Cervical Spine ✅ Flashcards by Wadhha Alajmi

What are the primary and secondary curvatures of the spine ?

Primary curvatures (nearly immobile):
present in fetus & remain same in adult
- thoracic
- sacral

Secondary curvatures (mobile):
develops when child lifts head/assumes upright position
- cervical
- lumbar

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What should be considered in the differential diagnosis for neck pain besides issue with cervical spine ?

Upper extremity
- shoulder
- elbow
- wrist/hand

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True or false

Between C1 and C2 , there is an intervertebral disc.

False

No IVD between C1 and C2

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What are the functional divisions of the cervical spine?

Cranio-cervical or Upper cervical
(Occipito-atlanto / atlanto-axial / C2 on C3 articulation)
Cervical or Mid cervical spine
(C2-C3 through C6-C7)
Cervico-thoracic spine
(C7 through T2-T3, 1st and 2nd ribs)

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The neck muscles are divided into 3 functional groups .

what are these groups?
what are the muscles in each group?

Examples of suboccipital group: Rectus capitis anterior and lateral, longus colli etc

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Which of the following is NOT function neck muscle group?

A. Posterior group
B. Anterior group
C. Posterolateral group
D. Suboccipital group

B. Anterior group

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What is the most complex joint in the axial skeleton?

Atlanto-occipital joint (C0-C1)

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True or false

Atlas has no vertebral body

True

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True or false

C1 is an atypical cervical vertebrae

True

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Movements at the Atlanto-occipital joint (C0-C1)

15-20 ° flexion-extension (nodding)
10 ° side flexion
NO ROTATION

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True or false

Rotation can occur at the Atlanto-occipital joint

False

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Which cervical vertebrae are considered atypical?

C1
C2
C7

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True or false

C1 does not have a vertebral body nor a spinous process

True

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What structure passes through the transverse foramen in the cervical vertebrae?

Vertebral artery

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What joint is considered the most mobile articulation in the cervical spine?

Atlanto-axial joint (C1-C2)

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What unique process does C2 have and what is its functional purpose?

C2 has the odontoid process (or dens), which acts as a pivot for rotation

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Movements at the Atlanto-axial joint ?

10 ° flexion-extension
5 ° side flexion
50 ° rotation

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What is the primary motion of the Atlanto-axial joint ?

Rotation

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What happens if rotation exceeds > 50 ° at the Atlanto-axial joint ?

What about at 45 ° of rotation

Rotation > 50 ° : Kinking of the CONTRALATERAL vertebral artery (VBA)

Rotation at 45 ° : may kink IPSILATERAL VBA

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What are the consequences if the vertebral artery is kinked?

(Hint: 3 Ns and 5 Ds)

Nystagmus
Nausea
Numbness
Drop attack
Dysarthria
Dysphasia
Dizziness
Diplopia (double vision)

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What is the function of the transverse ligament at the Atlanto-axial joint?

Stabilization of the dens process on C1

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True or false

Joints below C2 act as convex on concave articulations.

False

CONCAVE ON CONVEX articulations

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Describe the concave on convex articulations from C2 to C7 in flexion and extension

In flexion : the superior facets of the lower vertebra roll and glide in a SUPERIOR and ANTERIOR direction.

In extension : the superior facets of the lower vertebra roll and glide in an INFERIOR and POSTERIOR direction

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Where does the greatest flexion (90 °) /extension ( 70 °) occur in the cervical spine?

Lower cervical spine between C4 and C6 ,

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Movements that occur between C2 to C7

Greatest flexion (90 °) /extension (70 °) between C4-C6 Side flexion 20 ° - 45 ° Rotation is 70 ° - 90 °

Cervical rotation and side flexion occur together as a coupled movement . Why?

Because of the shape of the articular surfaces of the facet joints (coronally oblique ; so there’s no pure movement)

In the cervical spine, ROTATION to one side is always accompanied by ____________ to the SAME side.

SIDE FLEXION (Coupled movement) (Keep in mind this is NOT the case for lumbar spine)

True or false Facet joints are a main source of neck pain and low back pain

True

True or false In cervical spine, rotation and side flexion occur to the OPPOSITE side

False SAME side

Injuries to the cervical spine include :

Bamboo spine deformity can be seen in which pathology?

