve)

Disc Herniation: Retraction progressions (lower c-spine extension)
- Most ppl generally respond - assess directional preference
- Retraction = chin tuck = C3-7 extension ~ causes dick to migrate back (High > low pressure)
- Retraction + extension = progression (sligh ext into more ext)

18
Q

Brachial Plexus Injuries: Erb-Duchenne Paralysis

A

Injury to upper nerve root C5-C6 (Upper brachial plexus) causing paralysis of the arm (shoulder & elbow)

Muscles of the hand are not affected

“Waiter’s Tip” position:
- Shoulder IR
- Elbow extension
- Forarm pronation

Sensation over deltoid area & radial surface of forearm & hand are affected

Most commonly d/t shoulder dystocia during birth
- Head exits the canal but shoulders get stuck - traction injury b/c head is getting pulled - LATERAL traction

19
Q

Brachial Plexus Injuries: Klumpke’ Paralysis

A

Injury to lower nerve roots C8 & T1 (lower brachial plexus) causing weakness & paralysis in the muscles of the forarm, hand, & triceps

Due to involvement of T1, Horner’s syndrome with ptosis (drooping eyelid) and miosis (excessive pupil constriction) may develop

Position:
- Elbow flexion
- Forearm supination
- Wrist & MCP extension
- PIP & DIP flexion

Causes claw hand d/t involvement of ulnar nerve

Sensation over ulnar side of forearm and hand IS affected

Most commonly due to difficulties in childbirth
- Often d/t traction on an abducted arm as the child is being pulled out during birthing
** May also occur with arm traction as a result of grabbiing a hold of something as one is falling

20
Q

Facet Syndrome

A

Typically pain is worse with compression stress on the facet joints

  • Pain may refer into neck &/or scapular region
  • May be tested using coupled or combined movements (physiological & non-physiological
21
Q

Facet Syndrome:
Physiological Mvmt

A

Normal arthrokinematics of that region of the spine

The facet joint guide the movements in that region of the C/S - shape & orientation

C/S facet joints are angled towards the eyes

D/t the orientation of the facet joints in the C/S, side bending & rotation occur towards same side (this is normal arthokinematics of the spine)

Coupled movements into extension may be used to rile out facet joint involvement

22
Q

Facet Syndrome:
Non-Physiological Mvmt

A

Non-physiological coupled movements are movements that oppose the normal athrokinematics of that region of the spine - may cause additional SHEARING forces

Side-flexion & rotation are performed in opposite directions

Non-physiological movements are potentially more symptom provocative & should only be performed when physiological movements are full & pain free

23
Q

Vestibulobasilar Insufficiency (VBI)

A

Compression of the vertebral artery = DEC BF & ischemia to the brain - specifcally to areas of the brainstem (pons, medulla, & cerebellum)

5 Ds
- Diplopia (Double / blurred vision)
- Dizziness
- Dysphagia (Difficulty swallowing)
- Dysarthria (Difficulty speaking)
- Drop attacks (loss of power or consciousness)

3 Ns
- Nausea
- Nystagmus
- Neurological symptoms (other)

24
Q

Special Test: Vertebral Artery (Cervical Quadrant) Test

A
  • Patient is positioned in supine
  • Therapist passively takes patients head & neck into extension & side flexion & holds for 10-30 seconds

If no symptoms are produced, ipsilateral neck rotation is added & posiiton is held for 10-30 seconds

** EYES OPEN thoughout test

(+) = Dizziness or nystagmus. This indicates that the contralateral side artery is being compressed
- Tensioned & getting compressed as it passes through the canal

25
Q

Torticollis (congenital or acquired)

Description & Intervention

A

Unilateral shortened Sternocleidomastoid (SCM) muscle causing:
- Ipsilateral side flexion and contralateral rotation of the C-spine
- DEC AROM & PROM in opposite direction (side flexion away & rotation towards the affected side)
- Rx:
Stretch the affected side SCM
Strengthening exercises to improve balance b/t both sides
Positioning/ handling to simulate symmetry (ex also holding the baby on the same side - Tx: switch sides II Crib - move it to the center so the baby will look both ways)

