Cervical Spine Flashcards
SINSS
Severity, Irritability, Nature, Stage, Stability
What are the four components of the Four-Tier Safety Screen?
- Historical Review – PMH, MOI
- Medical Testing and Diagnostic Imaging
- Clinical Screening for Segmental Stability
- Clinical Screening for VBI
PMH refers to Past Medical History, and MOI refers to Mechanism of Injury.
What guidelines are referenced for Medical Testing and Diagnostic Imaging in the Four-Tier Safety Screen?
- ACR Appropriateness Criteria
- Canadian C-Spine Rules
- Nexus Criteria
These guidelines help determine the necessity and appropriateness of imaging.
What is assessed during Clinical Screening for Segmental Stability?
Upper ligamentous testing and stress testing
These tests evaluate the stability of the cervical spine segments.
What position is suggested for considering VBI screening?
Hatuant’s or progressive positioning with monitoring of symptoms
These methods aim to assess symptoms related to vertebral artery insufficiency.
What are the high-risk factors in the Canadian C-Spine Rules?
- Age 65 or older
- Dangerous mechanism of injury
- Paresthesia in extremities
What is the second step in the Canadian C-Spine Rules?
Assess if the patient has any low-risk factors that allow safe assessment of range of motion
What are the low-risk factors identified in the Canadian C-Spine Rules?
- Simple rear-end motor vehicle collision
- Ambulatory at any time
- Delayed onset of neck pain
What is the third step in the Canadian C-Spine Rules?
Determine if the patient can actively rotate their neck
What is the requirement for active neck rotation in the Canadian C-Spine Rules?
The patient must be able to rotate their neck 45 degrees left and right
True or False: The Canadian C-Spine Rules are applicable to all trauma patients.
False
List the 5-D’s symptoms.
- Dizziness
- Diplopia (including amaurosis fugax and corneal reflex)
- Drop attacks
- Dysarthria (including hoarseness and hiccups)
- Dysphagia
These symptoms are key indicators in assessing cranial nerve function.
What are the 2-A’s symptoms?
- Ataxia of gait
- Anxiety
These symptoms help in evaluating coordination and psychological factors.
Identify the 3-N’s symptoms.
- Nausea
- Numbness (Ipsilateral face and or contralateral body)
- Nystagmus
Nausea and numbness can indicate neurological disturbances, while nystagmus relates to eye movement disorders.
What is the test to see function of the hypoglossal nerve (CN XII)?
Stick out tongue; strength test resist into cheek
Which cranial nerve is associated with difficulty swallowing and the gag reflex?
Glossopharyngeal nerve (CN IX)
What does the vagus nerve (CN X) test involve?
Say Ahhhhh or assess for hoarseness
What is tested to assess the accessory nerve (CN XI)?
Check for poor or weak cough
What are the three dysfunctions of Horner’s syndrome?
- Ptosis – drooping eyelid
- Miosis – pupil constriction
- Anhidrosis of the face (dryness)
Fill in the blank: Horner’s syndrome includes _______ which is drooping eyelid.
Ptosis
What is the median nerve test represented by?
Make the OK sign
This tests the anterior interosseous nerve function.
What does the ulnar nerve test involve?
Spread fingers apart
This tests resistance to finger abduction.
What action represents the radial nerve test?
Stop - raise the hand up
This tests resistance to wrist extension.
What is the effect of C-Retraction on the upper and lower cervical spine?
Upper CS Flexion and Lower CS Extension
This action opens the OA space.
What occurs during C-Protraction in the cervical spine?
Upper CS Extension and Lower CS Flexion
This action compresses the OA space.
What is the main purpose of Thoracic Outlet Syndrome tests?
To check for vascular issues that can mimic radicular symptoms.
What indicates a positive result in Thoracic Outlet Syndrome tests?
Reduction in radial pulse or patient complaints of paresthesias (heaviness, numbness, tingling).
Describe the Adson’s test position.
Shoulder 15 degrees ABD; Inhale and hold breath; Cervical extension and rotation to ipsilateral side.
What is the required position for the Costoclavicular test?
Sit-up straight with chest out and shoulders back (shoulder retraction and depression).
What movements are involved in the ROOS test?