Ankylosing spondylitis

Upper cervical spine injuries include:

Pathologies of the cervical spine include:

Whiplash (cervical sprain) - Describe what happens. - What’s the problem with this injury?

Caused by sudden Hyperextension and Hyperflexion , leading to the reversal of the normal curvature of the cervical spine = INSTABILITY/ HYPERMOBILITY

We should not touch a whiplash patient until after they’ve seen a physician. Why?

To rule out fracture before PT treatment

Treatment for whiplash injury

1. Analgesic 2. PT treatment - neck isometric exercise - active movement - gradual resisted exercises (Stabilization and strengthening)

Prognosis for whiplash injury

Symptoms diminish after 3 months and go on improving over 1 to 2 years.

True or false The mid cervical region is the most common site for injury in the cervical spine

True

(Minor sprains and strains of the mid-cervical region) Restriction in side bending and rotation is on the opposite side of the symptoms (pain). This type of restriction is known as ____________________.

Opening pattern

(Minor sprains and strains of the mid-cervical region) Restriction in extension, side bending and rotation is on the same side of the symptoms (pain). This type of restriction is known as ____________________.

Closing pattern

Minor sprains and strains of the mid-cervical region - what may occur as a result? - treatment ?

- opening/closing pattern - catch in the spine - local and referred symptoms Rx: address irritability, specific mobilization

The disc is made up of a tough outer layer called the ___________________ and a gel-like inner center called the ___________________ .

Annulus fibrosus Nucleus pulposus

What happens to the nucleus pulposus as you get older?

May start to lose water content, making the disc less effective as a cushion

As a disc deteriorates, the annulus fibrosus can also tear, allowing the outward displacement of the nucleus proposes through a crack in the outer layer, into the space occupied by the nerves and spinal cord What is this called?

Cervical disc prolapse or herniation

What is the consequence of having a disc prolapse or herniation in the cervical spine?

The herniated disc can press on the nerves and cause symptoms in one or both shoulders or arms including : - pain -Numbness -Tingling -weakness - changes in reflexes, sensation, and strength

Can a cervical disc prolapse or herniation cause problems in the lower limb ?

Rarely if the herniated disc puts pressure on the spinal cord

What imaging methods can confirm herniated disc

MRI or CT

True or false If a herniated disc leads to motor issues such as weakness, then the disc is only causing minimal pressure on the spinal cord.

False Minimal pressure on the spinal cord can lead to sensory issues. However, more pressure is required to experience motor issues on top of the sensory issues.

During flexion and extension, what happens to the annulus fibrosis anteriorly and posteriorly ?

FLEXION: Anteriorly = compressed Posteriorly = distracted EXTENSION: Anteriorly = distracted Posteriorly = compressed

True or false MOST (not all) patients with disc bulge have more pain and symptoms with flexion, but are relieved with extension

True Because the anterior compressive forces on the disc during flexion pushes the nucleus pulposus more posteriorly, compressing the neuronal structures more , while extension relieves them

Cluster of abnormalities arising from chronic intervertebral disc degeneration, where the disc degenerates and flattens, becoming less elastic and the facet joints and the uncovertebral joints are slightly displaced and become arthritic, causing neck pain and stiffness Which condition is this?

Cervical spondylosis

Changes due to cervical spondylosis are most commonly seen in which region of the cervical spine?

Lower cervical region C5 to C7

How can cervical spondylosis cause pressure on the dura matter?

Bony spurs (osteophytes), ridges and bars are seen at the anterior and posterior margins of the vertebral bodies These posterior spurs may press the spinal cord, causing pressure on the dura matter

What are the signs that points to cervical spondylosis? (Hint: 5)

- Patient > 40 years old with neck pain and stiffness - Gradual onset , worse in the morning when getting up (chronic inflammation) - Radiating pain to the occiput, back of shoulder and down to arms - Paresthesia, decreased reflexes, weakness of arms and hands is possible - Tenderness of neck muscle with restricted neck movement

What is the term? __________________ : features arising from narrowing of the intervertebral foremen and compression of the nerve roots

Radiculopathy

What would an x-ray show in a case of cervical spondylosis?

Narrowing of one or more intervertebral spaces with spur formation or “ lipping” at the anterior and posterior margins of the disc

What method of imaging is best for cervical spondylosis?

