Cervical spine

Question 1

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Mechanism of injury - direction of forces eg flexion, flexion-rotation, extension, vertical compression

Answer 1

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Question 2

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Mechanism of spinal cord trauma - transection, compression, contusion, vascular injury

Answer 2

Spinal column injury may result in spinal cord or brain injury through a number of mechanisms:
-Transection - penetrating or massive blunt trauma resulting in spinal column injury may transect all or part of the spinal cord

• compression: When elderly patient with cervical OA and spondylosis forcibly extend their neck, the spinal cord may be compressed between an arthritically enlarged anterior vertebral ridge and a posteriorly located hypertrophied ligamentum flavum. Injuries that produce blood within the spinal canal can also compress the spinal cord
• Contusion - contusions of the spinal cord can occur from bony dislocations, subluxations or fracture fragments
• Vascular compromise - Primary vascular damage to the spinal should be suspected where there is a discrepancy between clinically apparent neurologic deficit and a known level of spinal column injury.

Knowledge of the location of nerve tracts within the spinal cord will help the clinician understand the syndromes that occur after injury.
A patient with complete cord syndrome will present early with flaccid paralysis and loss of sensation below the injury. Reflexes are absent and there will be no response to the Babinski test. Periapism may appear and generally lasts for a day. Within 1-3 days, hyperactive reflexes, positive babinski and spasticity develop.

Incomplete cord injury is usually more challenging to diagnose. There is significant variation in presentation. The anterior cord syndrome occurs in the setting of hyperflexion of the cervical spine in most cases. The anterior 2/3of the cord are affected and the dorsal columns, controlling light touch, proprioception and vibratory sense are spared to a variable degree.
Central cord syndrome is due to hyperextension, frequently in patients with preexisting cervical degenerative joint disease. In this setting, the central portion of the cord is compressed between the ligamentus flavum and bony osteophytes. Clinically, the patient will exhibit weakness that is greatest in the upper extremities with variable amounts of sensory loss and bladder dysfunction.
Lastly, the Brown-Sequard syndrome is a rare condition due to unilateral loss of cord function. The patient will exhibit paralysis with loss of proprioception, vibration, and light touch on the side of the damage and loss of pain and temperature sensation on the contralateral side.

Question 3

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

MVA details eg speed, direction of impact, use of seabelts

Answer 3

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Question 4

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

MBA/Cyclist details eg damage to helmet, speed

Answer 4

Motorcycle helmet removal - safe removal of a motorcycle helmet requires that manual cervical spine immobilisation be maintained continously, and this can be only be done with 2 people.

Question 5

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Fall from height (eg 3m, 5m) vs standing (force of impact), headstrike, loss of consciousness

Answer 5

Pain following a fall, especially in an elderly patient, suggests a possible fracture. In patients that sustain a more significant traumatic injury, a fractures should be considered until proven otherwise.

Question 6

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Skin integrity (wound)

Answer 6

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Question 7

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Time of injury, ability to move arms/legs post injury

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Question 8

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Mental status such as intoxicated at time of injury?

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Question 9

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Limb symptoms such as numbness, pins and needles, ‘dead’ arm or leg, tingling, weakness, foot drop

Answer 9

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Question 10

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Bladder bowel disturbance (both post injury and current)

Answer 10

Neck pain associated with lower extremity weakness, gait or coordination difficulties and/or bladder or bowel dysfunction suggests possible cord compression or myelopathy

Question 11

When obtaining a history discuss the implications of the following key areas and what associated questions may need to be asked to assess for red flag

Other sites of injury and potential for organs to be involved

Answer 11

Anterior neck pain is not typical for cervical spondylosis and non-spinal causes of neck pain, including angina pectoris and visceral etiologies should be considered.

Question 12

What other key information is required to assess for red flags?

Answer 12

Pain that persist at rest or is worse at night may herald un underlying malignancy or spinal infection.

The following clinical characteristics suggest the potential for serious disease that requires urgent evaluation
Neck pain associated with lower extremity weakness, gait or coordination difficulties and/or bladder or bowel dysfunction suggests possible cord compression or myelopathy

A shock like paresthesia occuring with neck flexion suggests compression of the cervical cord by a midline disc herniation or spondylosis but may also be a sign of intramedullary pathology such as MS

Neck pain associated with fever raises concern for infection. Immunocompromised patients and those with a history of injection drug use are at increased risk of infection and thus there is low threshold for performing an infectious workup

Neck pain with unexplained weight loss or history of cancer raises concern for malignancy

Neck pain associated with headache, shoulder or hip girdle pain or visual symptoms in an older person may suggest rheumatologic disease

Anterior neck pain is not typical for cervical spondylosis and non-spinal causes of neck pain, including angina pectoris and visceral etiologies should be considered.

