Cervical Spine Flashcards
What are the functions of the CS?
- protect vital tissues
- provide rapid movement response
- position the eyes
- provides foundation for mm of UE and scapula
T or F: there is NO disc structure at C0-2
T
Where is the transition point in the CS for mobility?
C2-3
Mechanics in the lower CS spine (C2-3 and below) involves coupled motion in the ____ direction
same
Mechanics in the upper CS involves coupled motion in the ____direction
opposite
T or F: 44% of pts with neck pn will go on to dev chronic sxs
T
Nerve roots exit ____ the named level
above
what is the difference between radiculopathy and myelopathy?
Radiculopathy: nerve root, sensory/motor changes
Myelopathy: spinal cord, UMN signs/sxs
What n innervates the diaphragm and what is it’s nerve roots?
Phrenic n (C3-4-5) keeps us alive!
What are risk factors for neck pain?
Activity: cycling
Health: smoking, previous neck pn
psychological: depression, job strain, work sitting, low co-worker social support, widower or separated
demographic: female, age (45-59), FHP (correlated in adults/older adults but not adolescents)
occupation: heavy labor, office & computer works, HC worker, unemployed
Physical work: sedentary/repetitive work, working w/ neck flexed/arms at or above shoulder height, head caring (loads on head)
what NDI score range indicates no disability?
0-4
(out of 50)
what NDI score range indicates mild disability?
5-14
(out of 50)
what NDI score range indicates moderate disability?
15-24
(out of 50)
what NDI score range indicates severe disability?
25-34
(out of 50)
what NDI score range indicates complete disability
> /= 35 (out of 50)
what is a pancoast’s tumor? and what are sxs?
lung cancer of upper lobe that invades lower brachial plexus (C7-T1)
pn in shoulder/scapula, pn referral down arm, cough, chest pn (uncommon)
What is horner’s syndrome? and sxs?
occurs when tumor invades the sympathetic chain
sxs: enophthalmos (sunken in eyes), ptosis (drooping eye lid), miosis (excessive constrition of pupil), anhidrosis (lil-non sweat)
What are the 4 “Child’s Classification Categories of Neck Pain”?
Neck pain with….
- Mobility deficits
- Headache
- Movement Coordination impairments
- Radiating pain
What 2 assessments are recommended for Neck Pain with Mobility Deficits?
- Cervical AROM
- CS/TS segmental mobility
What 3 assessments are recommended for Neck Pain with HEADACHES?
- Cervical AROM
- CS/TS segmental mobility
- Cranio-cervical flexion test
What 3 assessments are recommended for Neck Pain with MOVEMENT COORDINATION IMPAIRMENTS?
- Cranio-cervical flex test
- Deep neck flexor endurance test
- Flexibility deficits of UQ mm
What 4 assessments are recommended for Neck Pain with RADIATING PN?
- Cervical AROM
- Spurling’s test
- ULTT
- Neck distraction test
Stage I (High acuity) is characterized by what pain range and NDI score range? What is the goal for a pt classified in stage I?
Mod-severe pn
NDI: >24
Goal: dec pn
Stage II (Mod acuity) is characterized by what pain range and NDI score range? What is the goal for a pt classified in this stage?
mild-mod pn
NDI: 15-24
Goal: address relative impairments
Stage III (min acuity) is characterized by what pain range and NDI score range? What is the goal for a pt classified in this stage?
0-min pain
NDI: 0-14
Goal: return to work/sport
Review CPG recommended interventions for each classification category
Good job!
What is the Canadian Cervical Spine Rule used for?
Decision rule for detection of clinically important injury ( fx, dislocation, ligamentous instability)
What is the first Question you consider for the Canadian Cervical Spine Rule?
Any HIGH-risk factor that mandates radiography?
- Age 65+
- Dangerous mech (fall from 3+ ft/5 stairs, axial load to head, high-speed MVC)
- Paresthesias in extremities
- if any of the above are true, refer for imaging!
