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Clinic > Cervical Spine > Flashcards

Cervical Spine Flashcards

1
Q

Atlas (C1)

A 
• 1st vertebrae
• No vertebral body
• No true spinous process
• Transverse process
• Transverse foramen
• Supports the weight of
the head through the atlanto-occipital joint (C0-C1).
• Primary movement flexion/extension
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2
Q

Axis (C2)

A 
• 2nd vertebrae
• Small vertebral body with
superior projection
(Dens)
• Spinous process
• Transverse process
• Transverse foramen
• Atlanto-axial joint
• Dens and atlas articulation
• Pivot joint
• Primary movement rotation of the skull
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3
Q

Uncinate processes of the cervical spine

A
  • Bony elevations on the superior lateral margin of the cervical vertebrae
  • Uncovertebral joints • Joints of Luschka
  • Prevent posterior linear translation of vertebral bodies
  • Reinforces the disc posterolaterally
  • Limits lateral flexion
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4
Q

Brachial plexus nerve roots

A

C5-T1

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5
Q

Red flags for Cervical Spine

A 
• Major Trauma
• Neoplasm
• Systemic inflammatory
diseases and infections
• Cervical myelopathy
• Previous neck surgery
• 5D’sand3N’s
• Neurological symptoms
including upper or lower limb clumsiness, uncoordinated movements
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6
Q

Indications of cervical trauma

A
  • Complains of consistent, severe, neck pain.
  • Increase in pain and decrease of movement on examination.
  • Signs of neurological injury
  • Requires urgent MRI, CT or radiological referral
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7
Q

VBI

A
  • …a condition characterized by a temporary set of symptoms due to a decrease blood flow to the posterior portion of the brain. This is fed by two vertebral arteries that travel within the transverse foramen and join to become the basilar artery.
  • Atherosclerosis
  • Spondylosis (Osteophyte formation)
  • Trauma
  • Occlusion may occur during sudden or sustain movements of the head or neck
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8
Q

VBI subjective questioning

A
  • In EVERY patient presenting with upper quadrant dysfunction, questioning is specifically directed to elicit the presence of symptoms related to VBI. This is completed prior to assessment and treatment of the cervical spine.
  • The 5 D’s and 3 N’s • Dizziness
  • Diplopia (Double vision) • Dysarthria
  • Dysphagia
  • Drop attacks
  • Nausea (vomiting), Numbness (neurological), Nystagmus
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9
Q

VBI objective tests

A

• Minimum test include
• Sustained end range rotation technique L) and R) (ERRT)
• The position or movement which provokes symptoms
• All positions sustained for 10 seconds unless symptoms provoked sooner
• Therapist watches the patients eyes for nystagmus while the head is sustained and questions the patient on symptom reproduction.
• On return to neutral from sustained position a period of 10 seconds should be allowed before continuing onto the next position.
• Other Tests
• Cervical Extension
• Cervical rotation combined with extension
• Simulated manipulation position
• Quick movement of the head through the available range (patient dependant)
NOTE: This is done prior to ERRT or HVT (Manipulation)

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10
Q

Possible structures involved in cervical spine

A
  • Muscle •Z joint
  • Bone
  • Ligament • Disc
  • Vascular • Neural
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11
Q

regional disorders of Cx (upper, mid, lower)

A
  • Upper cervical spine
  • frequently cause of cervicogenic headaches
  • Mid cervical spine
  • commonly involve zygapophyseal joint dysfunction
  • Lower cervical spine
  • most frequent region for discogenic disorders and spinal nerve/nerve root compromise
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12
Q

WAD MOI

A
  • Acceleration - deceleration injuries of the cervical spine
  • Rapid hyperextension to hyperflexion movement +/- shear forces
  • Can also involve rotational and lateral shear forces depending on impact
  • Speed of impact and force of impact exceed capacity of tissue to cope which leads to failure of the tissues.
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13
Q

