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Orthopedic Diagnostics > Cervical Spine Assessment > Flashcards

Cervical Spine Assessment Flashcards

1
Q

What are the categories of things to ask about when doing a history for cervical spine dysfunction?

A
  1. Mechanism of Injury (MOI)
  2. Cardinal signs and symptoms (5 D’s, 3N’s, 2V’s, 1 A cord signs)
  3. Headaches
  4. Distal Symptoms
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2
Q

What are the two main categories for mechanism of injury for cervical dysfunction? What needs to be looked at in each category?

A

Traumatic:

Need to clear cardinal signs and symptoms.

Need to ensure ligamentous stability.

Insidious:

Need to look at posture and habitual patterns.

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3
Q

What are the cardinal signs and cord signs for cervical dysfunction?

A

Cardinal signs:

  • 5 D’s: Dysarthria, Dysphagia, Diplopia, Drop attacks, Dizziness (esp. associated w/ suboccipital headaches)
  • 3 N’s: Nausea, Nystagmus, Numbness (ipsilateral)
  • 2 V’s: Vomiting, Vertigo
  • 1 A: Ataxia

Cord signs:

  • Bilateral or quadrilateral numbness and tingling
  • Hoffman’s sign
  • Hyper reflexia?
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4
Q

What information needs to be gathered about headaches?

A
  • Frequency (obviously not relevant if it is acute and headache has just presented)
  • Location
  • Occurence
  • Associated Symptoms
  • Type
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5
Q

What are the different types of headache? What might it mean if headache is throbbing with the pulse?

A
  • Barometric pressure
  • Cluster
  • Migraines
  • Vascular

Note: If headache is throbbing with the pulse, that could be a sign of vertebral artery involvement. Vertebral artery supplies blood to 11 of 12 cranial nerves and to spinal cord.

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6
Q

What should be asked in regard to distal symptoms?

A
  1. Type of sensation/pain eg.Numbness/tingling, achy pain, sharp pain, shooting pain, lancinating pain, burning pain.
  2. Location of pain- dermatomal vs. peripheral nerve?
  3. Constant vs. Intermittent: altered by posture/movement/time of day
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7
Q

What sinew channels are most involved with cervical dysfunction?

A
  • Large Intestine Hand Yangming
  • Small Intestine Hand Taiyang
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8
Q

Where does the ulnar nerve arise from? What are the spinal roots for the ulnar nerve?

A

The ulnar nerve arises from the brachial plexus. It is a continuation of the medial cord, containing fibres from spinal roots C8 and T1.

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9
Q

What is the motor function of the ulnar nerve?

A

Innervates the intrinsic muscles of the hand (apart from the thenar muscles and two lateral lumbricals), and two muscles in the forearm; flexor carpi ulnaris and medial half of flexor digitorum profundus.

Deep branch of ulnar nerve:

  • Hypothenar muscles (a group of muscles associated with the little finger)
  • Medial two lumbricals
  • Adductor pollicis
  • Palmar and dorsal interossei of the hand
  • Palmaris brevis

The other muscles in the hand (such as the thenar eminence) are innervated by the median nerve.

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10
Q

What are the sensory functions of the ulnar nerve?

A

Innervates the anterior and posterior surfaces of the medial one and half fingers (pinky and half of ring finger), and the associated palm area.

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11
Q

What does the median nerve arise from? What are the spinal roots?

A

The median nerve is derived from the medial and lateral cords of the brachial plexus. It contains fibres from roots C6-T1, and can contain fibres from C5 in some individuals.

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12
Q

What are the motor functions of the median nerve?

A

Innervates the flexor and pronator muscles in the anterior compartment of the forearm (except the flexor carpi ulnaris and part of the flexor digitorum profundus, innervated by the ulnar nerve). Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand.

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13
Q

What are the sensory functions of the median nerve?

A

Palmar cutaneous branch – arises in the forearm and travels into the hand. It innervates the lateral aspect of the palm. This nerve does not pass through the carpal tunnel, and is spared in carpal tunnel syndrome.

Palmar digital cutaneous branch – arises in the hand. Innervates the palmar surface and fingertips of the lateral three and half digits.

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14
Q

Where does the radial nerve arise from? Spinal nerve roots?

A

The radial nerve is the terminal continuation of the posterior cord of the brachial plexus. It therefore contains fibres from nerve roots C5 – T1.

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15
Q

What are the motor functions of the radial nerve?

A

The radial nerve innervates the muscles located in the posterior arm and posterior forearm.