MRI is more reliable But x-ray can also be performed

Treatments for cervical spondylosis

Analgesic and PT - heat and massage - Exercise - Traction - Ultrasound

Narrowing of the spinal canal due to degeneration, birth defects, or space occupying lesions that can cause neurological deficits due to direct compression and ischemia of the spinal cord from impaired venous drainage and reduced arterial flow What is this also known as?

Spinal stenosis

How narrow does the spinal canal have to be in order for it to be considered as spinal stenosis?

If the distance is < 11mm

True or false Many people with spinal stenosis are asymptomatic

True

True or false Spinal stenosis is not a diagnosis

True

Consequences of spinal stenosis

Paresthesia Numbness Weakness Clumsiness of arms and legs INCREASINGLY UNSTEADY GAIT Neck pain - involuntary spasm in the leg and spontaneous clonus - Urinary and rectal dysfunction in severe case - Weakness and spasticity in the legs and numbness in the hands (UMNL)

True or false Spinal stenosis is a condition that is slowly progressive

True

Symptoms of spinal stenosis are aggravated by which motion?

Hyperextending neck

True or false Severe cases of spinal stenosis can cause urinary and rectal dysfunction

True

True or false Spinal stenosis can cause weakness and spasticity in the hands and numbness in the legs

False It’s the opposite Weakness and spasticity = legs Numbness = hands

True or false Spinal stenosis can cause involuntary spasm in the leg and spontaneous clonus

True

Treatment for spinal stenosis

( immediate decompression = surgery)

What treatment methods are contraindicated in spinal stenosis?

Manipulation and traction !! (Should NOT do)

Causes of neck dysfunction

Impingement syndrome - Describe the onset - symptoms and manifestation

SUDDEN onset without trauma - Sharp, unilateral neck pain with restricted movement - compression in weight-bearing and nonweightbearing is painful - sharp and excruciating neck pain - Stiff neck and muscle spasm

What is the most restricted movement in impingement syndrome?

(1) Extension and (2) rotation to the side of pain (closing restriction) (3) Lateral bending to the side of pain

True or false Impingement syndrome presents with an opening restriction

False Closing restriction , meaning restriction and pain are on the same side

Treatment for impingement syndrome

Manual traction and rotation mobilization

True or false Impingement syndrome has a gradual onset

False Sudden onset

True or false Repetitive manipulation can lead to joint hypermobility

True That’s why we have to be careful

True loss of neck passive ROM accompanied by signs of acute inflammation or muscle spasm. What is the issue here?

Hypomobility

True or false Hypomobility leads to equal loss of rotation and lateral bending to the same side of pain and loss of extension

False To the opposite side of pain Hypomobility results in opening restriction, not closing restriction, so the restriction is on the opposite side of the pain

What movements are restricted with hypomobility?

Equal loss of rotation and lateral bending Loss of extension

What is the capsular pattern for the cervical spine?

Full flexion Limited extension Symmetrically/equally limited side flexion and rotation

What type of restriction is this?

Open restriction

What type of restriction is this?

Closing restriction

Treatment for hypomobility

Mobilization Traction (Mainland grades 3 and 4 to increase ROM)

Signs of acute inflammation

Redness Swelling Heat Pain

Treatment for pain and inflammation

Rest NSAIDs Physical modalities (ice and TENS)

__________________ usually accompanies the early stages of neck dysfunction

Muscle spasm (Due to muscle guarding)

What measurements are compromised in the presence of muscle spasm?

Range of motion ROM Manual muscle testing MMT

Treatments for muscle spasm

Physical agent Hold and relax Massage Mobilizing exercise

History taking (just read)

In case of postural and overuse syndromes, what are some underlying impairments ? (Hint: 5)

- soft tissue strain - Muscular imbalances - Mild sprains of cervical articulations - habitual posturing - repetitive movement patterns (Important exam question)

In case of arthritic and degenerative conditions, what are some underlying impairments ? (Hint: 4)

- degenerative anatomical changes - Alteration in normal biomechanics - Potential loss of space - Decline in loadbearing tolerance (Important exam question)

In case of traumatic episodes, what can be gathered from the history? (Hint: 4)

- specific tissue injury - acute inflammatory process - Sudden rapid onset of symptoms - Complicated by underlying conditions (Exam question )

Assessment of cervical spine (Look over it)

مهم

True or false Flexion is usually spared in the cervical spine

True

What common restrictions should be ruled out before stating that a patient has true cervical spine flexion limitation?

