Cervical Spine Flashcards
Neck pain is the #_ cause of disability in the US
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What criteria are important for traumatic neck pain?
Nexus Criteria
What are the Nexus Criteria?
Midline tenderness? Alert and Aware? Not intoxicated? No abnormal neurologic findings? No distracting injuries? If any of these are a yes, patient needs a C-collar and imaging
Broad differential for Traumatic Neck pain?
Myofascial injury, cervical fx, ligamentous injury, disc injury, cord or nerve root injury, SCIWORA
Sx of myofascial neck pain
Pain, spasm, limited ROM, occipital headache without any evidence of injury on imaging
Ex. Whiplash, muscle strain, etc
Cervical Fx
occurs in ~_% of blunt trauma patients
3% of blunt trauma
If suspected via Nexus criteria, CT imaging most useful/common
Most are stable but unstable fxs require neurosurgery consult
MUST document initial presence/level of neurologic symptoms if present
SCIWORA (Spinal Cord Injury Without Radiographic Abnormality)
When a pt presents with neuro symptoms but has normal-appearing plain films and CT. Must have a high level of suspicion to order a STAT MRI and Neurosurgery consult
Cervical Spondylosis
Degenerative changes in the cervical spine that is the MOST COMMON CAUSE of chronic neck pain in adults
Can cause general neck pain, radiculopathy, and myelopathy
Myelopathy
Is workup/imaging urgent or emergent?
Any neurologic deficit related to the spinal cord: bilateral weakness, sensory deficits, gait disturbances, clumsy hands, sexual and bowel and bladder dysfunction
Requires EMERGENT MRI
Radiculopathy
Is workup/imaging urgent or emergent?
Neurologic deficits at or near the nerve root: more specific to dermatomes, slower onset paraesthesias, gradually worsening weakness
In cervical spine, C5-6 affected first then C6-7 follow
Requires urgent workup, non-emergent MRI, NSAIDS< OMM, and PT
Meningitis Sx, PE findings, Causes, Diagnosis
Sx: Fever, malaise, NECK PAIN/stiffness, AMS, petechial rash, and photophobia
PE Findings: Meningismus, Positive Brudzinski’s sign, Positive Kernig sign, Nuchal Rigidity
Causes: Bacterial- hemophilus, strep, oneumonia, NEISERRIA MENIGITIDIS- dangerous gram negative dipplococci.
Viral causes require symptom management
Diagnosed by LP
Thoracic Outlet Syndrome
Compression of the neurovascular bundle by various structures in the area between the 1st rib and the clavicle
Sx: arm pain, numbness, and weakness usually reproducible when patient uses arms above head for a period of time
Cause: More often neurologic than vascular
PE Findings: Positive Roo’s test or Adson’s Test
When should you image a non-traumatic neck pain?
Patient with progressive neuro findings, moderate-severe neck pain that affects sleep/daily activities, and those who do not respond to conservative management over 6 weeks
In regards to neck pain, what are you concerned about in a patient with…
a) chronic glucocorticoid use?
b) who is HIV positive?
c) with unexplained weight loss?
d) a history of IV drug use?
a) increased likelihood of fracture
b) increased likelihood of infection/ meningitis
c) cancer
d) increased likelihood of infection/ meningitis
How would you strength test…
a) C1
b) C2-4
c) C5
d) C6
e) C7
f) C8
g) T1
a) resisting head rotation
b) scapular elevation
c) shoulder abduction
d) biceps/wrist extension
e) triceps/wrist flexion
f) finger flexion
g) finger abduction
Cervical sensory exam, what root supplies…
a) Lateral neck?
b) lateral upper arm?
c) lateral forearm/thumb?
d) middle finger?
e) medial wrist/forearm?
f) medial elbow/upper arm?
a) C4
b) C5
c) C6
d) C7
e) C8
f) T1
Why shouldn’t you palpate both carotid pulses at the same time?
The patient could experience a hypotensive reflex due to the pressure of the baroreceptors and pass out
What should you NOT test in a traumatic neck injury before clearing Nexus criteria?
ROM!
HVLA contraindications
Rheumatoid arthritis, down syndrome (b/c of weakened odontoid ligament, local metastases, pts on anticoagulants, osteoporosis
Causes of tracheal deviation
Neck mass, mediastinal mass, atelectasis, and pneumothorax
How to palpate/assess the thyroid gland?
Have pt flex neck sightly, palpate gently below cricoid cartilage, have pt swallow and feel the gland move up and down
If enlarged, listed for bruit, which can be heard in hyperthyroidism, or toxic multinodular goiter
Central Neuropathy Definition
Nerve entrapment by MSK, or myofascial tissue that produces paresthesias in the area of the distribution of the nerve and creates sensory dysfunction and maybe weakness
Compression Test/ Spurlings Test
Compression Test: Head in neutral position, apply axial force, ask for any reproduction of symptoms or upper extremity pain, paresthesias, and numbness
Spurlings: Like compression, but if sx not reproduced in neutral, take them to extension and compress, then take to sidebending and rotation toward/away from side of dysfunction
DO NOT CONTINUE TESTING AFTER SYMPTOMS ARE REPRODUCED
Positive reproduction of symptoms indicated Central Neuropathy
Neck Distraction Test
Gently lift head from chin/occiput
Positive Test: alleviation of pain/ symptoms
Indicates: Central neuropathy
Adson’s Test
Find pulse on affect arm. Abduct, extend, and externally rotate the arm. Have patient extend thier head and rotate/look towards the arm as they inhale and hold their breath. Repeat but with patient extended and rotated away from the affected side.
Positive Test: change/loss of pulse in affected arm and/or reproduction of symtpoms
Indicates: Thoracic Outlet Syndrome….
Compression of Subclavian A. b/w scalenes if positive when pt looks away from side
or Compression between 1st rib and clavicle when looking towards the affects side
Roo’s Test
Have patient flex elbows to 90degrees and abduct his shoulders to 90 then open and close fists for up to 3 min
Positive Test: Reproduction of Sx
Indication: Thoracic Outlet Syndrome, specifically compression of the subclavian a.
Nuchal Rigidity Test
Pt lies supine and you passively flex neck
Positive Test: Pain/stiffness and resistance to flexion
Indication: Inflammation of subarachnoid space (meningitis or subarachnoid hemorrhage
Brudzinski’s Sign
When performing nuchal rigidity test and able to flex chin to chest, look for knees and hips to flex
Positive Test: flexion of hip and knees
Indication: Inflammation if subarachnoid space
Kernig’s Sign
Pt supine, flex hip and knee to 90. Attempt to passively extend leg at the knee
Positive Test: Pain behind the knee and increased resistance to extension
Indicates: Meningeal/dural irritation
Axial loading accounts for over _ of C-spine injuries
Neck flexion to 30 degrees increases susceptibility to injury because…
Axial loading accounts for over HALF of C-spine injuries
Neck flexion to 30 degrees increases susceptibility to injury because lordosis os lost and protective tissues are no longer protective.
Jefferson Fracture
A burst fracture of C1
Wedge Fracture
A fracture of the vertebral body due to a flexion and compression injury