Question 13

What key information would suggest an upper motor neuron lesion/cord compression or spinal syndrome?

Answer 13

Neck pain associated with lower extremity weakness, gait or coordination difficulties and/or bladder or bowel dysfunction suggests possible cord compression or myelopathy

A shock like paresthesia occuring with neck flexion suggests compression of the cervical cord by a midline disc herniation or spondylosis but may also be a sign of intramedullary pathology such as MS

Question 14

When one spinal fracture is present what else should you look for?

Answer 14

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Question 15

When is a spinal fracture classified as stable or unstable

Answer 15

To assess the stability of cervical spinal column injuries below C2, the spine is viewed as consisting of 2 columns. The anterior column is formed by vertebral bodies and IV disc which are held in alignment by the anterior and posterior longitudinal ligament. The posterior column, which contains the spinal canal, is formed by the pedicles, transverse processes, articulating facets, laminae, and spinous processes. The nuchal ligament complex, capsular ligaments and ligamentum flavum hold the posterior column in alignment.
If both columns are disrupted, the cervical spine can move as 2 independent units and there is high risk of causing or exacerbating a spinal cord injury. In contrast, if only one column is disrupted and the other column maintains structural integrity, the risk of spinal cord injury is far less.

Question 16

If a spinal fracture is suspected during history taken what action should be taken prior to proceeding with a clinical examiantion?

Answer 16

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Question 17

What key information is required to assess for vascular insufficiency or carotid artery dissection

Answer 17

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Question 18

What key information is required to assess dizziness

Answer 18

Most patients presenting with dizziness can be rapidly assessed and valid estimates can be made regarding diagnostic possibilities – thus informing management decisions.
Most of the uncertainty in dizziness presentations occurs when attempting to distinguish ‘peripheral’ from central causes. The key to distinguishing between these is understanding the 3 most common peripheral vestibular disorders (ie vestibular neuritis, BPPV and Meniere’s disease). Typically, the most effective way to ‘rule out’ a life-threatening central disorder is to ‘rule in’ a specific peripheral vestibular disorder.

Question 19

What key information would you ask to differentiate cervicogenic headache from non-musculokskeletal causes in the ED setting?

Answer 19

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Question 20

What key information is required in the setting of chronic neck pain problems in the ED?

Answer 20

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Question 21

What key information in a patient’s past medical history is important in neck pain/injuries in the ED setting?

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Question 22

What key information in a patient’s medication history is important in neck pain/injuries in the ED setting?

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Question 23

what key information in a patient’s social history is important in neck pain/injuries in the ED setting.

Answer 23

Social support and cultural differences in expectations in pain may play a role in development of persistent pain.

Question 24

What is the relevance of determining the first aid/pre hospital treatment?

Answer 24

First responders should be vigilant for spinal column injury in trauma patients. For any patient with a possible cervical spine injury, spinal immobilisation should be initiated at the scene.
Some form of cervical spine immobilisation and protection should be maintained until an unstable spinal injury is excluded using a validated assessment instrument or appropriate diagnostic imaging.

Question 25

What is the relevance of determining the compensable status or health insurance status of the patient?

Answer 25

Financial compensation can be one of the factors that may affect symptom duration.

Question 26

Routine physiotherapy subjective assessment of the cervical spine including upper cervical spine, 5Ds and VBI testing

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Question 27

Dizziness subjective questioning

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Question 28

Anatomy of the cervical spine

Answer 28

The spinal column includes 33 vertebraes: 7 cervical, 12 thoracic and 5 lumbar. The sacrum consists of 5 fused vertebrae and the coccyx. The 1st 2 cervical vertebrae are unique. The atlas is a ring like structure that articulates with the skull, where it is responsible for 50% of the neck’s ability to flex and extend. The odontoid process of the axis is secured to the anterior portion of the atlas and allows rotation.

The vertebral bodies gradually increase in size as they descend. The posterior arch encases the spinal cord and consists of broad pedicles, flat laminae and the spinal process. The transverse processes extend laterally near the junction of the pedicle and laminae. The posterior arch has 4 facets that articulate with the superior and inferior vertebrae forming synovial joints. Depending on their location, the transverse processes articulate with the ribs.
The ligaments of the spine include the anterior and posterior longitudinal ligaments that interconnect the vertebral bodies and run the length of the spine. Posteriorly, the ligamentum flavum, interspinous ligament, and supraspinous ligament provide stability.

