Cervical Spine Flashcards
Canadian C- spine rules
- Does the patient have high risk factors
- age >65
- paradthesia in UE’s
- dangerous MOI ( fall from >1 meter, mva speed >100kmh, mva with rollover/ ejection, bicycle or recreational vehicle.
- 2 or more X-ray required - Does the patient have any factors that permit an assessment f ROM
- ability to sit up
- ability to ambulate
- onset of neck pain not immediate
- absence of midline tenderness
- mva that does not include: being pushed into traffic, hit by a bus or truck, hit at high speed - Can the patient rotate neck 45 degrees- if not x ray required
What is the CPR for cervical manipulation?
- neck index <11.5
- bilateral involvement
- not performing sedentary work > 5 hours
- feeling better while moving the neck
- does not feel worse while extending the neck
- diagnosis of spondylitis without radiculopathy
- 4 or more variables present = successful outcomes from 60- 89%
What is the CPR for cervical traction?
- Peripheralization with lower cervical spine c4-7
- Positive shoulder abduction sign
- Greater than 55 years
- ULTT median nerve
- Relief with manual distraction test.
- 4 or more variables present successful outcome from 44- 94.8%
- 3 variables- successful outcomes from 44-53%
- 2 variables present- successful outcomes from 44- 79%
What is the CPR for thoracic spine manipulation?
- Symptoms < 30 days
- No symptoms distal to the shoulder
- Looking up does not aggregate symptoms
- FABQ PA- <12
- Diminished upper thoracic kyphosis T3-5
- Cervical extension <30
- 3 variables present= successful outcomes from 54- 86%
What s the CPR for neck pain with radicular symptoms?
- Cervical rotation <60 degrees
- ULTT median nerve
- Distraction test
- Spurlings test
- 4 test positive- + LR 30.3, 3 positive + LR 6.1
What are the chances of radiculopathy if biceps reflex absent?
Chance increases from 23-59%
What are the five neck pain treatment classification categories outlined by Fritz?
- Mobility
- Pain control
- Exercise and conditioning
- Centralization
- Headache
Mobility treatment classifications:
- Acute Pain (<12 weeks)
- non radicular symptoms
- <60 years of age
- restricted cervical ROM in rotation and sb
Pain control classification:
- High Pain and disability scores
- recent onset of symptoms(trauma)
- radiating symptoms into UE
- poor tolerance to exam or interventions
Headache treatment classification:
- unilateral headache associated with neck/ sub occipitals
- HA aggravated by ipsilateral posterior neck structures
- restricted cervical ROM and segmental mobility
- poor performance in cranial cervical flexion test
Centralization treatment classification:
- radicular symptoms into UE
- peripheralization or centralization with ROM
- signs of nerve root compresssion
Coordination and exercise classification:
- low pain and disability scores
- longer duration of symptoms
- no signs of nerve root compression
What are interventions for neck pain in mobility class?
- Cervical or thoracic mobilization
- AROM exercises
What are interventions appropriate for neck pain with HA class?
- cervical mobilization
- exercise, coordination, strengthening and neck endurance
- postural education
What are interventions that are appropriate for neck pain centralization class?
- traction and repeated motions
What are appropriate interventions for neck pain in the pain control class?
- gentle AROM with pain tolerance
- ROM to adjacent regions
- activity modifications
- modalities
What are interventions appropriate for neck pain exercise and coordination class?
- Strengthening and endurance activities
What is the level of evidence for using cervical mobilization/ manipulations?
-Strong evidence for the use of cervical manipulation and mobilization combined with exercise.
What is the level of evidence to support the use of patient education for patients with neck pain?
- strong evidence for to educate the patient on early return to non provocative pre accident activity
- strong evidence to assure the patient of good prognosis and full recovery commonly occurs
What is the level of evidence to support the use of coordination, strengthening, endurance, exercises for cervical pain?
- strong evidence for the use of coordination, strengthening, and endurance exercises.
What is the level of evidence to support upper quarter and nerve mobilizations for cervical pain?
- moderate evidence to support the use of upper quarter and nerve mobilization techniques.
What is the level of evidence to support the use of stretching and flexibility exercises for cervical pain?
- weak evidence for stretching and flexibility exercises
- can be considered- (scalene, UT, LS, PMinor, PMajor)
Wha s the level of evidence to support the use of centralization procedures?
- weak- May use repeated movements or procedures to promote centralization
What is the level of evidence to support use of thoracic mobilization/ manipulation to treat cervical pain?
- weak
- May use thoracic mobilization/ manipulation in patients with primary complaints of neck pain.
What are the symptoms of cervical myelopathy?
- multi segmental weakness
- hyperreflexia,
- UMN signs
- Bowel/ bladder dysfunction
- unsteady gait
- sensory changes in “ stocking glove distribution”
What are the five clinical predictors for cervical myelopathy?
- Gait deviation
- Hoffman’s test
- Inverted supination sign when testing c6/reflex
4 Babinski sign - Age 45 or older
What is the dermatone and myotome to test c3/4?
- Myotome
- shoulder elevation and C/ S rotation - Dermatone
- lateral face, supraclavicular region
What are the dermatone/myotome for C5?
- Myotome
- shoulder abduction and ER - Dermatome
- lateral shoulder
What are the dermatome/myotome for C6?
- Myotome
- biceps and wrist extensors - Dermatome
- distal thumb and index finger
What are the dermatome/ myotome for C7?
- Myotome
- triceps and wrist flexors - Dermatome
- middle finger
What s the dermatome/ myotome for C8?