In the arm, it innervates the three heads of the triceps brachii, which acts to extend the arm at the elbow. The radial nerve also gives rise to branches that supply the brachioradialis and extensor carpi radialis longus (muscles of the posterior forearm).

A terminal branch of the radial nerve, the deep branch, innervates the remaining muscles of the posterior forearm. As a generalisation, these muscles act to extend at the wrist and finger joints, and supinate the forearm.

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16
Q

What are the sensory functions of the radial nerve?

A

There are four branches of the radial nerve that provide cutaneous innervation to the skin of the upper limb. Three of these branches arise in the upper arm:

  1. Lower lateral cutaneous nerve of arm – Innervates the lateral aspect of the arm, inferior to the insertion of the deltoid muscle.
  2. Posterior cutaneous nerve of arm – Innervates the posterior surface of the arm.
  3. Posterior cutaneous nerve of forearm – Innervates a strip of skin down the middle of the posterior forearm.
  4. The fourth branch – the superficial branch – is a terminal division of the radial nerve. It innervates the dorsal surface of the lateral three and half digits and the associated area on the back of the hand.
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17
Q

Review dermatomes from C3-T1

A
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18
Q

Review myotomes from C1 to T1

A

C1/C2: neck flexion/extension

C3: neck lateral flexion

C4: shoulder elevation

C5: shoulder abduction

C6: elbow flexion/wrist extension

C7: elbow extension/wrist flexion/finger extension

C8: finger flexion

T1: finger abduction

C1-2: neck flexion (extension)

C3 and CN XI: neck lateral (side) flexion

C4 and CN XI: shoulder elevation

C5: shoulder abduction

C6: elbow flexion and/or wrist extension

C7: elbow extension and/or wrist flexion/finger extension

C8: thumb extension and/or ulnar deviation, (finger flexion)

T1: finer abduction and/or adduction of hand intrinsics

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19
Q

What postural things should you look for when doing observation for cervical dysfunction?

A
  • Head forward posture/chin poker
  • Upper crossed syndrome
  • Shoulder levels (hand dominant shoulder should be slightly lower)
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20
Q

What is upper crossed syndrome?

A

Upper crossed syndrome: shoulders rolled in (tight pecs), lengthened deep neck flexors and lengthened and weak rhomboids and lower traps, tight suboccipitals, upper trap muscles

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21
Q

What is the most common area of the C spine to have dysfunction?

A

Break down at C5/C6 most often because of the neck forward posture. Achy pain of muscles supplied by C5/C6 – rhomboids, levator scapula, traps

Understand that dominant arm is typically a little bit lower, this is normal.

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22
Q

What are the active range of motion degrees for the neck?

A

Flexion (80-90 degrees) – up to 2 fingers between chin and chest.

Extension (70 degrees) – plane of face is almost horizontal

Side flexion (20-45 degrees) – make sure patient keeps shoulders down.

Rotation (70-90 degrees)

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23
Q

When is PROM applied as overpressure?

How is PROM used if AROM is limited and/or painful??

A
  • Overpressure is applied if AROM is full and pain free – end feel is noted
  • If AROM is limited and/or painful – patient is placed in supine and taken through PROM, noting end feel as able.
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24
Q

What vertebrae does the passive cervical flexion/rotation test examine?

A

C1/C2

25
Q

Resisted Isometric movements are done in ________ position.

A

Resting

Flexion, extension, side flexion, rotation

26
Q

What are the cervical spine reflexes?

A

Levator Scapulae (C4)

Bicep (C5/C6)

Brachioradialis (C5/C6)

Triceps (C7/C8)

27
Q

What are SAM’s and what are they used for?

A

Small Amplitude Movements

  • Must clear ligament stability in cases of trauma
  • Can pick up areas of joint hypomobility
28
Q

What muscles of the cervical spine would we palpate to check for hypertonicity?

A
  • UFT Upper Fibers of Trapezius
  • Levator Scapulae
  • Rhomboids
  • Supraspinatus
  • Infraspinatus
  • Cervical paraspinals/multifidus
  • Thoracic paraspinals/multifidus
29
Q

What does hyper-reflexia indicate?

A

Sign of upper motor neuron issue, compression on spinal cord or brain somewhere

30
Q

What does hyporeflexia indicate?

A

Lower motor neurons (once they exit CNS) issue, low tone

31
Q

What are the spinal roots for the upper fibers of the trapezius?

A

Spinal Accessory, C2,3

32
Q

What are the spinal roots for levator scapulae and rhomboids?