Clinical presentation of WAD

A 
Dependent on severity of injury
• Neck Pain
• Headache
• Decreased neck mobility
• +/- thoracic, shoulder pain
• Arm pain
Note:
• Delay in the onset of symptoms
• Not to be missed: Fracture & vertebral artery injury
• Chronicity
• Depression, anxiety, dependence, psychosocial problems
• Liability issues – Legal matters etc.
 • Dizziness, tinnitus, blurred vision
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14
Q

Clinical dx of WAD Hx taking

A 
History Taking
• All of your normal information • Age, sex, occupation etc etc.
• Prior history of WAD
• Prior history of long term disability
• MOI of injury in detail
• OUTCOME MEASURES • NDI
• General Health Questionnaire
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15
Q

Clinical Dx of WAD physical exam

A

Physical Exam
• Observation
• Palpation
• ROM (Active and Passive) • Neurological Assessment
• Assessment of any other injuries (e.g. shoulder)

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16
Q

Recommended Rx of WAD

A
  • Reassure and stay active (Normal ADL’s)
  • Exercise
  • ROM, low load isometrics, postural endurance, strengthening
  • Pharmacology
  • Simple analgesics
  • NSAIDs Refer to pharmacist • Opioid analgesics
  • Manual Therapy (may be effective)
  • Manipulation (Thoracic Spine)
  • No evidence for efficacy of C spine manipulation in the treatment of acute WAD
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17
Q

Prognosis of WAD

A

Things that can impact on prognosis:
• Symptom severity (>5/10 VAS; >15/50 NDI)
• Physical symptoms (e.g. decreased initial neck ROM, cold hyperalgesia)
• Psychological factors
• Do you think you will get better soon?
• Posttraumatic stress (PTS) symptoms using the Impact of Events Scale (IES)
• Socio-demographic factors
• NOT predictive of ongoing pain

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18
Q

Acute Wry Neck

A
  • Sudden onset of sharp neck pain with protective deformity and limitation of movement.
  • Typically caused after a sudden quick movement or on waking from sleep.
  • Two common types of Acute Wry Neck • Zygapophyseal wry neck
  • Diskogenic wry neck
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19
Q

Zygoapophyseal Wry Neck Presentation

A
  • Most common in children and young adults
  • Most common at C2-C3 level
  • Associated with sudden movement resulting sharp pain
  • Locking of C0-C1 or C1-C2 may result from some form of trauma
  • Posture away from pain (lateral flexion and slight flexion)
  • Limited ROM
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20
Q

Zygoapophyseal Wry Neck Rx

A
  • Soft tissue techniques
  • Joint mobilisations/manipulation • AROM/PROM (if permitted)
  • Traction
  • EPAs (Heat)
  • Reassure, Advice and Education
  • Home Exercise
  • ROM exercises
  • Motor control exercises
  • Posture
  • Advice about cervical support during sleep
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21
Q

Diskogenic Wry Neck Presentation

A
  • More gradual onset compared to Z-joint wry neck
  • Most common after waking from long sleep
  • Most common in older group (e.g. middle aged adults)
  • Typically lower cervical or upper thoracic
  • Posture away from pain (lateral flexion , rotation and slight flexion)
  • +/- referred to scapular region
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22
Q

Diskogenic Wry Neck Rx

A
  • Important to differentiate between Z-joint and Diskogenic as manipulation may result in provocation of symptoms in these individuals
  • Gentle traction
  • Soft tissue techniques
  • Gentle mobilisations
  • EPAs (Heat)
  • Reassure, Advice and Education
  • Temporary soft collar
  • Motor control exercises as tolerated
  • Postural retraining as tolerated
  • Advice about cervical support during sleep
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23
Q

Cx Spondylosis

A
  • Refers to degeneration of the spine, typically associated with the aging process.
  • Degeneration of the disc – prolapse/breakdown • Joint space narrowing
  • Osteophyte formation
  • Spinal stenosis
  • Foramen stenosis
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24
Q

Spondylosis Clinical presentation

A
  • Most people don’t have significant symptoms • Neck and/or arm pain
  • Stiff neck
  • Headaches
  • Radiculopathy-nerve root compression • Neurological symptoms (unilateral)
  • Myelopathy-spinal cord compression • Neurological symptoms (bilateral)
  • Diagnosis
  • Patient history
  • Imaging (CT, MRI, X-ray)
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25
Q

