Cervical Spine Flashcards
Neck pain risk factors
Female, >40 yo, coexisting LBP, long/prior history of neck pain, cycling as regular activity, loss of strength in the hands, worrisome attitude, poor QOL, less vitality, smoking history.
Clinical course of neck pain
Variable
High rate of recurrence/chronicity (50% fully recover within 1 year). Episodic coures is most common.
~6 mo average for clinically meaningful decrease in pain intensity
Recovery appears to happen most rapidly in first 6-12 weeks, with rate of recovery slowing considerably after this window.
Risk factors for persistent problems when captured in acute or subacute WAD (<6 weeks from injury)
- High pain intensity
- High self-reported disability scores
- High post-traumatic stress symptoms
- Strong catastrophic beliefs
- Cold hyperalgesia
Risk factors for persistent problems in work-related or nonspecific neck pain
- Prior history of other MSK disorders
2. Older age
When imaging is indicated according to neck pain classification (in the absence of red flags):
- With mobility deficits - not indicated
- With radiating pain - MRI if non-resolving. CT to ID bony injury or ligamentous disruption.
- With movement coordination impairment - Should not use MRI to examine alar or transverse ligaments as routine work up.
- Painful and traumatic myelopathy - MRI
When imaging is indicated according to neck pain classification (in the absence of red flags):
- With mobility deficits - not indicated
- With radiating pain - MRI if non-resolving. CT to ID bony injury or ligamentous disruption.
- With movement coordination impairment - Should not use MRI to examine alar or transverse ligaments as routine work up.
- Painful and traumatic myelopathy - MRI
What constitutes a positive cervical flexion-rotation test?
rotation <32 degrees, or 10 degrees reduction of either side.
Findings in patients with neck pain with mobility deficits
- Central and/or unilateral neck pain
- Limitation in neck motion that consistently reproduces symptoms. Pain reproduced at END RANGE of A/PROM.
(Associated shoulder girdle or UE pain may be present) - Restriction and reproduction of pain with segmental mobility testing. Pain may also be reproduced with provocation of cervical musculature. Primarily concerned with lower c-spine (C3-7)
- Deficits in cervicoscapulothoracic strength and motor control may be present in individuals with subacute or chronic neck pain.
Acute pts often have onset linked to recent unguarded/awkward movement or position
Findings in patients with neck pain with movement coordination impairment (WAD)
- Mechanism of onset linked with trauma/whiplash
- Associated shoulder girdle or UE pain
- Associated varied nonspecific concussive signs/symptoms, dizziness, nausea, headache
- Positive cranial cervical flexion test
- Positive neck flexor muscle endurance test
- Positive pressure algometry
- Neck pain with MIDRANGE motion that worsens with END RANGE
- Point tenderness, trigger points
- Sensorimotor/ proprioception impairment
- Pain reproduced by provocation of involved cervical segments.
Often more chronic in nature in clinic
Findings in patients with neck pain with headache
- Noncontinuous, unilateral neck pain and associated headache
- Headache precipitated by neck movements or sustained positions/postures.
- Positive cervical flexion-rotation test
- HA reproduced with provocation of upper cervical segments
- Limited cervical ROM, especially upper cervical
- Limited strength/endurance/coordination of neck muscles.
Findings in patients with neck pain with radiating pain
- Neck pain with radiating (narrow, lancinating pain) into UE.
- UE dermatomal paresthesias or numbness, myotomal weakness
- radiculopathy testing (ULTT, Spurlings, distraction, rotation ROM - 3+ positive)
Neck pain prevalence, demographics, etc.
- 25% of patients seen in PT
- Most common in females, 5th decade
- 25% experience recurrence within one year. 30% develop chronic sxs
- Cost associated is second only to lumbar pain in annual worker’s comp costs in US.
Upper cervical ligaments
Alar ligaments: From dens to occiputal condyles (one on each side)
Cruciform ligaments: Includes transverse ligament.
Transverse ligament: Attaches on either side of C1, wraps around dens.
Function of ligamentum nuchae
Increases depth of cervical spinous processes for muscular attachment.