Upper T/S CT junction If those are cleared, then the problem is true C/S flexion limitation

If we have true cervical flexion limitation and distal symptoms, what should we suspect?

Space occupying lesion (Further work up is needed)

What to observe during assessment?

Read

What to observe during assessment?

Read

What do we palpate for during cervical spine assessment

Just read

Range of motion of Atlanto-occipital joint, Atlanto-axial joint, and mid to lower cervical spine (Revision)

Manual muscle testing MMT for cervical spine

Neurological testing to test for nerve integrity involves what three assessments?

Dermatomes Myotomes Deep tendon reflexes DTRs (including Hoffman’s)

C5 neurological level -motor - Reflex - sensation

C6 neurological level - motor - reflex - sensation

C7 neurological level - motor - Reflex - sensation

Biceps reflex belongs to which spinal root

C5,6

Brachioradialis reflex belongs to which spinal root

C6,7

Triceps reflex belongs to which spinal root

C7,8

Which nerve root supplies the sensation of the lateral portion of the arm

Which spinal root supplies the sensation of the lateral portion of the forearm and thumb

Which spinal root supplies the sensation of the middle finger

Which spinal root supplies the medial portion of the forearm with the little finger

Which spinal root supplies the sensation of the medial arm?

C5 myotome

Shoulder abduction Elbow flexion (Deltoid and biceps)

C6 myotome

Wrist extension (Wrist extensors)

C7 myotome

Wrist flexion Elbow extension (Wrist flexors and triceps)

C8 myotome

Finger flexion (Finger flexors and hand intrinsics)

T1 myotome

Finger abduction (Hand intrinsic)

Special test: Vertebral artery test VBI - positive signs - indication

Patient is supine, neck goes into extension then rotation

What treatment methods are contraindicated in patients with positive VBI ?

Traction Joint mobilization

How to perform modified VBI test? (Notice how it is different from the original VBI test)

Foraminal compression (a special test) has another name. What is it?

Spurling’s test

Spurling’s test - positive sign - indication - contraindication/precaution

Spurling’s test is contraindicated in what conditions?

OA RA Osteoporosis Spinal stenosis

True or false Spurling’s test can be applied on a patient with spinal stenosis

False Contraindication

Distraction test - positive sign - indication - contraindication

When is the distraction test contraindicated?

Vertebral instability /hypermobility

The positive finding for distraction test is pain relief. If the distraction test increased the pain, what would that indicate?

Muscular or ligamentous damage

Valsava test - positive sign - indication - contraindication

(Due to increased intrathecal pressure ! )

Shoulder abduction test - positive sign - indication

- positive sign: pain decreases or disappears - indication: radicular pathology

Name 3 stability tests (special test for stability) .

Restricted C/S flexion could be due to :

Fracture Subluxation C/S disc CT junction or upper T/S (most common reason)

Read about C/T junction and segmental instability

True or false Pain regarding CT junction can be radiating

False All symptoms are localized if issue is at CT Junction

How to treat hypomobility? (Arthritic/degenerative changes in the mid cervical spine)

Mobilization

Thoracic outlet syndrome (Read)

Ex: right TOS will be aggravated if patient turns head left ?

Treatment for limited flexion

C/T junction manipulation 👇🏻(if not improved) C/S traction 👇🏻 (if not improved) MRI

Treatment for opening restriction

Stretching

Treatment for opening restriction

Stretching Seated mobilization

When is traction considered an effective treatment?

Lower mobility testing = causes peripheralization Shoulder abduction test = positive Distraction test = positive Distal symptoms that are provoked or increased by neck movements

When performing traction as a treatment, how long should you hold and how long should you relax?

Hold traction 20 seconds Relax 8 seconds

Distal symptoms that are provoked or increased by opposite side bending is probably caused by what?

Thoracic outlet syndrome TOS

Treatments for instability or hypermobility

Stabilization and strengthening

Treatments for instability or hypermobility

Stabilization and strengthening