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cervical spine Flashcards

1
Q

Whiplash associated disorders

A
  • 80% of patients with WAD will reports symptoms up to 12 months
  • 20-25% report severe disability
  • little to no consistent evidence of boney or soft tissue injury
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2
Q

Signs and symptoms of WAD

A
  • pain
  • stiffness
  • HA
  • sleep disturbance
  • cognitive interference
  • sensory hypersensitivity
  • heightened distress and anxiety
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3
Q

NEXUS criteria for imaging

A
  • no posterior midline tenderness
  • no evidence of intoxication
  • a normal level of alertness
  • no focal neurological deficit
  • no evidence of a painful distracting injury (an injury thought to be painful enough to distract from a secondary neck injury)
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4
Q

Canadian C-spine rules

A
  • high risk factors
  • -age >65 y/o
    • dangerous MOI
    • parasthesia in extremities
  • low risk factors
  • -simple rear-ended MVA
  • -sitting position in ER
  • -delayed onset of neck pain
  • -absence of midline C-Spine tenderness
  • -able to actively rotate >45 degrees
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5
Q

Signs of neuropathy

A
  • SLANSS score >12
  • cold hypersensitivity
  • allodynia or hyperalgesia
  • non-mechanical patterns or symptoms
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6
Q

Hypotropia

A

one eye deviated down

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7
Q

Hypertropia

A

one eye deviated up

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8
Q

Exotropia

A

one eye deviated out

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9
Q

Esotropia

A

one eye deviated in

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10
Q

Low risk WAD patients

A
  • 25-30%

- educate, reassure, and follow from arms length

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11
Q

Moderate risk WAD patients

A
  • 50-65%

- advice, education and reassurance, watchful waiting with in person follow up.

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12
Q

High risk WAD patients

A
  • 10-20%

- identify primary risk profile and consider initiating early targeted intervention

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13
Q

High confidence of risk factors for chronicity

A
  • high pain >6/10
  • high neck related disability
  • post traumatic stress symptoms
  • catastrophizing
  • cold hypersensitivity
  • mechanical hypersensitivity
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14
Q

High confidence of no effect on outcome

A
  • angular deformity of the neck
  • impact direction
  • seating position
  • awareness of collision
  • head rest in place
  • older age
  • vertical speed
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15
Q

Predisposing factors for the development of chronic neck pain

A
  • > 40 y/o
  • co-existing LBP
  • loss of strength in hands
  • worrisome attitude
  • poor quality of life
  • long hx of neck pain
  • cycling as a regular activity
  • less vitality
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16
Q

Risk factors for new onset neck pain

A
  • female sex
  • older age
  • high job demands
  • being an ex smoker
  • low social or work support
  • previous hx of neck or low back disorders
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17
Q

Recovery from WAD timeline

A
  • most of the recovery occurs within the first 6-12 weeks post injury with rate of recovery slowing afterwards.
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18
Q

Individuals can follow 1 of 3 trajectories with recovery from WAD

A
  1. mild problems with rapid recovery 45%
  2. moderate problems with some but incomplete recovery 40%
  3. severe problems with no recovery 15%
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19
Q

Risk factors for persistent problems when captured in acute or subacute WAD <6 weeks

A
  1. high pain intensity
  2. high self reported disability score
  3. high post traumatic stress symptoms
  4. strong catastrophic beliefs
  5. cold hyperalgesia
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20
Q

Symptoms of cervical radiculopathy

A
  • pain radiating into arm coupled with motor, reflex, and/or sensory changes in the upper limb
  • parasthesia or numbness
  • median nerve test may be useful
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21
Q

Patients considered high risk for cervical fracture if…

A
  • age >65 y/o
  • dangerous MOI
  • parasthesias in extremities
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22
Q

Risk factors indicating safe cervical ROM assessment

A
  • patient able to sit in emergency room department
  • was in a simple rear-end MVC
  • patient is ambulatory at any time
  • delayed onset of neck pain
  • no midline cervical spine tenderness
  • patient able to actively rotate the head 45 degrees in any direction.
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23
Q

Symptoms of cervical radiculopathy

A
  • positive spurling
  • positive traction/distraction test
  • valsalva test
  • negative neurodynamic test may rule it out
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24
Q

Cervical flexion rotation test

A
  • maximally flex cervical spine then rotate R and L
  • (+) if restriction of ROM, ROM <32 degrees
  • mean for healthy individuals = 39-45
  • patients with cervicogenic HA = 20-28 degrees
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25
Q