Spondylosis Clinical Rx

A
  • Surgery
  • Potential to refer for decompression surgery depending on severity of symptoms
  • Soft tissue
  • Muscle strengthening • Traction
  • Stretching
  • ROM exercises
  • Advice & Education
  • Reassurance
  • Medication
  • Alternative therapies • Dry needling
  • Heat
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26
Q

Craniovertebral Instability

A
  • Excessive movement at C1-C2 vertebrae as a result of bony or ligamentous abnormality
  • Neurological symptoms can occur when the spinal cord or adjacent nerve roots are involved.
  • Causes
  • Acute Trauma
  • Degeneration
  • Congenital conditions
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27
Q

Craniovertebral Instability Presentation

A
  • Neck pain
  • Wry neck posture • Headache
  • Myelopathy
  • Cord compromise signs and symptoms:
  • Difficulty walking & clumsiness with hands • Lack of coordination
  • Bowel & bladder dysfunction
  • Positive Babinski & ankle clonus
  • Hyperreflexia
  • Spasticity
  • Vascular symptoms
  • Feeling of instability (something isn’t right?)
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28
Q

Craniovertebral instability Dx

A
  • Severe signs and symptoms and acute trauma require urgent referral for diagnostic imaging
  • Radiography
  • CT
  • MRI
  • Neurological examination
  • Damage to alar ligaments can increase rotation by up to 30% - frank instability
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29
Q

Cervical Radiculopathy

A
  • A compression of the nerve root as it exists the vertebral column of the cervical spine.
  • Trauma
  • Disc issues – younger population
  • Spondylosis – older population
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30
Q

Cervical Radiculopathy Clinical presentation

A
  • +/- neck pain
  • +/- arm pain
  • Neurological Symptoms - dermatome • P+N, Tingling, Numbness
  • Weakness - myotome • Reflex changes Diagnosis
  • Patient history
  • Neurological Examination
  • Spurling’s test – provocative • Diagnostic Imaging
31
Q

Cervical Radiculopathy Rx

A
  • Traction
  • Immobilisation
  • Pharmacotherapy
  • Soft tissue
  • Manual therapy
  • (manipulation not recommended)
  • EPA’s (limited evidence)
  • As pain improves • ROM
  • Strength training
  • Steroid injection
  • Referral
32
Q

’s review

A

1/55-57

33
Q

Vertebral Artery trauma

A 
• 46% report neck pain
• 67% report occipital headaches
• Abrupt onset
• May be associated with fractures
• May have nerve root symptoms
• Posterior-lateral location
If you believe your patient has vertebral artery trauma refer to Emergency Department immediately.
34
Q

General management (physio) of cervical spine

A 
• Education
• Posture retraining
• Motor control exercises 
- Extensors
- Flexors
- Axio-scapular
• Stretching
• ROM exercises
• Manual therapy
• Soft tissue techniques
• Neural tissue mobilization
• Manipulations 
• Dry needing
• Heat
•EPA
• Stress management
35
Q

Cervicogenic HA

A

Pain perceived as arising in the head, but whose actual source lies not in the head but in the cervical spine. As such, it constitutes cervical pain that is referred to the head.
The neuroanatomical basis for cervicogenic headache is convergence in the trigeminocervical nucleus between nociceptive afferents from the field of the trigeminal nerve and the receptive fields of the first three cervical nerves.