If a pt does not have any high-risk factor that mandates radiography what question do you consider next?
Any LOW-risk factor that allows safe assessment of ROM?
- Simple rear-end MVC
- Sitting position in ED
- Ambulatory at any time
- Delayed onset of neck pn
- Absence of midline CS tenderness
If a pt does NOT have any HIGH-risk factors that mandate radiography AND DOES have a low-risk factor that allows for safe assessment of ROM, how do you proceed?
Assess neck AROM rotation
According to the Canadian Cervical Spine Rule, if a pt is unable to ROT neck R/L 45 deg, how should you proceed?
Refer to imaging
T or F: the Canadian Cervical Spine Rule is really good at ruling OUT a clinically important injury related to the CS but poor at ruling IN.
T
Sn = 0.99-1.0
Sp= 0.43
what are S&S of upper cervical instabilty? (ie Atlantoaxial instability)
- Suboccipital pn (C2)
- Bilat UE/LE paresthesias
- Clumsiness/LOB
- Nystagmus
- HAs
- Blurred vision
- UMN signs
- HYPERreflexia
- Spasticity
- Abnormal gait
- Clumsiness
- Babinski’s sign
What are potential causes of atlantoaxial instability (upper cervical instability)?
- congenital body malformation
- DS
- Inflammatory (RA, Psoriatic arthritis, AS, osteomyelitis)
- Trauma
- Chronic corticosteroid use
How do you interpret a +LR > 10 and a -LR < 0.1
generate large and often conclusive shifts in probability
How do you interpret a +LR 5-10 and a -LR 0.1-0.2
generate mod shifts in probability
How do you interpret a +LR 2-5 and a -LR 0.2-0.5
generate small but sometimes important shifts in probability
How do you interpret a +LR 1-2 and a -LR 0.5-1
alter probability to a small and rarely important degree
What are the S&S of vertebrobasilar insufficiency?
5 D’s:
Dizziness
Diplopia
Dysarthria
Dysphagia
Drop attacks
+
Nausea & vomiting
Sensory changes
T or F: the Vertebral Artery test/ VBI test is not a good screening tool
T
It has poor sensitivity so a neg test is NOT a meaningful finding
What is included in the cluster test for radiculopathy?
- ULNT median
- Cervical rot (<60 deg)
- Cervical distraction test
- Spurling’s
*best diagnostic accuracy for radiculopathy is w/ clustering of tests (If all 4 +, Sp = 0.99, Sn = poor)
How would a CT be beneficial as an imaging technique for the CS?
CT would show the relationship of bone to neural canal in transverse plane
How would an MRI be beneficial as an imaging technique for the CS?
Visualization of spinal cord and soft tissues
How would an Myelogram be beneficial as an imaging technique for the CS?
visualization of spinal cord and nerve roots (w. contrast injected into subarachnoid space)
What imaging technique would you use to get a good image of a disc?
Discogram (inject contrast material into disc)
Review Table 4: Neck Pain impairment/function-based fx, exam, and intervention recommended classification criteria!!
Good job!
What are expected sxs of a pt with Neck Pain w/ MOBILITY DEFICITS?
- Unilat neck pn
- lim neck motion
- onset of sxs often linked to recent unguarded/awk mvmt/position
- assoc (referred) UE pn (may be present)
What are expected sxs of a pt with Neck Pain w/ HA?
- noncontinuous, unilat neck pn and assoc (referred) HA
- HA is precipitated/aggravated by neck mvmts/sustained postures
What are expected sxs of a pt with Neck Pain w/ MOVEMENT COORDINATION IMPAIRMENTS?
- neck pn & assoc (referred) UE pn
- sxs often linked to a precipitating trauma/whiplash & may be present for an extended period of time
What are expected sxs of a pt with Neck Pain w/ RADIATING PN?
- neck pn w/ assoc radiating (narrow band of lancinating) pn in involved UE
- UE paresthesia, numbness, weakness (may be present)
Which cervical discs have the GREATEST occurrence of disc disease?