4 categories to classify neck pain

A
  1. neck pain with mobility deficits
  2. neck pain with movement coordination impairments (including WAD)
  3. neck pain with HA
  4. neck pain with radiating pain
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26
Q

Neck pain with mobility deficits symptoms

A
  • central and/or unilateral neck pain
  • limitation in neck motion that consistently reproduces symptoms
  • associated shoulder girdle or UE pain may be present
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27
Q

Neck pain with mobility deficits symptoms expected exam findings

A
  • limited cervical ROM
  • neck pain reproduced at end range active and passive motions
  • restricted cervical and thoracic segmental mobility
  • intersegmental mobility testing reveals characteristic restriction
  • neck and referred pain reproduced with provocation of the involved cervical and upper thoracic segments or cervical musculature
  • deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic pain.
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28
Q

Neck pain with movement coordination impairments (WAD) common symptoms

A
  • mechanism of onset linked to trauma or whiplash
  • associated (referred) shoulder girdle or UE pain
  • associated varied non specific concussive signs/symptoms
  • dizziness/nausea
  • HA, concentration, or memory difficulties, confusion, hypersensitivity to mechanical, thermal, acoustic, odor, or light stimuli, heightened affective distress
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29
Q

Neck pain with movement coordination impairments expected exam findings

A
  • (+) cranial cervical flexion test
  • (+) neck flexor endurance test
  • (+) pressure algometry
  • strength and endurance deficits of neck muscles
  • neck pain with mid-range motion that worsens with end-range positions
  • point tenderness may include myofascial trigger points
  • sensorimotor impairment may include altered muscle activation patterns, proprioceptive deficits, postural balance or control
  • neck and referred pain reproduced by provocation of involved segments
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30
Q

Neck pain with headaches common symptoms

A
  • non continuous unilateral neck pain and associated HA

- HA is precipitated or aggravated by neck movements or sustained positions/postures

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31
Q

Neck pain with headaches common exam findings

A
  • (+) cervical flexion rotation test
  • HA reproduced with provocation of the involved upper cervical segments
  • limited cervical ROM
  • restricted upper cervical segmental mobility
  • strength, endurance, and coordination deficits of the neck muscles.
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32
Q

Neck pain with radiating pain common symptoms

A
  • neck pain with radiating pain into involved UE

- UE dermatomal paresthesia or numbness, and myotomal muscle weakness

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33
Q

Neck pain with radiating pain expected findings

A
  • neck and neck related radiating pain reproduced or relieved with radiculopathy testing
    • (+) test cluster: upper limb mobility, spurling’s test, cervical distraction, cervical ROM
  • may have UE sensory, strength, or reflex deficits associated with the involved nerve roots
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34
Q

Treatment for acute neck pain with mobility deficits

A
  • thoracic manipulation
  • neck ROM exercises
  • scapulothoracic and UE stretching and strengthening
  • cervical manipulation/mobilization (C level)
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35
Q

Treatment for subacute neck pain with mobility deficits

A
  • provide neck and shoulder girdle endurance exercises

- may provide thoracic manipulation and cervical manipulation/mobilization

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36
Q

Treatment for chronic neck pain with mobility deficits

A
  • thoracic manipulation and cervical manipulation/mobilization
  • mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise, stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements
  • dry needling, laser, or intermittent traction
  • may provide trunk, shoulder girdle, and neck endurance exercises, patient education and counseling strategies.
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37
Q

Treatment for neck pain with movement coordination impairments

A
  • education of the patient to: return to normal, nonprovocative preaccident activities ASAP, minimize use of collar, perform postural and mobility exercises to decrease pain and increase ROM
  • reassurance to the patient that recovery is expected to occur within the first 2-3 months
  • manual therapy
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38
Q

Chronic neck pain with movement coordination impairments

A
  • patient education
  • mobilization combined with an individualized, progressive submaximal exercise program with cervicothoracic strengthening, endurance, flexibility, and coordination
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39
Q

Treatment of neck pain with headache

A
  • coordination
  • strengthening
  • endurance exercises
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40
Q

Treatment of acute neck pain with headache

A
  • supervised instruction in active mobility exercises

- may utilize C1-2 self SNAG exercise

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41
Q

Treatment of subacute neck pain with headache

A
  • cervical manipulation and mobilization

- C1-2 self SNAG exercises

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42
Q

Chronic neck pain with headache

A
  • cervical or cervicothoracic manipulationor mobilizationcombined with shoulder girdle and neck stretching, strengthening, and endurance exercises
43
Q