Limits flexion ROM
Scalene attachments/role in relation to ribs
Anterior and middle scalenes: Attach to first rib.
Posterior scalenes: Attach to second rib.
Elevates ribs when neck is fixed.
What muscles does C2 nerve run through?
Semispinalis cervicus. Entrapment of the nerve can lead to greater occipital neuralgia.
Arthrokinematics of c-spine
Not well understood. No consensus as to what actually occurs.
What to do if you have a patient with suspected bactrial meningitis
Refer pt for immediate medical management.
Candian C-spine rules
- X-Rays required if patient has 2+ high risk factors (65+, paresthesias in extremities, dangerous mechanism of injury)
- If <2 high risk factors, check if they are appropriate for ROM assessment. (Can assume seated position, can walk, delayed onset of pain, no midline tenderness, low impact MVA).
- If they aren’t appropriate for ROM assessment > Xray - Assess ROM. If <45 deg in one direction > Xray
What does use of intravenous drugs put patient at increased risk for?
Sepsis, septic arthritis
MCID for numeric pain rating scale
1.3
MDC = 2.1
NDI MCD
10 points (out of 50)
Patient-specific functional scale vs. NDI
PSFS is more responsive. May be more meaningful for patients.
FABQ
Work subscale has the best corelation with NDI.
Higher score = higher FAB = higher risk for prolonged disability.
Upper cervical instability tests
Sharp purser = Transverse ligament (cruciform)
- Positive: head moves posteriorly without axis moving; reproduction of sxs during flexion; decrease in sxs with posterior force.
- 69% Sn, 96% Sp
Alar ligament test
- Positive: Delay in movement of spinous process of C2
*Pts with instability can initially present like patients with mobility deficit. Make sure to screen for instability.
Evidence for VBI testing/ correlation with HVLA
- No evidence of excess risk for stroke with cervical HVLA, no link with occurrence of serious adverse events.
- Negative VBI testing may neither predict the absence of arterial pathology NOR the propensity of artery to be injury during HVLA. (Neither Sn or Sp)
- If there is high suspicion of VBI based on patient’s history, passive end range provocative testing should be avoided, pt referred.
Sxs that should > suspicion of VBI
Vertigo Tinnitus Dizziness Visual-perceptual disturbances Fainting
Most common sx of vertebral artery dissection = pain in head and neck, usually unilateral and suboccipital. 25% have sudden onset of pain.
Most common cause of suddent onset VBI
High velocity, flexion-distraction and rotational trauma. Proceed with heightened suspicion of VBI in any patient with hx of this type of trauma.
When not to stretch upper trap
Patient presents with depressed/ downwardly rotated scapula. Trap is already lengthened.
Typical starting point for most patients with mobility deficit
Mobility interventions. Progress to stability exs to maintain mobility gains as needed.
Mechanism of pain relief with manual therapy
Stimulating descending inhibitory pain mechanisms - particularly PAG area.
Thrust vs. nonthrust manual therapy
Thrust patients almost always do better.
Predictors of positive response to cervical spine manipulation
Tseng study (4+ positive):
- Initial NDI <11.5
- Bilateral pain
- Do not perform sedentary work >5 hours per day
- Feel better when moving the neck
- Extension does not increase pain
- Have dx of spondylosis without radiculopathy
Puentedura study (3+ positive):
- Sxs <38 days
- Expectation of manipulation efficacy
- > 10 degree difference side to side rotation ROM
- Pain with PA spring testing of middle c-spine
CPG for positive response to thoracic manipulation
3+ present
- Sxs <30 days
- No sxs distal to shoulder
- Extension does no increase pain
- <12 FABQ
- Diminished upper thoracic kyphosis
- Cervical extension AROM <30 deg.
Normal upper cervical rotation AROM
39-45 degrees
Normal cervical rotation that occurs at each level below C1-2
4-8 degrees
Objective findings to differentiate patients with migraines vs. cervicogenic HA
Pts with cervicogenic HA have less ROM into flexion and extension and upper cervical hypomobility (joint and muscle)
Normal/ Abnormal performance on cranial cervical flexion test
Normal: Increase in pressure 16-30 mmHg, maintained for 10 seconds.