Congenital Torticollis:
- Etiology unknown but believed to be due to trauma during birthing process (delievery) or intrauterine malpositioning
- Positional plagiocephaly (flattened head syndrome) may develop as a result of uneven pressure distribution for porlonged periods when lying in positions
Cranial remodling orthosis (baby helmet) & frequent repositioning may help prevent plagiocephaly

Interventions:
- Repositioning
- Stretch tight SCM mm

26
Q

Posture Dysfunctions: Upper Cross Syndrome

Description & Interventions

A

Forward head posture (chin poking) may result in adaptive shortening of the lower cervical flexions (SCM & anterior/middle scalene mm)

Upper cervial extensors (suboccipital mm & capitis mm) may lead to deep neck flexor weakness

UCS =
Weak: deep neck flexors
Tight: Upper trap & levator scapula
Weak: Lower trapezius, rhomboids & serratus anterior
Tight: Pectorals

**May lead to alignment changes in the c-spine leading to increased stress on the psoterior structures (ie facets & posterior disc)

Interventions:
1. Postural correction - go to answer
2. Strengthen weak & elongated mm
3. Stretch tight structures

27
Q

Cervical Instability

A

Excessive motion between 2 adjacent vertebra
- D/t ligament damage, fracture, dislocation, joint damage (stenosis, dehydrated discs - period before osteophytes are formed leading to stiffness)
- May be caused by trauma, congenital malformations, long-term corticosteriod use (weaken tissues), or secondary to pathologies (RA, DS, osteoporosis)

IF instability is suspected mobilizations &/or manipulations should not be performed (contraindicated)

28
Q

Cervical Instability: S/S

10 + 2

A
  1. Dizziness
  2. Lip or facial paresthesia
  3. Lump in throat
  4. Nausea/ vomitting
  5. Nystagmus
  6. Patient is hesitant to move head or neck (especially into flexion)
  7. Pupil change
  8. Severe headache (especially w/ mvmt)
  9. Severe mm spasm
  10. Soft end-feel

SCI S/S
- Quadrilateral paresthesia
Paresthesia down all 4 limbs
- Cord compression S/S

29
Q

Special Test: Anterior Shear or Saggital Shear Test

A

Tests the integrity of supporting anterior ligaments & capsular tissues

Procedure:
- Patient in supine, head in neutral
- Therapist stabilizes the vertebra by placing both thumbs over the anterior aspect of the TPs
- Therapist applies an anterior force on the adjacent vertebra above the stabilized vertebra
May apply force through SP or bilaterally through the posterior arch (lamina)

(+) = Excessive motion &/or S/S of cervical instability

30
Q

Special Test: Lateral Flexion Alar Ligament Stress Test

A

Tests the integrity of the contralateral alar ligament

Procedure:
- Patient in supine, head in neutral
- PT stabilizes C2 with wide pinch grip around SP & lamiina
- PT side flexes C1 & head

(+) = excessive side flexion
An intact alar ligament results in a strong capsular end-feel

31
Q

Special Test: Lateral (Transverse) Shear Test

A

Tests the integrity of lateral ligaments & capsular tissue

Procedure:
- Patient in supine, head in neutral
- Forwarn patient that test may cause pain and discomfort **
- PT places the radial aspect of the 2nd MTP joint of one hand aginst the TP of one vertebra & the radial aspect of the 2nd MTP joint of the other hand on the TP of an adjacent vertebrae on the other side of the neck
- PT hands are then pushed together carefully creating a shearing force of one vertebra over the other

(+) = Excessive motion or sumptoms of instability, spinal cord, or vascular pathology
- Minimal motion and no symptoms should be produced with intact ligaments & capsular tissue