- Myotome
- Thumb and finger extension - Dermatome
- little finger
What is the dermatome/ myotome for T1?
- Myotome
- hand intrinsic - Dermatome
- medial elbow
What is the difference between nerve sliding and nerve tension?
Tension- movement of one or several joints to elongate the nerve.
- tensioning increases Intraneural pressure and tension
Sliding- elongation and one joint balanced by reduction in length of nerve bed at adjacent joint
- sliding = > greater nerve excursion
What is the appropriate treatment strategy for WAD?
- AROM and exercise based on strong evidence
- normal activities ASAP
- NSAIDS
- progress to isometric and deep flexors as needed
- chronic >3 months - multidisciplinary Pain management has been found to be useful
What is the best outcome measure for WAD?
Tampa Scale of Kinesphobia( TSK)
- higher score = greater kinesphobia
- TSK > 41; probability of WAD increases to 83%
- NDI >. 15 raises suspicion to 54%
What are cervical spine traction parameters?
- Occipital wedges- halter that pulls from Occiput instead of chin- reduces causes of TMJ
- Force: 25-40 lbs causes joint seperation
- Position: supine to promote relaxation
- Cervical angle: head and neck in about 15 degrees of flexion
- Initial treatment: 15 mi of intermittent traction (60 on 20 off) with initial pull of 10-12 lbs. MAX to 40 lbs.u
What is the most reliable indicator of brachial plexus injury?
Testing Sensory nerves is the most reliable indicator.
What is Erb’s Palsy?
- Affects C5-6 nerve root; superior trunk
- presents as waiter’s tip position ( arm extended, IR and forearm pronation)
What are the five nerve roots of the brachial plexus.
c5,6,7,8 and T 1
- has three extra branches: dorsal scapular, first intercostal, long thoracic
What are the three trunks of the brachial plexus?
- Superior, Middle and inferior
- crosses posterior triangle over the first rib and behind subclavain artery
- has two extra branches: suprascapular and nerve to subclavius
How many divisions does the brachial plexus have?
- Six: 3 anterior and 3 posterior
- located posterior to middle of clavicle
- anterior innervate the flexors
- posterior innervate the extensors
How many cords in the brachial plexus?
- Lateral, posterior and medial cord
- contains seven extra branches:
- medial/lateral pectoral, upper and lower subscap., thoracodorsal, medial cutaneous of arm and forearm
- contains seven extra branches:
What are the terminal branches of the brachial plexus?
- Musculocutaneous, axillary, radial, median, ulnar
- find the “M” shape - for median nerve.
What nerve innervates the Rhomboids and lavator scapular?
Dorsal scapular- C5
What nerve innervate the serrated anterior?
Long thoracic C5-7
What nerve innervate subclavius?
-Nerve to subclavius C5,6
What nerve innervates supraspinatus, infraspinatus?
-Suprascapular C 5-6, superior trunk
What nerve innervates pec major?
Lateral pectoral nerve- C5-7 lateral cord
What nerve innervates latissimus dorsal?
Thracodorsal C6-8, posterior cord
What muscle does upper subscap innervate?
Superior portion of subscapularis C5-6 posterior cord
What muscle does lower subscapular nerve innervate?
Inferior portion of subcsapularis, teres major
— c5-6 posterior cord
What does the medial pectoral nerve innervate?
Pec minor, major
- C8-T1
What does the medial cutaneous nerve of forearm innervate?
Skin on medial side of forearm
- C8 medial cord
What does the medial cutaneous nerve of the arm innervate?
Skin on medial side of the arm
- T1 medial cord
What muscle(s)does the musculocutaneous nerve innervate?
Biceps brachial, brachialis, coracobrachialis,
What does the axillary nerve innervate?
Teres minor, deltoid, skin over anterior deltoid
Describe the cranial cervical flexion test.
- Patient is supine in hooklying
- biofeedback cuff is inflated to 20 mmhg
- patient performs cranial cervical flexion and holds for 10 seconds
- test is repeated at 22, 24, 26, 28, and 30 mmhg
- 10 second text between tests
What is considered to be an abnormal response to the cranial cervical flexion test?
- unable to increase pressure by 6 mmhg
- unable to hold contraction for 10 seconds
- uses superficial neck muscles to accomplish cervical flexion
- uses a sudden movement of the chin or pushes forcefully against the pressure device
How do you score the cranial cervical flexion test?
- Activation score: Pressure achieved and held for ten seconds
- Performance index: increase in pressure x number of reps
Describe the neck flexor muscle endurance test.
The patient lies supine in hooklying and while maintaining the chin maximally contracted, the patient lifts the head until its approx. 2.5 cm off the table
- clinician places hand on the table below the occiput and gives verbal command “tuck your chin” and “ hold your head up”
- test is terminated if skin folds separate or if the patients occiput touches the clinicians hand
What are Cervical red flags to be aware of?
- blood in sputum
- alters mental status
- progressive neurological deficits
- numbness in perinatal region
- pathological changes in bowel bladder
- pulsation abdominal mass
Symptoms not associated with mechanical neck pain
What are factors the require precautionary examination and treatment procedures?
- age >50
- clonus
- fever
- elevated esr
- gait deficits
- h/o cancer, unexplained weight loss
- h/o metabolic bone disease
- non healing sores
- long term workman’s comp
What factors require further physical testing and differential analysis?
- abnormal reflexes
- Bilateral or unilateral radiculopathy
- unexplained referred pain
- unexplained significant upper/ lower limb weakness
