Cervical Spine Disorders

Question 1

Cervical Radiculopathy

Answer 1

• Definition:
  
  • neurogenic pain distribution of a cervical nerve root (from squeezing/stretching of a nerve) +/- associated numbness, weakness, or loss of reflexes
• Etiology:
  
  • Young patients: herniated discs that entrap the nerve root (injury)
  • -Old patients: stenosis (foramen narrowing & arthritic involvement)
• Cervical Nerve Roots:
  
  • C4: lower neck, trapezius
  • -C5: lateral arm, neck, shoulder
  • -C6: dorsolateral arm, neck, thumb
  • -C7: dorsolateral forearm, middle finger, neck
  • -C8: medial forearm, neck ulnar digits
• S/sxs:
  
  • Neck pain: relieved when hands places on head (decreases nerve root tension)
  • -Radicular upper extremity (shouler, arm), pain, numbness, & paresthesia
  • -Muscle spasms within the myotomes
  • -Weakness
  • -Headache (d/t neck muscle spasm)
  • -Lack of coordination
  • -Changes in handwriting
  • -Decreased grip strength
  • -Decreased fine motor skills
• PE:
  
  • Test axial rotation & extension (ROM will be decreased d/t pain & spasms)
  • -Assess motor/sensory (C5-T1)
  • -Reflexes & UE motor
  • -Full neuro exam
  • -Spurling’s A/B
• Dx:
  
  • R/o shoulder pathology
  • XR = 1st line, spondylosis, arthritis
  • -MRI or CT = 2nd line, confirmatory
  • -Electromyography (EMG) = 3rd line, helps to localize the neurological dysfunction
• Tx:
  
  • **resolves in 2-8 weeks
  • -Anti-inflammatory meds: NSAIDs, Steroids
  • -PT: cervical traction
  • -Surgery: Microdiscectomy, laminectomy, fusions
  • ***AVOID: narcotics & manipulation of cervical spine

Question 2

Cervical Spondylosis

Answer 2

• Definition:
  
  • degenerative disc disease of the cervical spine. Arthritis of the neck.
• Causes:
  
  • ingrowth of bony spurs, buckling or protrusion of ligamentum flavum, herniation of disc material. Sports history like gymnastics
• Anatomical alterations: narrowing of neural foramen, stenosis of cervical spine
• S/sxs:
  
  • Limited cervical spine ROM (d/t compression of vertebral bodies)
  • -Chronic neck pain: worse with upright activity
  • -Muscle spasms
  • -Headaches radiating to neck
  • -Radicular pain in upper extremities & shoulder region (may trick you into cervical radiculopathy)
  • -increased irritability, fatigue, sleep disturbances, impaired work tolerance
• PE:
  
  • -Long-tract signs (clonus muscle spasticity or bladder involvement)
  • -Subtel gait disturbances
  • -Decreased UE dexterity
  • Hyperreflexia: Hoffman reflex (support hand, squeeze middle finger →reflex compression)
• Dx:
  
  • XR:
  • -Osteophytes (fancy word for bone spurs)
  • -Anterior subluxation of 1 vertebra onto the vertebra below
  • -Degenerative changes common at C5-C6 & C6-7
• Tx:
  
  • supportive reassurance (sx relief)
  • -NSAIDs
  • -TCA: Doxepin, amitriptyline (may help with sleep)
  • -Cervical pillows
  • -PT
  • -Surgery: definitive treatment (for intractable pain), decompressions & fusions

Question 3

Cervical Strain (Neck Sprain/Whiplash)

Answer 3

• Definition:
  
  • Muscle or ligament injury of the neck. “Whiplash”. Common & self-limiting
• Etiology:
  
  • acceleration-deceleration of the neck with rapid flexion-extension (MVA, football hit)
• S/sxs:
  
  • *Acute onset (injury)
  • -Neck pain: non-radicular, focal, worse with motion, accompanied by spasms
  • -Pain from base of skull → cervical thoracic junction
  • -Pain in sternocleidomastoid & trapezius
  • -Occipital headaches
  • -Irritability, fatigue, sleep disturbances
• PE:
  
  • Tenderness along lateral, anterior, posterior C-spine & medial border of scapula
  • -Limited ROM
  • -Normal neurologic exam
  • Positive O’Donoghue (lifting arm)
    
    • -Active: muscular
    • -Passive: ligamentous
  • *NO Radicular sxs → Can r/o these etiologies
• Dx:
  