Abnormal:
- Unable to generate an increase in pressure at least 6 mmHg
- Unable to hold generated pressure for 10 seconds
- Uses superficial neck muscles
- Sudden movement of chin or extending neck forcefully against the pressure device.
Neck flexor muscle endurance test
Stopped when pt loses skin fold or touches therapist’s hand for >1 second.
Mean time for patients without pain: 39 seconds.
Mean time for patients with pain: 24 seconds.
Mean time for men: 39 seconds.
Mean time for women: 29 seconds.
(Study also found sedentary patients had better score than active patients, but smaller sample size)
Assessment of muscle length in patients with sprain/strain
Typically not indicated.
Single best neurological screen for cervical radiculopathy
Biceps DTR
Best screen for cervical radiculopathy
ULTTA
Predictors of patients most likely to achieve success with PT
- Age <54 years
- Dominant arm not affected
- Sxs do not worsen with looking down
- Tx including manual therapy, cervical traction, and DNF strengthening for at least 50% of visits.
Predictors of patients likely to respond well to intermittent cervical traction
- Peripheralization with lower cervical spine mobility testing
- Positive shoulder abduction sign
- Age > 55 years
- Positive ULTTA
- Relief of sxs with manual distraction test.
Interventions for neck pain with mobility deficit - ACUTE
B: Should do thoracic manipulation, program of neck ROM exercises, and scapulothoracic and upper extremity stretching and strengthening
C: May do cervical manipulation/moblization
Interventions for neck pain with mobility deficit - SUBACUTE
B: Should provide neck and shoulder girdle endurance exercises
C: May provide thoracic/cervical manual
Interventions for neck pain with mobility deficit- CHRONIC
B: should include multimodal approach of:
- Thoracic and cervical manual
- Cervical/scapulothoracic NMR, stretching, strengthening, endurance training, aerobic conditioning,
- Dry needling, laster, intermittent traction
C: May counsel patient on active lifestyle, cognitive/affective factors.
Interventions for neck pain with MCD/WAD- ACUTE
B: Education to return to normal activity, postural and mobility exercises (for pain and mobility), education that recovery is expected within 2-3 mo
B: Multimodal approach of manual, exercise for patients expected to have slow recovery
C: For patients at low risk for chronicity, may provide single session of early advice/ exercise instruction, TENS
F: Monitor status to ID delayed recovery
Best self report questionnaire to predict future disability
FABQ
Craniocervical flexion training va. Cervical endurance training
Craniocervical flexion resulted in better improvements in pain/ function
Interventions for neck pain with MCD/WAD - CHRONIC
C: Patient education/encouragement
C: Mobilization + submaximal exercise program
C: TENS
Interventions for neck pain with HA - ACUTE
B: AROM
C: C1-2 self-SNAGs
Interventions for neck pain with HA - SUBACUTE
B: Cervical manual
C: C1-2 self-SNAGs
Interventions for neck pain with HA - CHRONIC
B: Manual (cervical or CT) + Shoulder girdle and neck stretching/strengthening/ endurance.
Interventions for neck pain with radiating pain - ACUTE
C: Mobility and stability exercises, laser, short term us of collar
Interventions for neck pain with radiating pain - CHRONIC
B: Mechanical intermittent traction in combo with exercises and manual
B: Education/counseling for active/normal lifestyle
% of patients expected to follow each trajectory for WAD
40-45% mild disability
40-45% moderate improving to mild
16% chronic
Orientation of facet joints in each part of the spine
Cervical spine: 45 degrees to the transverse plane, more parallel to frontal plane than other regions. Allows for more rotation and side bending.
Thoracic Spine: Increasingly more sagittal down the spine
Lumbar: Most sagittal orientation
Cervical myelopathy CPR
- Gait deviation
- Positive Hoffmann’s test
- Positive inverted supinator sign
- Positive Babinski test
- Age > 45 years
Well’s Criteria scores
> 3: High Probability
1-2: Moderate Probability
0: Low Probability