36
Q

Cervicogenic HA - structures implicated

A
  • Only structures innervated by Cl-C3 have been shown to be capable of
    causing headache
  • These are the muscles, joints and ligaments of the upper three cervical segments, but also include the dura mater of the spinal cord and posterior cranial fossa and the vertebral artery
37
Q

HA classification - recurring types

A

Cervicogenic headache – Tension type headache
– Migraine
■ Migraine without aura (common migraine) ■ Migraine with aura (classic migraine)
– Cluster headache

38
Q

HA classification non-recurrent

A 
Cranial neuralgia
■ Trigeminal neuralgia
–  Cranial inflammation
–  Specific diseases of; ■  ocular
■  aural ■ nasal sinus
39
Q

Cervicogenic HA clinical features

A

■ chronic
■ non-vascular
■ degenerative changes of the zygapophyseal jts ■ hypo-mobility syndrome
■ Cl -C3 segments
■ treatable with manual therapy
■ 1. Pain other than lancinating pain, typically dull or aching in quality, located in the occipital, parietal, temporal, frontal or orbital regions of the head, or in any combination of these regions, unilaterally or bilaterally.
■ 2. Some indication of abnormality in the cervical spine such as neck pain, focal neck tenderness, impaired cervical motion, aggravation of the headache by neck movements or a history of neck trauma.

40
Q

Tension HA

A

■ sustained contraction of neck and scalp muscles
■ state of anxiety or chronic depression
■ sustained contraction leads to hypo-
mobility
■ tender points on palpation of pericranial m
■ treatment with “environmental manipulation”
■ underlying joint pathology?

41
Q

Vascular HA/ Migraine

A

■ Migraine diagnosis proposed by Ogden (1952) can be established if four of the following criteria are present or if three criteria including numbers one and two are present.

  1. Unilateral or bilateral headache
  2. Gastrointestinal distress
  3. Hereditary history of headache
  4. Prodromal symptoms
  5. Throbbing type of headache
42
Q

Migraine

A

■ A classical migraine is differentiated from a common migraine by the presence of focal neurological features of which involvement of the visual system is the most common
■ It is in the area of common migraine diagnosis that the majority of overlapping symptoms are common with a cervicogenic headache

43
Q

Differential diagnosis for cervicogenic vs migraine

A 
■  Cervicogenic headache
–  increasing periodicity
–  decreasing response to analgesics
–  insidious onset
–  not described as an
attack
–  variable in intensity
symptoms ipsilateral? – 
–  no relief from – 
migrainous drugs
–  lack of familiar tendency – 
–  not related to sexual –  maturity
side consistency
■  Migraine
–  stable periodicity
–  limited response to analgesics
–  related onset
–  described as an
attack
–  severe intensity
no clear correlation
migrainous drugs relieve
familiar history onset at puberty
–  no side consistency
44
Q

Cluster HA

A

■ A distinctive, specific and relatively rare syndrome that is separate from frequent migraine. Unilateral pain localised above the eye or in the temple.
■ Severe pain lasting 15-180 mins, usually less than 60 mins. Attacks occur up to 8 times/day, often at night, in clusters lasting weeks or months.
■ Associated with at least one of the following signs on the side of the pain: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, facial swelling, eyelid oedema, miosis, ptosis. Most common in men, rare in women which is a helpful differentiation point for triaging acute headache

45
Q

Decision to treat

A

■ Is the cervical spine;
– primary cause?
– partial cause?
– enhancing/maintaining symptoms? – not involved?

46
Q

Rx of cervicogenic HA

A 
■  mobilisation
■  manipulation
■  postural/ergonomic
■  exercise therapy
■  muscle conditioning –  deep cervical flexors
■  neurodynamics?
47
Q

Neck Pain

A

– One of the four most commonly reported MSK disorders
– Adult world population = mean lifetime prevalence of 50%
– Approx 20% of adults previously pain free report new episode of neck pain in 1 year period
– Not associated with high morbidity BUT
– High prevalence + episodic nature = high cost
• Minor portion of cost is direct healthcare (23%)
• Majority is indirect cost – e.g. work absenteeism & disability

48
Q

Risk factors for neck pain

A 
• 4 categories (McLean et al, 2010)
– Physical
– Psychosocial
– Sociodemographic
– Clinical
– Lack of quality research investigating predictive nature of 4 categories
• Possibly
– Previous Hx of neck pain
• Strongly predictive of progression to recurrent, persistent or
disabling neck pain
– Hx of LBP and pain at other sites
• Unsure of reason for link...
– Female gender
– Older age > 50yo (males not females...) 
**– High job demands**
**– Low social or work support**
– Ex-smoker
49
Q