Shoulder 90 degrees ABD and ER, 90 degrees elbow flex; make a fist and open x 3 minutes.
What distinguishes the Hyperabduction (Wright’s Test) from Adson’s test?
Lateral flexion and rotation away from the contralateral side.
Cervical radiculopathy CPR
- Spurling’s (POS)
- Neck Distraction (POS if relieves symptoms)
- C-ROT < 60 on Ipsilateral side is a POS
- Neurodynamic Upper Limb Tension Test - A (ULTTA)
What is Cervical Spondylosis?
Chronic degenerative condition affecting the cervical spine, primarily due to age-related wear and tear.
More common in women over 30.
What are the early presentation symptoms of Cervical Spondylosis?
Pain and stiffness in the neck, mild-moderate DJD.
DJD stands for Degenerative Joint Disease.
What is the late presentation of Cervical Spondylosis?
Increased cervical pain and reduced ROM, joint osteophytes.
What defines Zygapophyseal (Facet) Joint Dysfunction?
Acute unilateral neck pain or locking caused by a sudden movement.
What is the prevalence of Zygapophyseal Joint Dysfunction?
Can affect all ages; often triggered by a sudden extension-rotation injury.
What are the early presentation symptoms of Zygapophyseal Joint Dysfunction?
Unilateral neck pain with restricted movement to one side.
What is the late presentation of Zygapophyseal Joint Dysfunction?
Long-term restriction in ROM if untreated.
What is Cervical Radiculopathy?
Neural radicular signs affecting the upper extremities, usually due to disc herniation.
What are the early presentation symptoms of Cervical Radiculopathy?
Sharp, shooting, intermittent pain in the upper extremity following a dermatomal pattern.
What is the late presentation of Cervical Radiculopathy?
Persistent sensory disturbances (paresthesia) and weakness in affected dermatomes.
What are Movement Coordination Impairments (Whiplash)?
Cluster of neck and head symptoms caused by trauma (typically car accidents).
What is the prevalence of Movement Coordination Impairments?
Higher risk in younger adults and those involved in collisions.
What are the early presentation symptoms of Movement Coordination Impairments?
Acute pain, typically following trauma.
What is the late presentation of Movement Coordination Impairments?
Chronic pain and difficulty with neck movement.
What are Neck Pain with Headaches (Cervicogenic Headaches)?
Headaches originating from cervical spine dysfunction.
What are the early presentation symptoms of Cervicogenic Headaches?
Pain localized to the neck and occiput, radiating to the head.
What is the late presentation of Cervicogenic Headaches?
Non-continuous, unilateral neck pain with headache.
What is Cervical Myelopathy?
Compression of the spinal cord, usually caused by central canal stenosis.
What is the prevalence of Cervical Myelopathy?
More common in people over 30 years old; Asians are at higher risk.
What are the early presentation symptoms of Cervical Myelopathy?
Motor impairment before sensory issues, with clumsiness in fine motor skills.
What are the late presentation symptoms of Cervical Myelopathy
Gait worse, Severe Pain, Loss of B&B control
What is Rheumatoid Arthritis (RA)?
Chronic autoimmune disorder causing inflammation in multiple joints, including the cervical spine.
What is the prevalence of Rheumatoid Arthritis?
Highest in adults over 50, with a female predominance (2:1 ratio).
What are the early presentation symptoms of Rheumatoid Arthritis?
Progressive disease marked by intermittent morning stiffness and inflammation.
What is a concern if RA causes cervical instability?
Increases the risk for spinal cord compression.
What are Spinal Compression Fractures?
Endplate or vertebral body fractures, commonly due to osteoporosis.
What are the early presentation symptoms of Spinal Compression Fractures?
Osteoporotic wedge deformities in the thoracic spine.
What is the late presentation of Spinal Compression Fractures?
Severe kyphosis from multiple fractures can develop in untreated cases.
What occupation risk is associated with Cervical Spondylosis?
Jobs with excessive overhead or cervical strain
These jobs may include construction or certain manual labor positions.
What occupation risk is associated with Zygapophyseal Joint Dysfunction?
Overhead jobs or contact sports
These activities can lead to increased stress on the cervical spine.