C6/7: 60-70% (C7)
What are Cloward’s areas?
- Irritation of ant cervical disc results in interscapular pn (location of pn is relted to level of disc irritation
C6/7 (C7) has the greatest occurrence of disc disease, based off of cloward’s areas, if a pt has irritation of the anterior cervical disc at this level, where would they feel pain?
Interscapular area: at the level of T7 and the inf angle of scapula
what is the most serious consequence of cervical spondylosis?
cervical spondylitic myelopathy
What are sxs of cervical spondylitic myelopathy?
- Bilat neuro sxs in UE & LE
- Gait clumsiness
- Loss of hand dexterity
- Severe: B&B changes
What is the test cluster for cervical spondylitic myelopthy?
- Babinksi
- Inverted supinator sign
- Hoffman’s reflex
- Reflex testing
What factors make prognosis worse for a pt w/ cervical spondylitic myelopathy?
- age > 50
- duration of sxs > 12 mo
- involvement of multiple levels
According to the McKenzie Classification, what are the 3 syndromes of mechanical pain?
- Postural syndrome
- Dysfunction syndrome
- Derangement syndrome
Postural syndrome is one of the 3 syndromes of mechanical pn according to the McKenzie Classification. What is it and what are it’s characteristics?
= proposed as caused by mech deformation or vascular insufficiency of normal tissue as a result of sustained loading
- gradual onset, dull, symmetric pn
- full cervical AROM
- no referred pn
- neck pn w/ sustained end range positions may take > 15 min
Dysfunction syndrome is one of the 3 syndromes of mechanical pn according to the McKenzie Classification. What is it and what are it’s characteristics?
= caused by mech deformation or vascular insufficiency of abnormal tissue (shortened & fibrosed or lengthened)
- intermittent neck pn
- loss of cervical AROM
- neck pn at end-range
- no arm pn
Derangement is one of the 3 syndromes of mechanical pn according to the McKenzie Classification. What is it and what are it’s characteristics?
= (disc primarily) caused by internal disruption or displacement of tissues (thought to be disc related)
- loss of cervical AROM
- constant neck pn
- pn radiated into shoulder/arm
- neck/arm pn affected by repeated movement (peripheralization: pn inc in limb, centralization: pn lessens in limb)
What is the most common CS postural impairment?
FHP
what is the effect os FHP on the CS & mm activity?
- increased facet loading
- slight ext of upper CS: forward gaze
- inc post cervical mm activity
What are predictors that a pt would benefit from cervical trx + exercise?
- Age 55+
- Shoulder abd test (hand on head)
- ULTT A (median N)
- Sx peripheralization w/ central P/A motion testing at lower cervical (C4-7) spine
- neck distraction test
If 4+, then 94.8% probability
If 3+ then 79.2% probability
23 years ago, the PT intervention choices for Neck pn were:
- heat
- flexibility
what is whiplash?
an abnormal acceleration deceleration of head beck and torso
T or F: 20-25% of pts with WAD will become chronic
T
What are chronicity prognostic indicators for WAD that have high evidence?
- elevated pain scale & disability ratings
-excessive initial self-reported pain intensity (7/10) - extreme disability (NDI >40/100)
-low self-efficacy - catastrophizing
- lower educational level
- reduced cervical ROM
-Anxiety
-large # of initial sxs
T or F: increase sensitivity to cold is assoc w/ ongoing disability after whiplash?
T
What ligament test would you perform first?
sharp-purser
what is a jefferson’s fx?
C1 fx from axial load
what is a hangman’s fx?
C2 pedicle fx from sudden hyperext
what is a odontoid fx?
C2 dens fx from combined hyperext/rot
what is the intervention for a pt with a STABLE fx w/o compression of neural elements?
immobilization in a rigid cervical orthosis for 8012 weeks
what is the intervention for a pt with an unstable fx(s) w/ or w/o neurological deficit?
generally require operative tx (early ORIF) indicated to obtain stability