  • Evaluate for vertebral instability
  • • XR: *AP, lateral, open mouth (odontoid)
  • -Anterior displacement of pharyngeal air shadow indicates soft tissue swelling (follow fx, disc injury, or ligament injury)
  • -Loss of normal cervical curvature due to muscle spasms
  • • Presence of pre-cervical swelling mandates a specialist consultation!
  • → prevertebral soft tissue width should not exceed ⅓ the width of the C3 vertebral body
• Tx:
  
  • *Resolves in 4-6 weeks
  • -Reassurance & encourage early return to activities
  • -Acute care: soft cervical collar, NSAIDs, muscle relaxants (2-3 weeks),
  • -Cervical pillow, message, PT
  • ***No manipulation of cervical spine

Question 4

Fractures of the Cervical Spine

Answer 4

• Suspect in all trauma pts reporting neck pain & unconscious/intoxicated patients
• Etiology:
  
  • high-energy trauma (fall from height, diving)
• S/sxs:
  
  • Severe neck pain: radiating to the shoulder or arm
  • -Numbness
  • -Tenderness along bony processes
  • -Sensory or motor deficits
• PE:
  
  • -Neck swelling, ecchymosis, & tenderness
  • -Gap or step off from spinal process (handle with care to not move head)
  • -Motor/sensory deficits of UE/LE
  • -Check perianal sensation, sphincter tone, bulbocavernosus reflex
  • -Positive Russ Test
  • -Normal amount of soft tissue:
  • →C2 → 6mm of soft tissue
  • →C6 → 22mm of soft tissue
• Dx:
  
  • XR:
    
    • *Ap, lateral, open mouth, cross-table lateral C1-T1 (most important!!!)
    • → Do not order flexion-extension radiographs until eval of primary images to rule out instability!
    • -Commonly missed fracture: superior & inferior fractures d/t poor visualization
    • -May need CT or MRI
• Tx:
  
  • Medical emergency
  • -Immobilization at time of extraction from accident scene with bracing & spinal board
  • -IV steroids (decreased inflammation around cervical nerve)
  • -Cervical collar
  • -PT
  • -Surgery: halo, ORIF
  • *PTs with normal radiographs, but have persistent pain should be treated conservatively in a collar

Question 5

Fractures of the Thoracic Spine

Answer 5

• Etiology:
  
  • High-energy trauma: MVA, fall from height
  • -Minimal trauma: pts with poor bone quality (osteoporosis, tumors, infection, long-term steroid use [avascular necrosis]), usually compression or burst fractures
  • -Abd injury
• Presentation:
  
  • hx of lap belt injury, old lady fell on butt
• S/sxs:
  
  • Moderate to severe back pain exacerbated by motion
  • -Numbness, tingling, weakness
  • -Bowel/bladder dysfunction
  • → decreased bowel motility
• PE:
  
  • Inspect for ecchymosis & swelling of the trunk, chest, & abdomen
  • -Tenderness to palpation at level of injury
  • -Hematoma formation, step off, &/or gap of spinous processes
  • -Sensory motor function of all nerve roots to injury
  • -Loss of reflexes
  • -ankle clonus, positive Babinski
• Dx:
  
  • XR: AP, lateral
  • -CT scan with reconstruction
  • -US: fast test → looking for fluid
  • *Pay close attention to anatomy spacing
• Tx:
  
  • Immobilization at time of extraction from accident scene with log rolling & spinal board
  • -Oral narcotics: short term
  • -Encourage walking, but NO bending, stooping, twisting, lifting
  • -Bracing TLSOs (thoracic, lumbar, sacral orthosis)
  • Surgery: Fusions (for younger patients with big burst fractures), kyphoplasty (balloon plasty then fill with cement)

Question 6

Kyphosis

Answer 6

• Definition:
  
  • curvature of the sagittal plane of the spinal column. “Humpback”. Normal thoracic spine is 20-40degrees vs Kyphosis > 50
• Types:
  
  • Postural kyphosis: females
  • -Scheuermann: males
• S/sxs:
  
  • Poor posture +/- back pain
  • -Pain is activity related & relieved by rest
• PE:
  
  • Adams forward bend test: sharp angulations, flat in the middle. Normal spine should be shaped like a rainbow
• Dx:
  
  • XR:
    
    • *Weight bearing AP & lateral
    • -Measured between T5-T12
    • -Xray tube should be position 6’ from the patient with 14”x36” film & grade
    • -Any curvature > 50 degrees is abnormal
• Tx:
  
  • Conservative = most common: PT
  • -Brace
  • -Surgery: Spinal fusion (VERY RARE)