What is Cervical Radiculopathy often caused by?
Herniated Nucleus Pulposus (HNP)
This condition involves nerve root compression in the cervical spine.
What occupation risk is associated with Cervical Radiculopathy?
Jobs involving repetitive flexion or rotation of the neck
Such jobs may include assembly line work or certain medical professions.
What occupation risk is associated with Movement Coordination Impairments?
Car crashes and contact sports
Both scenarios are known for causing whiplash injuries.
What is Neck Pain with Headaches also known as?
Cervicogenic Headache
This type of headache originates from the cervical spine.
What occupation risk is associated with Neck Pain with Headaches?
Sustained sitting or desk jobs, especially in drivers and office workers
Prolonged static postures can contribute to this condition.
What condition is associated with cervical spinal cord compression?
Cervical Myelopathy
This condition can lead to neurological deficits.
What occupation risk is associated with Cervical Myelopathy?
Non-specific
This means it can arise from various occupational hazards.
What autoimmune condition affects the cervical spine?
Rheumatoid Arthritis (RA)
RA can lead to joint inflammation and damage.
What occupation risk is associated with Rheumatoid Arthritis?
Non-specific
RA can affect individuals in various occupations.
What condition can lead to Spinal Compression Fractures?
Bone disorders or conditions like osteoporosis
Osteoporosis increases the risk of fractures in the spine.
C-Spondylosis / OA / DJD Key features
Joint stiffness & hypomobility unilaterally, Pain with PA spring testing with C5-6 is most common, followed by C6-7; progression to Cervical Radic
Zygapophyseal (Facet) Joint Dysfunction Key features
Unilateral, Describes locking or tightness or neck just feels stuck; Absent neuro signs, No radiculopathy; DDX from C-Strain
Cervical Radic caused by Disc Herniation (HNP) Key features
Unilateral intense pain, Dermatomal pattern; Pt finds position of comfort (self traction, Barkody sign)
Movement Coordination Impairments (Whiplash) key features
Traumatic cause, hyperalgesia, allodynia, potentially with sensory & motor & psychological
Neck Pain with Headache Key features
Non-continuous unilateral neck pain and associated HA that is precipitated by neck movements or sustained positions
Cervical Myelopathy Key features
Per CPR and Lhermitte sign
Rheumatoid Arthritis Key features
Blood tests for Rh factor, CCP antibody (anti-cyclic citrullinated peptide antibody)
Spinal Compression Fractures key features
Palpation pain or percussion testing to the SP reproduces the pain
List of 9 “Do not want to miss” for medical screening of serious patholoy
Major Depression
Suicide Risk
Femoral Head and Neck Fractures
Cauda Equina Syndrome
Cervical Myelopathy
AAA
DVT
PE
Atypical MI
CPR for C-Myleopathy
Age > 45 years,
Babinski test
Gait deviation;
Hoffmann’s test; and
Inverted supinator sign
If one is NEG SN of 94% with LR NEG of 0.18
If 3+ are POS SP is 99% with LR POS of 30.9
CPG: Neck Pain With Radiating Pain (Radicular)
CPR: upper-limb nerve mobility (ULTTA), Spurling’s test, cervical distraction, cervical ROM < 60 ipsilateral side
What are the two types of mechanical pain?
Constant or Intermittent
Mechanical pain can be categorized based on its presence over time.
What are the two possible onsets of mechanical pain?
Acute or Gradual
The onset of mechanical pain can occur suddenly (acute) or develop over time (gradual).
How is mechanical pain related to activity?
Directly proportional to activity (i.e. tissue loading)
Mechanical pain often increases with physical activity that loads the affected tissues.
What is a characteristic response pattern of mechanical pain?
Movements in one direction may increase vs. movements in another direction may decrease or abolish
This response pattern indicates that certain movements can exacerbate or relieve pain.
What type of movements can influence mechanical pain?
Responds to Repeated movements
Mechanical pain often changes in response to repeated movements, highlighting its dynamic nature.
What is the onset of chemical pain?
Acute
Chemical pain typically presents suddenly.
List the signs of inflammation associated with chemical pain.
- Edema
- Rubor
- Calor
- Tenderness
These signs indicate the body’s response to injury or irritation.