Treatment for neck pain with radiating pain

A
  • use upper quarter and nerve mobilizations
  • specific repeated movements to promote centralization
  • mechanical intermittent cervical traction combined with manual therapy, strengthening exercises
44
Q

Treatment of acute neck pain with radiating pain

A
  • mobilizing and stabilizing exercises, laser, short term use of a cervical collar
45
Q

Treatment of chronic neck pain with radiating pain

A
  • mechanical intermittent cervical traction, combined with stretching and strengthening exercise, cervical and thoracic mobilization/manipulation
  • education and counseling
46
Q

Low or very low effect with the following for WAD

A
  • TENS
  • ER education
  • ROM exercises
  • thoracic manipulation
  • massage
  • NSAIDs and acetaminophen
  • active interventions improve recovery but parameters unclear.
47
Q

Some evidence supports the use of the following for WAD

A
  • ROM
  • low load isometrics
  • postural endurance and strengthening exercises
  • may use neuro re-ed as well
48
Q

3 trajectories of acute WAD

A
  • rapid complete recovery 20-30%
  • slow-recovery 55-60%
  • non-recovery, chronic disability 10-15%
49
Q

Chronic WAD

A
  • 50% with WAD report symptoms 12 months later, 20% will report severe disability or interference
50
Q

Chronic WAD symptoms may be due to…

A
  • maladaptive beliefs and cognitions
  • stress system dysregulation
  • genetic vulnerability
  • injury to CNS
51
Q

Low to moderate confidence for treatment of WAD

A
  • exercise
  • combined strength/ROM/flexibility programs
  • yoga
  • cervical manipulation, similar outcomes to K-tape
  • acupuncture or dry needling
  • intermittent traction (short term benefits)
  • scapulothoracic endurance training
52
Q

Muscle function and coordination are disturbed in chronic and acute WAD

A
  • increased fatty infiltrate
  • not seen in non-traumatic
  • some evidence shows targeted exercise can address the muscle structures
53
Q

Indications for cervical flexor training

A
  • functional issues
  • -> poor active control of cervical extension in upright posture
  • -> forward head postures
  • -> difficulties lifting head off bed
  • patient responds well to cervical flexion exercises
54
Q

Indications for extensor training

A
  • functional issues
  • -> poor active control of upright cervical flexion
  • -> forward head posture
  • -> prominent reports of sensorimotor disturbances and positive sensorimotor tests
  • patient responds positively following extension exercises.
55
Q

Fatty infiltration

A
  • higher in cervical extensors and appears greatest in the non-recovered WAD group
  • clinical observation of altered kinematics may be explained by increased fatty infiltration
56
Q

Facet involvement in WAD

A
  • about 60% of patients with WAD may have pain from the facet joints
  • most common facets injured are C2/3 and C5/6
57
Q

C2/3 facet referral pattern

A

-occipital region

58
Q

C2/3, C3/4 facet referral pattern

A
  • sub occipital region
59
Q

C3/4, C4/5 facet referral pattern

A
  • lower cervical region
60
Q

C4/5, C5/6, C4, C5 facet referral pattern

A
  • cervicothoracic region
61
Q

C4/5, C5/6, C4 facet referral pattern

A
  • upper trap/cervicothoracic region
62
Q

C6/7, C6, C7 facet referral pattern

A
  • rhomboids/upper trapezius
63
Q

C7/T1, C7 facet referral pattern

A
  • rhomboids/lower trapezius
64
Q

Cervical ligaments

A
  • alar ligament connect the sides of the dens to tubercles on the medial side of the occipital condyle. Check side to side movement when the head is turned
  • transverse ligament prevents anterior displacement of C1 and C2
65
Q

Anterior neck muscles

A
  • sternocleidomastoid
  • scalenes
  • platysma
  • hyoids
  • deep neck flexors
66
Q

Posterior neck muscles

A
  • upper trapezius
  • levator scapula
  • paravertebrals
  • suboccipitals
67
Q

Kinematics of atlanto-occipital joint

A
  • allows for flexion and extension
68
Q

Kinematics of atlanto-axial joing

A
  • provides rotation, about 50% of all rotation comes from this joint
69
Q

Cervical side bending kinematics

A
  • atlas may slide a little in the direction of the weight of the head
  • no true side bending at AA joint
  • occurs with facet gliding during SB C2-C7
  • -> SB R, ipsilateral side moves inferiorly, contralateral side moves superiorly
70
Q