A

C3,4, dorsal scapular nerve: C5

33
Q

What are the spinal roots for supraspinatus and infraspinatus?

A

Suprascapular nerve, C5/6

34
Q

Where is the pain located in TMJ dysfunction? What are adjunct signs and symptoms?

A

Pain location: Anterior ear

Adjunct signs and symptoms: Joint noise, locking, headache, neck ache, eye and ear symptoms.

35
Q

What observations might you make when examining TMJ dysfunction?

A
  • Postural evaluation: upper cross syndrome
  • Avoidance of jaw movement during speech
  • Mouth breather
  • Scapula protracting and dumping forward
36
Q

What are the normal active range of motion measurements for the temperomandibular joint?

A
  • Opening (40-60 mm)
  • Closing
  • Protrusion (8-12 mm)
  • Retrusion
  • Lateral deviation (8-12 mm)
37
Q

What are abnormal mandibular movement patterns?

A
  • “S” deviation >2mm (muscular)
  • “C” Lateral deviation >2mm – deviation is ipsilateral to restricted side (joint-OA)
  • Locking (open or closed)
  • Clicking – reproducible
38
Q

What movements would you do with passive mobility testing?

A
  • Opening
  • Closing
  • Laterotrusion
  • Protrusion
  • Retrusion

Accessory Movements:

  • Caudal distraction
  • Distraction
  • J-stroke, caudal movement with anterior glide
  • Compression Note: With an arthritic jaw or inflamed TMJ a cranial compression will be painful. Not a glide that we do for treatment but just for checking.
39
Q

What muscles are involved in the following movements:

  1. Depression
  2. Elevation
  3. Protrusion
  4. Retraction
A
40
Q

What are the C1/C2 ligament tests?

A
  • Transverse Ligament Test (Direct Anterior Translation test)
  • Alar Ligament Stress Test
41
Q

How do you perform the Transverse Ligament Test (Direct Anterior Translation Stress Test)?

A
  1. Patient assumes a supine position
  2. The examiner’s thumbs are placed medially and anteriorly over the anterolateral aspect of the axis. The examiner’s fingers are placed posteriorly over the posterior arch of the atlas.
  3. The examiner applies a stress between the fingers and the thumbs.
  4. A positive test is identified either by reproduction of myelopathic symptoms during translation or excess displacement during movement.
42
Q

Contraindicaitons for Transverse Ligament Test?

A
  • Should not be performed on patients with Down’s syndrome
  • Should not be performed on patients with rheumatoid arthritis
  • Should not be performed on patients with suspected dens fracture
43
Q

How do you perform the Alar Ligament Stress Test?

A
  1. The patient assumes a sitting or supine position (Nadine prefers supine). The head is slightly flexed to further engage the alar ligament. The examiner assesses resting symptoms.
  2. The examiner stabilizes the C2 spinous porcess using a pincer grasp. A firm grip ensures appropriate assessment of movement.
  3. Either side flexion or rotation is passively initiated by the examiner. During these passive movements the examiner attempts to feel movement of C2.
  4. A positive test is failure to “feel” movement of C2 process during side flexion and rotation.
44
Q

Considerations and precautions with Alar Ligament Stress Test?

A
  • Do not perform on patients who may have a dens fracture.
  • Any movement of C2 during side flexion or rotation should be considered normal
  • The patient may experience some discomfort during the procedure, specifically post-trauma and this finding should be considered a “red flag” for high velocity techniques
45
Q

What are the four components of Wainner’s Clinical prediction rule for cervical radiculopathy?

A
  1. Cervical rotation less than 60 degrees
  2. Spurling’s Compression Test (p. 115)
  3. Cervical Distraction Test (p. 117)
  4. Positive Upper Limb Tension Test (p. 118)
46
Q

How do you perform Spurling’s Compression test?

A
  1. The patient assumes a neutral cervical posture while in sitting position. Assess resting symptoms.
  2. The patient is instructed to side flex their neck to the side of referred symptoms. If radicular pain is present the test is positive
  3. If no symptoms up to this point, the examiner then applies a combined compression and side flexion force in the direction of side flexion. If radicular pain is present the test is positive.
47
Q

How do you perform the Cervical Distraction Test?

A
  1. The patient assumes a supine position. The patient’s symptoms require assessment prior to examination.
  2. The examiner uses a chin cradle grip around the head of the patient, specifically targeting the occipital shelf of the neck (Nadine does a football hold where she puts her shoulder on person’s forehead and has both of her hands underneath head at occiput)
  3. A traction force is applied and the patient’s symptoms are reassessed. Pain is respected and the same pattern of movement to pain, movement beyond pain, and repeated movement should be implemented.
  4. A positive test is reduction of symptoms during traction.
48
Q

How do you perform the Upper Limb Tension Test?