Occupational exposure for neck pain

A

• Proposed to be related to higher levels of static contraction,
prolonged static loads or extreme working postures (Mayer et al, 2012)
– Posture+repetition&force
– Sitting–Cxspine
• May be sensitive to temporal pattern in blue collar workers
• Moderate sitting times NOT short or prolonged (Hallman, 2016)
• Tension neck syndrome – Cxstiffness
– Musclespasm/tightness
– Pain±referredpainintoTxorupperlimb
– Cervicogenicheadaches,tensionheadaches
• Rotator cuff tendinopathy
– Supraspinatus>infraspinatus>LHbiceps

50
Q

Cervicogenic HA clinical presentation

A 
• Pain
– Typically dull or aching
– Located in occipital, parietal, temporal, frontal or orbital regions of the head
– Any combination of above regions, unilaterally or bilaterally
– Chronic
• Cx spine symptoms – Neck pain
– Focal tenderness
– decr Cx ROM
– Aggrav of HA by Cx ROM
– Hx of Cx trauma
– Degenerative changes of the z- joints
– Cx hypo-mobility syndrome • Cl-C3segments
51
Q

Tension HA

A

• Sustainedcontractionof neck and scalp muscles
– Leads to Cx hypomobility
• Stateofanxietyor
chronic depression
• Tenderpointson palpation of pericranial muscles
• Underlyingjoint pathology?

52
Q

What can we do to help - Rx

A 
• Mobilisation
• Manipulation
• Exercisetherapy
• Muscleconditioning – DNF
• Neurodynamics?
• Postural&ergonomic
re-education
– Get patients to sit (stand??) well
53
Q

As physios

A

• Self-reported constructs stronger predictors of outcome than observational factors
– Pain intensity, disability, psychological distress and coping
strategies
>
– Structural pathology on diagnostic imaging, Cx ROM of angular deformities (Walton et al, 2013)
• Therefore cognitive aspects > physical aspects impact on recovery
– You need a comprehensive patient history!!! – Treat the whole patient!!!

54
Q

Functional purpose of the musculature of the axial skeleton

A
  • Control posture
  • Stabilise axial skeleton
  • Protect spinal cord & internal organs
  • Move body as a whole
  • Fine mobility of head and neck
55
Q

craniocervical muscles anterior-lateral

A
  • Sternocleidomastoid
  • Scalenus anterior
  • Scalenus medius
  • Scalenus posterior
  • Longus colli
  • Longus capitus
  • Rectus capitus anterior
  • Rectus capitus lateralis
56
Q

craniocervical muscles posterior

A 
•  Superficial
–  Splenus cervicus 
–  Splenus capitus
• 
Deep (suboccipital)
–  Rectus capitus posterior major 
–  Rectus capitus posterior minor 
–  Obliquus capitus superior
–  Obliquus capitus inferior
57
Q

Function of craniocervical muscles

A

– Stabilisation of craniocervical region
– Producing head & neck movements to optimise visual, auditory and olfactory systems
– Suboccipital muscles
• Precise control of atlanto-occipital & atlanto-axial joints essential for optimal positioning of eyes, ears & nose
– NB: Full axial rotation of Cx spine allows > 180o rotation of visual scanning

58
Q

Stabilisation from craniocervical muscles

A

• Musclesprovidebulkofneckespeciallylaterally& posterior
• Protectcervicalviscera,bloodvessels,intervertebraldiscs, apophyseal joints and neural :ssues
• Ver:calstability
– Ideal antero-posterior alignment allows co-contrac:on of flexor
&extensor muscles è counterbalance + ver:cal stabilisation
• Dynamic stabilityèessen:al for correct func:on & avoiding pain

59
Q

Dynamic stability

A

• Protect neck from outside forces
– Extreme – contact sports, racing car drivers
– Timing of muscular contrac:on of prime importance in protec:ng neckè an:cipatory contrac:ons
• Clinicallyèwhiplash injuries