Question 29

Anatomy of the nervous system including spinal cord, nerve roots, brachial plexus, peripheral nerves

Answer 29

The spinal canal and cord are largest in the cervical region. In the thoracic spine, the spinal canal is very narrow and therefore, small displacement can lead to significant neurological injury.

There are 8 cervical spinal nerves, each arising from the spinal cord and consisting of a ventral and a dorsal root. The ventral root contains efferent fibres from alpha motor neurons in the ventral horn of the spinal cord. The dorsal horn carries primary sensory afferent fibres from cells in the dorsal root ganglion. Cervical radiculopathy may be caused by degenerative changes in the spine that affect the nerve root. The findings vary with the level of nerve root involvement
The dorsal and ventral spinal roots combine to form the spinal nerve. This spinal nerve then divides into 2 branches, a dorsal primary ramus and a ventral primary ramus. The dorsal ramus innervates the muscular, cutaneous, and articular components of the posterior neck. The ventral ramus innervates the prevertebral and paravertebral muscles and forms the brachial plexus, which supplies the upper limb. A myotome is the group of muscles innervated by a spinal nerve.

Question 30

Routine physiotherapy objective assessment

Upper limb neurological assessment and assessment of upper motor neuron lesion

Answer 30

A neurological examination is warranted for all patients with new-onset neck pain, trauma, moderate or persistent neck pain symptoms, and referred shoulder or arm pain. It should include muscle strength, sensation, reflex and gait testing.

Question 31

Routine physiotherapy objective assessment

Testing of neural dynamics

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Question 32

Routine physiotherapy objective assessment

Shoulder joint screening

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Question 33

Routine physiotherapy objective assessment

Palpatory assessment

Answer 33

In the cervical spine, the muscles are relaxed in the supine position, making the deeper bony and ligamentous structures more readily palpable in this position. The examiner begins by feeling the occiput and the base of the skull in the midline. The posterior bony structures are best palpated if the examiner stands behind the patient’s head and cups the hands under the neck so that the fingertips meet at the midline. The first structure noted is the spinous process of C2. The posterior arch of C2 is not palpable. Loss of alignment of the spinous processes is seen in unilateral facet joint dislocation or with a fracture.
C7 has the largest spinous process in most individuals and is a helpful landmark. the facet joints are palpated lateral to and between the spinous processes on each side. Tenderness over the facet joints suggests arthritis, fracture or ligamentous injury.

Question 34

Routine physiotherapy objective assessment

Assessment of the dizzy patients

Answer 34

Evaluations of Emergency presentations
1. Determine if the dizziness is the principal symptom as opposed to a minor accompanying symptoms
Dizziness in most cases is a minor accompanying symptoms rather than the principal symptom. One of the main problems with dizziness presentation is that the patient’s description of dizziness can be very vague, inconsistent and unreliable. So prior to focusing all attention on the dizziness symptom, first consider if other symptoms are more prominent.