A
  1. The patient assumes a supine position. The examiner assesses resting symptoms.
  2. The examiner blocks the shoulder girdle to stabilize the scapulae. Symptoms are again assessed.
  3. If no reproduction of symptoms has occured, the glenohumeral joint is abducted to 110 degrees with slight coronal plane extension. Symptoms are again assessed.
  4. If no reproduction of symptoms has occured, the forearm is supinated completely and the wrist and fingers are extended. Ulnar deviation is implemented. Symptoms are again assessed.
  5. If no reproduction of symptoms hase occurred, elbow extension is applied. Symptoms are again assessed. One may measure the degree of elbow extension if range of motion is an objective.
  6. Lateral flexion of the neck is used to sensitize the procedure. A positive test is reproduction of symptoms during distal movement.
49
Q

Differentiation of dizziness, what are the different potential causes of dizziness?

A
  • Cervicogenic – something coming from joints in the neck
  • Vertebral artery - Huatant’s test
  • Vestibular – vertigo
50
Q

How do you perform Wallenberg’s Position?

A
  1. The patient is places in a sitting position.
  2. The head is rotated to one side and extension is added. This position is held for 30 seconds.
  3. The process is repeated on the opposite side.
  4. A positive test is identified by initiation of symptoms such as dizziness, diplopia, dysphasia, dysarthria, drop attacks, nausea, nystagmus.
51
Q

How do you perform Hautant’s (Houtard’s) Test? What does it test for?

A
  1. The patient is in a sitting position facing you.
  2. Ask the patient to extend both arms in front of them at 90 degrees (level with floor) and palms up.
  3. Have the patient close their eyes and rotate their head to one side and into extension for 30 seconds.
  4. Positive test the patient will show pronation and lowering of the arm on the same side that they rotated toward, but will be unaware they are doing this.

If this test is negative it rules out vertebral artery dysfunction as a contributing factor to their dizziness.

52
Q

What is Bakody’s sign? What does it test for?

A

Movement where hand is placed on top of the head, palm up. Classic C5/C6 disc pathology is relieved by this movement as it elevates the shoulder girdle and takes pressure off of lower cervical spine.

53
Q

What is a test for cervicogenic headache?

A

Cervical Flexion Rotation Test

54
Q

How do you perform the Cervical Flexion Rotation Test?

A
  1. The patient assumes a supine position. The examiner stands at the head of the patient. Resting symptoms are assessed.
  2. The patient actively moves their neck into maximum flexion.
  3. The examiner then applies a full rotational force to both sides. Symptoms are queried to determine if concordant.
  4. The test is both a pain provocation test and a test for range of motion loss. If a loss of 10 degrees or greater is noted the test is considered positive.

Note: The test likely isolates C1-C2, and most likely does not assess the presence of cervicogenic headache at other levels. Does not rule out problems in the rest of the C-spine.

55
Q

What is Hoffman’s sign?

A

This is a test for an upper motor neuron lesion. Patient’s hand is relaxed and noxious stimulus such as a flick is applied to the nail of the second or third digit. Positive sign is involuntary curling in of the thumb.

56
Q

What test looks at disc displacement during movement of the temperomandibular joint?

A

Deviation from Symmetrical during Mouth Opening

57
Q

What are the steps of Deviation from Symmetrical During Mouth Opening?

A
  1. The patient is seated with the mouth partially closed, near its resting position.
  2. The patient is instructed to open their mouth near end range.
  3. The patient is instructed to their mouth laterally (left and right) near end range.
  4. The patient is instructed to close their mouth to end range.
  5. A positive finding is any deviation from midline or a variation in lateral excursion from right to left.
58
Q

What are the Canadian C-spine rules for when people do NOT need an x-ray?

A

The following people do not need x-ray imaging…

  1. Patients who are cognitively intact and have no neurological symptoms
  2. Patients who are under the age of 65
  3. Patients who are not fearful of moving the head upon command
  4. Patients who were not involved in a distraction based injury
  5. Patients who demonstrate no midline pain
  6. Any positive finding in any of the above five cateogories should result in a radiographic test.
59
Q

What are SAMies?

A

Small Amplitude Movements. These are used to pick up hypomobility in the C-spine. Can also be turned into therapeutic manipulations.

Orthopedic Diagnostics (10 decks)

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