What is the characteristic of movements in the presence of chemical pain?
All movements are painful
This indicates a heightened sensitivity in the affected area.
What happens to pain levels with activity, movement, or positions in chemical pain?
No activity, No movement and No position decrease the pain
Chemical pain remains constant regardless of changes in position or activity.
How does chemical pain generally change over time?
Generally speaking over TIME chemical pain decreases
This suggests that chemical pain is often temporary.
What should be suspected if chemical pain does not decrease over time?
NON-MSK pain (i.e. Non-Normal Pain Behavior)
This indicates that the pain may be due to a condition outside of musculoskeletal issues.
What is Local Mobility?
A concept involving the ability to move specific body parts effectively
What are PIVMS?
Passive Intervertebral Movements, techniques used to assess and improve spinal mobility
What are PAVMS?
Passive Accessory Vertebral Movements, techniques aimed at enhancing spinal joint mobility
Define Global Stability.
The ability to maintain a stable body position during movement
Fill in the blank: Activation refers to _______.
[isolated muscle contraction/movement pattern]
What does Acquisition involve?
Movement coordination, such as lumbar and hip movements
What is Assimilation in the context of movement?
Functional multiplanar movements like lifting/lowering, push/pull, reaching, handling
SINSS: Severity
clinicians’ assessment of the intensity as related to the pts. functional ability
SINSS: Irritability
(Intensity/Quality) amount of activity to stir up the symptoms and how long till they reduce
SINSS: Nature
(Location/MOI). Hypothesis of the structures, potential serious pathology, patient biopsychosocial factors
SINSS: Stage
(Temporal characteristics) Acute, Sub-Acute, Chronic, Acute on Chronic
SINSS: Stability
(Temporal characteristics) Episode over time – Getting better / Worse or staying the same
C-Spine Manipulation Intervention CPR
Symptoms < 38 Days,
Side to Side C-Rot Difference > 10 degrees,
Pain with PA spring testing Mid C-Spine (C3-C7)
If 3/4= +LR 13.5
If 4/4 = Infinity
WAD Prognosis CPR
Age > 35 years old
NDI > 40%
Hyperarousal symptoms > or = 6 on the PDS (Posttraumatic Stress Diagnostic Scale)
Quebec Task Force WAD Grade 1
the patient complains of neck pain, stiffness, or tenderness with no positive findings on physical exam.
Quebec Task Force WAD Grade 2
the patient exhibitsmusculoskeletal signs including decreased range of motion and point tenderness.
Quebec Task Force WAD Grade 3
the patient also shows neurologic signs that may include sensory deficits, decreased deep tendon reflexes, muscle weakness.
Quebec Task Force WAD Grade 4
the patient shows a fracture
Craniocervical Flexion Test (CCFT)
Begin at 20mmHg, progress up by 2 mmHg, holding each for 10 seconds: 22-24-26-28…
Instruct to nod “yes”
Observe for over-activation of SCM or Anterior Scalene
Relax between each increment (30 Seconds)
Deep Neck Flexor Endurance Test
Instructions: Tuck chin and lift head off table only one inch, hold
Norms:
Men 38.9 seconds ± 20.1
Women 29.4 seconds ± 13.7
Pattern Assist
Defined as any technique to inhibit (unloaded) or facilitate (loaded) tone (muscle & connective tissue tension)
What is the goal of activation?
“Hypo-active” muscles & Inhibit the Global muscles
What is the goal of acquisition?
coordinate the use of the newly found muscle in a movement with other muscles as intended
What is the goal of assimiliation?
integrate the refined movement into ADL’s & dynamic environments
List common signs and symptoms of TMD.
- Headaches (frontal, temporal, occipital)
- Facial pain (masseter, temporalis, TMJ region, neuralgia)
- Ear pain
- Pain reported with eating and opening of mouth
- Abnormal movement patterns of the mandible
- Popping and clicking
Fill in the blank: TMD usually coexists with _______ pain and other upper quarter dysfunction.
cervical
Which muscles are involved in closing the jaw?
Masseter, temporalis, medial pterygoids
These muscles work together to elevate the mandible.