2. Define the characteristics of the dizziness symptoms
   Vertigo (visualised movement of the environment) is one common type of dizziness symptom
   Other types of dizziness symptoms to consider are light-headedness with presyncope, light-headedness without presyncope or imbalance.
   Because of the problem with patient description of dizziness symptoms, in many cases the characteristics of the symptom may be equally or even more important than defining the exact symptoms itself. Defining the characteristics of the symptom starts with defining whether the symptom is episodic or constant. If the symptom is episodic, then one should probe regarding triggers of the symptom and the frequency and duration of the episodes. Determining accompanying symptoms is also a vital step, particularly gathering information about auditory symptoms or focal neurological symptoms.
   The information from the history will help classify presentations into: acute severe prolonged dizziness, recurrent spontaneous dizziness attacks, recurrent positionally triggered dizziness attacks.
3. Perform general neurological examination
   A general neurological examination is important because any relevant motor, sensory, or language deficits will likely warrant a workup for a central disorder regardless of the other characteristics of the dizziness symptom. Unillateral hearing loss on the other hand, will strongly suggest a peripheral etiology.
4. Perform a Neuro-Otologic assessment
   If the source of the symptom is not clear after performing steps 1-3, then the neuro-otologic assessment becomes paramount. Subtle differences in eye movements or the vestibuloocular reflex can be highly localising. The key neuro-otologic examination components are the following: an assessment of nystagmus, positional testing when applicable and head thrust test when applicable.
   Pathological nystagmus occurs as the result of an acute imbalance of the vestibular system which can stem from a lesion of peripheral or central vestibular structures.
   In patients with acute severe prolonged vertigo, a unidirectional spontaneous horizontal nystagmus is highly suggestive of a lesion of the vestibular nerve. A central lesion is resumed in acute severe vertigo presentations whenever a pattern other than unidirectional horizontal nystagmus is observed.
   Positional testing is an important component of the bedside examination when the type of presentation is recurrent positional dizziness. Generally no spontaneous nystagmus is present is positionally triggered dizziness presentations. In positionally triggered attackes caused by BPPV, the nystagmus can change directions, which occurs with changes in head position. In addition, a principally vertical nystagmus is the characteristic pattern of the most common BPPV variant. In posterior canal BPPV, the Dix-Hallpike test triggers a burst of upbeating and torsional nystagmus which lasts less than 1 min. When patients sit back up, then burst of downbeating and torsional nystagmus is triggered. If persistent down-beating nystagmus is triggered by the Dix-Hallpike test, then a central nervous system lesion is presumed.
   If the Dix-Hallpike positional test does not trigger the nystagmus of BPPV, then supine positional testing is used to test for the less common horzionatal canal variant of BPPV. With this test the patient lies supine and the head is turned frist to one side and held for at least 30s and then to the other side and held for the same duration. A burst of horizontal nystagmus beating toward the ground is characteristic of the horizontal canal variant of BPPV. The side with stronger nystagmus is the abnormal side.
   The head thrust test is an important bedside examination component when the type of dizziness presentation is acute severe dizziness. The head thrust test allows a direct assessment of the vestibular-ocular reflex (VOR) and an abnormal result is highly suggestive of a vestibular nerve lesion.
5. Formulate the differential diagnosis

Question 35

Routine physiotherapy objective assessment

Assessment of vascular insufficiency in the cervical spine

Answer 35

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Question 36

Routine physiotherapy objective assessment

Testing of thoracic outlet syndrome

Answer 36

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Question 37

Describe the anatomy of the vascular structures in the neck

Answer 37

The head and neck receives the majority of its blood supply through the carotid and vertebral arteries.
The right carotid artery arises from bifurcation of brachiocephalic trunk (right subclavian artery is the other branch). This bifurcation occurs roughly at the level of the right SC joint.
The left carotid artery branches directly from the arch of aorta. The left and right carotid arteries ascend up the neck, lateral to the trachea and the oesophagus. At the level of the superior margin of the thyroid cartilage (C4), the carotid arteries split into the external and internal carotid arteries.
The external carotid artery supplies the areas of the head and neck external to the cranium. After arising from the common carotid artery, it travels up the neck, passing posteriorly to the mandibular neck and anteriorly to the lobule of the ear. The artery ends within the parotid gland by dividing into the superficial temporal artery and the maxillary artery.
The internal carotid artery do not supply any structures in the neck, entering the cranial cavity via the carotid canal.
The vertebral arteries are paired vessels which arise from the subclavian arteries, just medial to the anterior scalenes. They ascend the posterior aspect of the neck, passing through holes in the transverse processes of the cervical vertebrae.
The vertebral arteries enter the cranium via the foramen magnum and converge to form the basilar artery which continues to supply the brain. The vertebral arteries do not supply any branches to the neck or other extra-cranial structures.

Question 38

Describe classification of spinal column injuries in the cervical spine and common fractures and dislocations in the cervical spine region, including method of injury and clinical signs and symptoms

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Question 39

Describe common ligamentous injuries and spinal cord injury without radiological abnormality, including method of injury and clinical signs and symptoms

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Question 40

In the setting of suspected spinal column injury, discuss if you would examine the spine and if so how you would examine the spine

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Question 41

How would you assess the vascular status of the upper limbs?

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Question 42

How would you assess for carotid artery dissection if this was suspected?

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Question 43

How would you assess for cervical cord compression is this were suspected?

Answer 43

Neurogenic shock is most common after cervical spine (20% patients). Vital sign reveal a low systolic BP (<100mmHg) and bardycardia (<60-80 bpm). These abnormalities usually occur several hours after cord injury. The pathogenesis is related to loss of sympathetic tone and decreased peripheral vascular resistance. Neurogenic shock should be distinguished from the term spinal shock which refers to an initial loss, but a gradual recovery of some neurologic function after a spinal cord injury.