Cervical ROM

A
  • flexion: 80-90 degrees
  • extension: 70 degrees
  • side bend: 20-45 degrees
  • rotation: 70-90 degrees
71
Q

-5 D’s AND, 2 N’s

A 
5 D's
- dizziness
- diplopia
- drop attacks
- dysarthria
- dysphagia
AND
- ataxia
- anxiety
2 N's (provoked with cervical movements)
- nausea
- numbness
- nystagmus
72
Q

Red flags of headache

A
  • sudden onset of severe HA (not likely referred to PT for this)
  • worsening or changing symptoms without known cause (neurological signs, dizziness)
  • headache triggered by cough, valsalva, exertion (subarachnoid hemorrhage, mass lesion)
  • headache triggered during pregnancy, delivery, post-partum (carotid A dissection, pituitary apoplexy, corticol vein/cranial sinus thrombosis
  • onset of HA >50 y/o
73
Q

Yellow flags with HA

A
  • FABQ

- behaviors (extended rest, withdrawal from ADLs, high reported pain score, excessive use of aides, self medication)

74
Q

Differential diagnosis of HA

A
  • cervical arterial dysfunction
  • upper cervical instability
  • pancoast tumor
  • cervical myelopathy
  • neck pain with radiating pain
  • neck pain with movement coordination impairments
  • neck pain with mobility deficits
75
Q

Vertebral artery

A
  • 11% of cerebral blood flow
  • supplies posterior cranial circulation
  • greatest stress with upper cervical rotation
76
Q

Carotid artery

A
  • 89% of cerebral blood flow
  • supplies anterior cranial circulation
  • greatest stress with mid cervical extension
77
Q

Risk factors for arterial dysfunction

A
  • female ages 30-39
  • hx of migraines
  • oral contraceptive use
  • diabetes
  • hypertension
  • hx of smoking
78
Q

Clinical features of vertebral A dissection

A
  • non-ischemic (local) signs and symptoms
  • -> ipsilateral posterior neck pain and occipital HA
  • -> C2-C6 cervical nerve root impairment (rare)
79
Q

Hind brain TIA

A
  • 5 D’s, nausea, nystagmus, facial numbness, ataxia, vomiting, hoarseness, short-term memory loss
  • limb weakness, anhidrosis, hearing disturbances, malaise, perioral dysthesia, photophobia, papillary changes, clumsiness, and agitation
80
Q

Hind brain stroke

A

wallenberg’s syndrome

  • hoarseness
  • dizziness, nausea, and vomiting
  • rapid involuntary eye movements
  • difficulty with balance and gait coordination
  • problems with body temperature sensation
  • lack of pain and temperature sensation on one side of the face, or different symptoms on each side of the body
  • uncontrollable hiccups
  • loss of taste on one side of the tongue
  • decreased sweating
  • changes in HR and BP
81
Q

Non-ischemic (local) signs and symptoms of internal carotid dissection

A
  • horner’s syndrome, ptosis (falling of upper eyelid), anhydrosis, miosis (constricted pupil), facial flushing, enopthalmas (retracted eyeball)
  • pulsatile tinnitus
  • cranial nerve palsies (usually 9-12)
82
Q

Ischemic (cervical or retinal signs and symptoms) of internal carotid dissection

A
  • TIA
  • ischemic stroke
  • retinol infarction
  • greatest stress with mid cervical extension
83
Q

Clinical presentation of cervical instability

A
  • spinal cord signs
  • C1-2 instability influences spinal cord stability and cuase signs of cervical myelopathy
  • occipital HA and numbness
  • movement limitations (often severe) d/t protective muscle spasms
  • locking of neck with certain movements
  • crepitations
  • insufficient muscle control
  • often feel better in AM than PM
84
Q

Symptoms of cervical myelopathy

A
  • instability walking/balance problems/stumbling
  • ataxia
  • sensory loss/motor loss in patchy distribution
  • loss of bowel/bladder control
  • hyperreflexia
  • pathological reflexes (babinski, clonus, hoffman’s)
85
Q

Klippel Fiel Syndrome

A
  • congenital fusion of any two of seven vertebrae. Can be single or multiple levels
86
Q