What is the role of the superior lateral pterygoids in jaw movement?
Protrusion
The bilateral heads of the superior lateral pterygoids are primarily responsible for moving the jaw forward.
Which muscle assists retrusion of the mandible?
Posterior temporalis, assisted by deep masseter
Retrusion is the movement of the jaw backward.
What muscles are involved in lateral trusion/deviation of the mandible?
Contralateral contraction of medial pterygoid and lateral pterygoid, ipsilateral temporalis and masseter
This movement involves coordination between muscles on opposite sides of the jaw.
True or False: The medial pterygoids are involved in both protrusion and lateral trusion of the mandible.
True
Medial pterygoids assist in multiple movements of the mandible.
What occurs during the first portion of mandibular depression?
Opening-anterior rotation of condyle on lower disc surface (first 25mm of opening)
This initial movement is crucial for the beginning of jaw opening.
What happens in the second portion of mandibular depression?
Anterior translation of disc/condyle along the fossa surface-further 25mm
This movement completes the normal opening process.
What is the normal range of mandibular opening?
40-50mm
This range is considered typical for healthy jaw function.
What is the normal range of motion (ROM) for lateral deviation?
8-10 mm
This movement allows for side-to-side motion of the jaw.
TMJ S-Curve
anterior displacement of disc off condyle-anterior translation is blocked until disc reduces itself on condyle during depression, after reduction of disc then mandible returns to midline( usually associated with click or pop)
TMJ C-Curve
Capsular pattern of restriction, usually no click or pop, mandible deviates towards restricted side
TMJ Protrusion normal values
10mm
TMJ Retrusion normal values
5mm
TMJ Compression Bite Test
This test is comprised of forceful unilateral biting for 20s on a tongue depressor in the first molar region. Familiar pain on the contralateral side to the clenching side was considered a positive testfor joint pain and ipsilateral pain indicative of muscle disorder
Disc Displacement without reduction
Disc remains displaced anteriorly blocking anterior rotation and translation for full opening motion- restricts movement to approximately 25mm
No click as disc is stuck in anterior position
Postural Syndrome
Intermittent pain brought on only by prolonged static position. Pain is localized. No pain with movement and no ROM deficits. Posture correction abolishes symptoms
Dysfunction in relation to MDT
Pain caused by mechanical deformation of structurally impaired soft tissue. Intermittent Pain that ONLY occurs at end range of the Restricted movement. Gradual onset due to lack of use or 6-8 weeks post trauma. Pain is localized (except in case of adherent nerve root). Symptoms do not persist after repeated movement testing
Management of Dysfunction
Perform the restricted movement 10-15 reps every 2-3 hours.
Exercise must produce their pain every repetition.
Pain should subside following exercise within 10 minutes.
If pain persists, overstretching has occurred or maybe you have exposed an underlying derangement.
Describe Derangement Classification
Onset can be gradual or sudden, symptoms are variable and inconsistent. Pain can change sides, wry neck or kyphosis may be present
What are the 5 Hallmarks of Derangement?
Centralization
Peripheralization
RAPID CHANGE
VARIABLE SYMPTOMS
Mechanically Determined Directional Preference
Red light during MDT
Lasting peripheralization of pain, pain worse, unable to change the location of pain. Stop what you are doing, may need force change, direction change, etc
Yellow (amber) Light for MDT
Pain is not getting significantly better. You are getting positive effects in the clinic but no lasting change.This may require more or less force or frequency. A change in the way it is delivered or a direction change once force is fully explored.
Green light for MDT
Patient is centralizing, pain is decreasing, mechanical changes are favorable, etc. A positive response to treatment. Keep going.
What are some exam findings for Cervicogenic headache?
Cervical Flexion Rotation Test
HA reproduced by provocation of upper C-Spine segments (i.e. joint mobs)
limited upper CS joint mobility
HA from neck motions
What are some exam findings for movement coordination?
Cranial Cervical Flexion Test (uses the stabilizer)
Deep neck flexor endurance test (timed isometric hold)
Positive pressure algometry (AKA Pain pressure thresholds); sensory-motor changes
Symptoms: Dizziness & N, Concussive signs, Hypersensitivity to odors, light, sound