Question 44

What is the relevance of any local skin changes/open wounds to the neck?

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Question 45

When is an assessment of vital signs indicated?

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Question 46

How would you differentiate musculoskeletal cervical spine pain from non musculoskeletal cervical spine back pain?

Answer 46

Abnormal neck ROM is a nonspecific finding that may be seen in musculoskeletal cervical spine pain.
Tenderness on palpation is a nonspecific finding seen in many conditions (MSK Cx pain).

Question 47

How would you differentiate a peripheral neuropathy from a radiculopathy/brachialgia when only upper limb symptoms are present?

Answer 47

Cervical radiculopathy is associated with compromised nerve conduction (altered sensation, reduced muscle strength and reduced reflex) which is not evident in peripheral neuropathy

Electrodiagnostic tests are sometimes used to distinguish cervical radicular pain from other causes of extremity dysesthesia (eg peripheral nerve entrapment, peripheral neuropathy).

Question 48

What are the most common non-musculoskeletal presentations of cervical pain

Answer 48

Many non-spinal conditions can present with a constellation of symptoms that include neck pain. However, in most of these conditions, neck pain is not the most prominent feature and the diagnosis is often evident from other characteristic clinical manifestation. 
Cardiovascular disease
Infection
Malignancy
Neurologic conditions
Referred shoulder pain
Rheumatologic conditions
TOS
Vascular conditions
Visceral etiologies

Question 49

When would an X-ray be indicated for a patient with a cervical spine injury? and which views?

Answer 49

The typical trauma series includes AP, open mouth (odontoid) and lateral view. the lateral view should include CT junction.

The clinician should have a systemic approach to avoid missing important injuries. Before beginning, assess the adequacy of the films, specifically whether the open mouth view allows visualisation of the dens and lateral masses and whether the lateral view demonstrates all of the cervical vertebrae and the top of T1.
Next, consider alignment of the vertebrae on the lateral view. Look closely for fractures of the vertebral bodies or posterior bony structures. Loss of height of a vertebral body suggests a compression fracture and an abnormal angle between vertebral bodies suggests an unstable fracture. Lastly, evaluate the prevertebral soft tissues and the predental space.

CT scan of the cervical spine is becoming the more common initial imaging study because plain radiographs are less sensitive and frequently inadequate at demonstrating the entirety of the cervical spine.

Question 50

When would an X-ray be indicated for a patient with a cervical spine pain without history of trauma

Answer 50

In patients with recent trauma, clinical decision rules can be used to determine the need for cervical spine imaging.
NEXUS criteria to clinically exclude a cervical spine fracture or Canadian C-Spine rule

the NLC cannot be applied to patients over 60 and CCR mandates imaging for all patients 65 or older and neither rule can be used for children.

Question 51

When would a CT scan be indicated for a patient with cervical spine problem/injury?

Answer 51

CT scan of the cervical spine is becoming the more common initial imaging study because plain radiographs are less sensitive and frequently inadequate at demonstrating the entirety of the cervical spine.

Question 52

When would an MRI be indicated for a patient with a cervical spine problem/injury?

Answer 52

Imaging is generally reserved for patients with red flag, patients with progressive neurologic findings and patients with moderate to severe neck pain who do not respond to conservative treatment over 6 weeks.

However, if there is any concern for a pontentially serious diagnosis (eg infection, malingancy, serious neurologic deficits or signs of cord compression), an urgent MRI of the cervical spine should be performed.

Question 53

When would blood investigations for a patient with a cervical spine problem/injury be indicated?

Answer 53

Laboratory studies are not necessary for routine evaluation of neck pain, particularly if a musculoskeletal etiology is suspected. Laboratory testing may be helpful when non-spinal causes of neck pain are suspected.

Question 54

What are other investigations that may be indicated in a patient with cervical spine pain/injury?

Answer 54

Electrocardiogram and troponin are appropriate if myocardial ischemia is suspected.

Question 55

Describe the normal X-ray of the cervical spine

Answer 55

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Question 56

What type of cervical spine conditions would require the involvement of the ED medical team?

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Question 57

What type of cervical spine condition would require the involvement of the Orthopaedic or Neurosurgical team on the day of assessment?

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Question 58

What type of cervical spine condition would require referral to the Orthopaedic or Neurosurgical team for assessment at a future date?

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Question 59

How would you provide adequate pain control if required?