Ehlers Danlos syndrome

A
  • connective tissue disorder leads to decreased stability
87
Q

Arnold chiari malformation

A
  • downward displacement of cerebellar tonsils through foramen magnum
  • spinal cord compression symptoms
  • decompression surgery
  • often leads to chronic HA
  • most often congenital but may be due to ehlers danlos syndrome or marfans
88
Q

Neurological exam

A
  • cranial nerves
  • myotomes
  • dermatomes
  • upper motor neuron testing (babinski, hoffman’s, clonus, rhomberg)
  • cervical AROM and PROM
  • special tests (sharp purser, transverse ligament test, alar ligament test)
89
Q

Positive sharp’s purser test

A
  • dorsal movement of occiput and C1
  • possibly a click or clunk
  • reduction in symptoms
  • a stable segment should not allow any movement with a hard elastic end feel
90
Q

Cervical radiculopathy

A
  • disease of cervical spine root, most often caused by cervical disc herniation or other space occupying lesion resulting in nerve root impingement, inflammatory or both.
  • strength loss in myotomal distribution, sensory loss in dermatomal distribution. Diminished or absent reflexes.
91
Q

Pancoast tumor

A
  • tumor of apical lung
  • can involve caudad cervical nerve roots
  • can initially mimic cervical radiculopathy
  • typically smokers
  • horner’s syndrome (develps due to secondary sympathetic nervous system damage)
92
Q

Cervical myelopathy

A
  • can occur d/t cervical spondylosis
  • long tract signs (weakness, spasticity, hyper reflexia)
  • lhermitte’s sign: cervical flexion produces electrical sensation from spine into extremities.
93
Q

Cervical myotomes

A
  • C4: shoulder shrugging
  • C5: shoulder ABD
  • C6: biceps and wrist extension
  • C7: triceps
  • C8: finger flexion
  • T1: finger inter ossei
94
Q

Individuals with cervical radiculopathy likely to respond to PT

A
  • age <54 y/o
  • dominant arm not affected
  • looking down doesn’t aggravate symptoms
  • multimodal prescription for 50% of visits (OMPT, traction, DNF strengthening)
  • -> 3 variables present: +LR=5.2
  • -> 4 variables present: +LR=8.3
95
Q

Those likely to respond to cervical traction

A
  • age >55 y/o
  • shoulder ABD test
  • ULTT A
  • symptom peripheralization with lower cervical C4-C7 P-A motion testing
  • neck distraction test (>4 variables present: +LR=11.7)
96
Q

Traction parameters

A
  • 15-24 degrees of flexion
  • 60 seconds on, 20 seconds off (50% pull during off time)
  • 10-12 lbs of pull initially
  • -> adjusted to optimally decrease symptoms
  • -> moderate to strong to strong without aggravation
  • -> max pull of 40 lbs
  • -> any pull 23 lbs
  • 15 minutes duration
  • f/u with exercise
  • 6 sessions over 3 weeks
97
Q

Cervical headache

A
  • a HA arising from dysfunction or inflammation of the musculoskeletal structures of the upper cervical spine. Most common symptom following head or cervical trauma
98
Q

Cervicogenic HA symptoms

A
  • unilateral HA with neck/suboccipital symptoms aggravated by movement
  • HA produced/aggravated with provocation of ipsilateral posterior cervical myofascia and joints
  • restricted cervical ROM
  • restricted segmental mobility
  • abnormal/substandard performance on cranial cervical flexion test
99
Q

Migraines

A
  • prevalence 10%
  • occurs upon waking or later in the day
  • lasts 4-24 hours
  • increased sensitivity to light, noise, and tension
  • nausea, vomiting
  • may be triggered by vomiting
100
Q

Classic or neurologic migraine

A
  • aura, vision loss, weakness, vertigo
101
Q

Cluster HA’s

A
  • unilateral
  • usually male
  • nocturnal
102
Q

Tension HA’s

A
  • bilateral symptoms
  • moderate intensity
  • pressure without throbbing
  • tightness or aching
  • lasts 30 min-7 days
  • provoked by fatigue, nervous strain, depression, anxiety
103
Q

Meningeal criterion

A
  • meningitis/subarachnoid bleed
  • steady, deep pain, generalized, bioccipital, frontal
  • single episode, rapid evolution, hours to minutes
  • neck stiffness bending forward
  • (+) kernig sign (unable to perform SLR d/t neck pain)
  • (+) brudzinski sign (supine head flexion leads to flexion of LE)
  • (+) Llhermitte’s sign (cervical flexion in sitting leading to electric shock to LE)

OCS (11 decks)

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