NEED to refer patient - at risk for numerous adverse events (stroke)

32
Q

Special Test: Sharp-Purser Test

A

Should be performed with extreme caution

Test to determine subluxation of C1 (atlas) on C2 (axis)
- Transverse ligament helps maintain position of th eodontoid process of C2 relative to C1. If the transverse ligament is torn, C1 will sublux by translating forward relative to C2 in flexion
- Patient may be hesitant or reluctant to perform forward flexion

Procedure:
- PT places one hand over the patient’s forehead & the thumb of the other hand is placed over the C2 SP in order to stabilize C2.
- Patient is asled to slowly flex head forward, while the PT applied pressure against the patient’s forehead. May hear a clunk - could possible reduce the subluxation

(+) = PT feels the head slide backwards during the movement
- Indicates relocation of subluxed atlas. May be accompanied by a clunk

33
Q

Special Test: Cervical Flexion-Rotation Test
Exorcist Test

A

Indicates C1-C2 dysfunction
Validated as a diagnostic test for C1-2 related CERVICOGENIC headache

Procedure:
- Patient in supine
- PT fully flexes the patient’s c-spine (chin-chest) & proceeds to rotate the patient’s head to the RT & LT (while maintaining full c-spine flexion) to assess ROM
FULL FLEX: locks C3-7) to evulate how much rotation is at C1-2

(+) =
- Increased or decreased ROM 45 degrees upper c-spine rotation ROM indicating a C1-2 dysfunction
- Reproduction of headache indicating C1-2 cervicogenic headache

False (+) if you do not lock the pt C/S well

34
Q

Segmental Instability (Clinical Instability)

Long Explanation & Intervention

A

Clinical Stability - will not see this on radiograph compared to the other instabilities
Related to how well the inner unit mm are working - stabilizing mm - are they coordinatde & have appropriate timing

Inner unit mm:
- Attach segmentally
- Function as stabilizers (tonic mm - constantly on) NOT prime movers
Analogy - stabilizers = marathon runners - can go a long time BUT are not very strong. Prime mover = sprinters
- Includes:
Deep neck flexors
Deep neck extensors
Suboccipitals
- Can become weak - after a traumatic injury (MVA - inhibited by pain)

Dysfunction in these mm can lead to segmental (clinical) instability, potentially leading to aberrant movement (Not moving smoothy - clunk into place) b/t segments or at certain ROM causing pain

May also lead to increased recruitment of superficial global mm in an attempt to maintain stability causing overuse of global musculature (TONIC contractions - can get fatigued which leads to pain - INC lactic acid - lead to area becoming sensitized)

Intervention:
1. Deep Neck Flexor (DNF) Training
- Coordination & timing
- Analgesic effect - slight mvm when other mvmt is tolerated - helps with pain

35
Q

Special Test: Craniocervical Flexion Test (Pressure Feedback Test)

A

Procedure:
- Test deep neck flexor mm function
- Patient positioned in supine in crook-lying with c-spine in neutral (place towels under head to achieve neutral c-spine if necessary)
- Place inflatable pressure sense (BP cuff) under the upper c-spine
- Inflate presure device to a base level of 20 mmHg
- Instruct the patient to perform upper c-spine flexion by nodding the head slowly & gently in order to reach a pressure grade of 22 mmHg & hold for 10 seconds
If actication of SCM occurs = pt is doing it wrong
- This is repeated at increasing pressure grades (22, 24, 26, 28, and 30)
- Most young & middle-aged patients can successfully perform test at 26 & hold for 10 seconds

(+) =
- Patient is unable to increase pressure to at least 26 mm Hg
- Unable ot hold contraction at given pressure for 10 secs (or it teters)
- Inability to raise pressure in small increments (2 mm Hg)
- Uses compensatory patterns:
Uses superficial neck mm (SCM)
Extends the head
*Overacitivty of global mm & underactivity of deep mm

MSK (13 decks)

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