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Question 60

Describe how your management of a cervical spine injury will vary if your patient is

Diabetic

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Question 61

Describe how your management of a cervical spine injury will vary if your patient is

on anti-coagulants

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Question 62

Describe the signs, symptoms and management of

Stable fractures (secondary consult)

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Question 63

Describe the signs, symptoms and management of

Acute wry neck

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Question 64

Describe the signs, symptoms and management of

Cervical radioculopathy/brachialgia with and without neurological signs

Answer 64

Cervical radiculopathy refers to dysfunction of the spinal nerve root. Degenerative changes of the spine (eg cervical foraminal stenosis, herniated disc) are responsible for 70-90% of cases. Cervical radiculopathy generally presents with pain, sensory abnormalities, and/or weakness in an upper extremity. Provocative manoeuvres are often positive . The diagnosis of cervical radiculopathy is suspected on the basis of clinical presentation. MRI with evidence of cervical nerve root compression is supportive but not necessary unless there is progressive neurologic impairment.

Question 65

Describe the signs, symptoms and management of

Cervical canal stenosis with and without neurological signs

Answer 65

Cervical spondylotic myelotpathy refers to spinal cord injury or dysfunction caused by degenerative changes narrowing the spinal canal. Patients may present with variety of neurologic complaints including lower extremity weakness, gait or coordination difficulties, and bladder or bowel dysfunction. Physical examination may show upper motor neuron signs in the arms and/or legs. Lhermitte’s sign may be present. Provocative maneuvers such as Spurlings should be avoided.
The diagnosis of cervical spondylotic myelopathy is suspected clinically and confirmed by MRI scan.
Distinguishing cervical spondylotic myelopathy from other causes of neck pain is critical because optimal neurologic recovery depends on early surgical decompression.

Question 66

Describe the signs, symptoms and management of

Cervicogenic headache

Answer 66

CGH is in principle a unilateral headache.
Headache can be moderate-severe, non-throbbing and non-lancinating pain, usually starting in the neck. Episodes can vary in duration, lasting few days to weeks.
Major criteria of CGH include
1. signs and symptoms of neck involvement - aggravation of headache with neck movement and/or sustained posture over by external pressure over the upper cervical or occipital region
2. Restricted cervical ROM
3. Ipsilateral neck, shoulder or arm pain
4. Confirmatory evidence by diagnostic anaesthetic block
5. Unilaterality of headache, without side shift

Question 67

Describe the signs, symptoms and management of

Thoracic outlet syndrome

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Question 68

Describe the signs, symptoms and management of

Chronic neck pain with signs of centralised pain mechanisms

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Question 69

Describe the signs, symptoms and management of

Acute neck pain with yellow flags

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Question 70

Describe the signs, symptoms and management of

Suspected pathological fracture

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Question 71

Describe the signs, symptoms and management of

Suspected discitis

Answer 71

Cervical discogenic pain results from disc degeneration. It typically presents with pain and/or stiffness on neck movement, which is sometimes associated with pain in the upper extremities. Symptoms are often exacerbated when the neck is held in one position for prolonged periods. Physical examination shows decreased ROM associated with pain and cervical radicular signs are usually absent.
Pain in this setting is largely mechanical

Question 72

Describe the signs, symptoms and management of

Cervical muscle or facet joint sprain/strain

Answer 72

Cervical strain generally presents with pain and/or stiffness on neck movement.
Physical examination shows tenderness on palpation of the neck and trapezius muscles.
The diagnosis of cervical strain is made on the basis of clinical presentations. Imaging is unnecessary.
Neck pain and stiffness may last up to 6 weeks.

Question 73

Describe the signs, symptoms and management of

Whiplash injury or whiplash associated disorder

Answer 73

Whiplash injury is defined as neck injury resulting from an acceleration-deceleration mechanism that causes sudden extension and flexion of the neck.
The extension-flexion mechanism can injure intervertebral joints, discs, and ligaments, cervical muscles and/or nerve roots. Injury to the facet joint is likely the most common cause of whiplash-related neck pain and headaches.
Whiplash injuries are classified according to the associated signs and symptoms:
Grade 1 - Complaints of neck pain of stiffness only
Grade 2 - Complaint of neck pain or stiffness with associated musculoskeletal signs (eg decreased ROM, point tenderness)
Grade 3 - Complaint of neck pain or stiffness with associated neurological signs
Grade 4 - Complaint of neck pain or stiffness with associated fracture or dislocation