60
Q

Whiplash movements

A

Rear end car accident
1. Craniocervical retraction (before hit head restraint)
2. Cervical hyperextension
– Occurs over relatively large ROM as maximum flexion restricted by chin hittng chest

61
Q

Structures at risk from whiplash

A

• Retraction
– Anterior longitudinal ligament
• Hyperextension
– Alar ligaments – esp if head is rotated
– Excessive strain of flexor muscles – esp longus colli & longus capitis
• Longus colli strain- upper trapezius loses stable cervical attachment which leads to difficulty shrugging shoulders
– Strain of other flexors (SCM + ant scalenes) as well as cervical viscera – Compress z joints + posterior Cx spine elements
• *DNF dysfunction noted clinically – Need to retrain!!
• Link to insurance claims…..

62
Q

Craniocervical Muscles - anterior lateral

A

• Sternocleidomastoid
– Prominent, superficial, anterior
• Unilaterally = LF + contralateral axial rota:on
• Bilaterally = flexor + extensor
– Flexor- below approx C3 = strong flexion torque mid to low Cx spine
– Extensor- C1-C2 = minimal extension torque mid to low Cx spine

63
Q

Sternocleidomastoid

A

• Sagittal plane torque potential strongly influenced by posture
• Clinically - forward head posture
– Nearly doubles flexion torque potential
– Has greater flexion at mid to low Cx region + upper Cx extension
• May perpetuate biomechanics of poor posture
– Clinically - important wrt Cx pain & cervicogenic HA

64
Q

Scalenes

A

• Function bilaterally– varies depending on fixation of skeletal elements
– Cx spine stabilised
• Main role - raise ribs for inspiration
– Ribs stabilised
• Move Cx spine BUT limited moment arm for
Cx flex
• Excellent bilateral & ver:cal stability of mid to low Cx spine
– link to neck pain patients
• Unilaterally
– Important function - returning Cx spine to near neutral from fully rotated position
• Brachial plexus passes through anterior & medius
– Clinically tight scalenes = potential for neural compression

65
Q

Longus colli and longus capitis

A

• Function as dynamic anterior longitudinal ligament
– Important element of vertical stability
• Longus colli
-Only muscle attaches to ant surface vert column in entirety
– Anterior fibres flex Cx spine
– Lateral fibres vertically stabilise
• Longus capitis
– Primarily Flexion + stabilisation of upper Cx spine
– Secondary= Lateral flexion
• Clinically - DNF exercise for Cx dysfunction & pain

66
Q

Upper cervical spine movement

A

Protraction
• Extension of upper cranial region
Retraction
• Extends or straightens lower to mid Cx spine + flexes upper craniocervical region

67
Q

Spinal coupling

A

• Movement in one plane associated with an automatic movement in another
– “Mechanical” coupling
– E.g. rotation + transla:on
• Consensus
– Relatively consistent pattern between lateral flexion & rotation in craniocervical region
– Inconsistency in description of other regions

68
Q

Spinal coupling cervical spine

A

• Lateral flexion + axial rotation coupling pattern
– Upper vertebra follows plane of lower vertebra articular facet
• degree of LF + Rot occur simultaneously
– Atlanto-axial (+ atlanto-occipital)- contralateral coupling
• LF to R coupled with L Rot
– Mid – low Cx - ipsilateral coupling
• Dictated by approx 45o inclination of facets from C2-C7 • LF to R coupled with sl R Rot
– Combination of upper Cx + remaining Cx spine coupling minimises rotation of head when LF

69
Q

Clearing tests

A

TMJ, Tx, Shx

70
Q

Physiological ROM

A

Flex, Ext,LF, Rotation, Protraction, retraction, combined movements

71
Q

Palpation

A

spinous processes, mastoid process, TMJ, Trapezius,

72
Q

PPIVMs

A

same mvmts as physiological active

73
Q

PAIVMs

A

central PA
Unilateral PA
Transverse pressure
Unilateral AP

74
Q

Special tests

A

Traction, Spurling’s test, neuro if indicated, DNF tests

Clinic (17 decks)

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