cervical spine disorders Flashcards
What are the key cervical nerve motor functions
C3, C4 and C5 keep the diaphram alive
C4 motor functions
scapular winging - serratus, shoulder shrug
C5 motor functions
shoulder abduction, wrist extension: biceps reflex
C6 motor functions
C7 motor functions
C8 motor functions
T1 motor functions
when is an MRI with contrast indicated
previous surgery
malignancy
infection
when may you need a CT
trauma or if they are unable to get and MRI
when might you get a CT myelogram
pacemaker and people who need contrast but cannot get an MRI
What are the surgical options for cervical spine
discectomy, laminotomy/foraminotomy
cervical fusion (anterior, posterior or both)
what patient have poor outcomes after cervical surgery?
nicotine users
uncontrolled DM
BMI >40
chronic narcotic use
What is another name for cervical strain
whiplash when associated with accelerated-deceleration injury (MVC)
what does nicotine impeed
bone healing
what are symptoms that may be associated with cervical strain
muscle spasms
headaches (occipital)
stiffness
dizziness/vertigo
blurred/double vision
What is the treatment of cervical strain
NSAIDs
+/- muscle relaxers
+/- soft cervical collar as needed for pain (long term use can exacerbate pain)
how long until MRI is indicated for cervical strain
> 6 weeks
what is the population affected by cervical DDD
aprox 90% of M>50 and F>60
result of normal degenerative process
chronic and progressive
what is the typical presentation of cervical DDD
headache
axial neck pain - may be exacerbated by posture, occupational stresses, activities
neck stiffness
+/- radicular complaints
What is possible for a physical exam finding with cervical DDD
+/- sensory motor deficits if associated with numbness, paresthesia and weakness
what is the first line for workup of cervical DDD
x-rays first line to assess for disc height loss, osteophytes, degenerative deformity
what disc is less commonly impacted and is a good comparison for normal disc height
C2 and C3
what can be present with advanced cervical DDD
dysphagia that is secondary to large ‘bone spurs’ (osteophytes)
DISH - ossification of ligaments in the spinal column
what is DISH
Diffuse Idiopathic Skeletal Hyperostosis
what is dysphasia
trouble swallowing
what is the treatment of Cervical DDD
osteophytectomy
What is cervical radiculopathy
nerve root ‘irritation’ originating in the cervical spine
pain radiating down the UE - dermatomal distribution
usually a symptom of some other cervical spine pathology
What is a cervical herniated disc
herniation of the nucleus pulposus (jelly donut)
What is the patient population for cervical herniated disc
F>M (60% female)
ages: 50-60 years old
what disc are most commonly involved in cervical disc herniation
C56 and C67
what is the presentation for cervical herniated discs
radicular pain (past the elbow)
numbness
paresthesias
weakness
neck pain
What special tests are used for cervical herniated discs
spurling
compression
distraction
Lhermitte sign
What is the spurling test
push down on the crown of the head while flexing laterally
(not forcing most lateral flexion - compressing the neutral foramen)
Pain in UE toward which the neck is flexed indicated nerve root compression
What is Lhermitte sign
flexion of the neck results in UE radicular pain
What is the test of choice for cervical herniated disc
MRI to look at the disc
what cervical patients suspected for herniated disc are not given the treatment buffet
those with large, symptomatic disc herniations
What is cervical spinal stenosis
narrowing of the spinal canal +/- foramen
what special tests are used for cervical spinal stenosis
spurlings
compression
distraction
lhermitte
What is cervical myelopathy
severe compression of the cervical spinal cord - thought to cause cord ischemia
most commonly secondary to cervical spinal stenosis
what is ischemia
lack of blood flow
what are the symptoms of myelopathy
progressive symptoms:
cervical radiculopathy, UE weakness, LE weakness/gait disturbances
BALANCE CHANGING(walking like they are drunk)
What is present on the physical exam for cervical myelopathy
varying degrees of sensory motor dysfunctions
fatiguability
balance changes
upper motor neuron symptoms
What is rhomberg test
patient stands with eyes closed and arms out in front, + if losses balance
What is Hoffman’s test
extend the MCP joint and stabilize the PIP of the middle finger. force the DIP into flexion (flick the tip of the finger), + spontaneous flexion of fingers, particularly the thumb and first finger
What special tests would be positive with cervical myelopathy
hoffmans and babinski’s test
What is myelomalacia on an MRI indicative of
cervical myelopathy - evidence of long standing trouble
What is the treatment for cervical myelopathy
Recommend surgical decompression to preserve remaining function
may have some neurologic improvement but dont typically return to baseline
What is kyphosis
exaggerated thoracic curvature
commonly referred to as “round back” or “hunchback”
what are the causes of kyphosis
congenital
postural
scheuermann’s kyphosis
hyperkyphosis (osteoporosis, age related degeneration)
What is scheurmann’s deformity
juvenile structural deformity - sharp and angular curvature, rigid deformity doesn’t correct with posture/laying supine
M>F primarily age 13-16
likely a hereditary component
what is the clinical presentation of kyphosis
back pain
stiffness
visible deformity (cosmesis)
what is seen onthe physical exam for kyphosis
often normal except for deformity
can progress to include:
LE weakness/numbness/tingling
sensory changes in the trunk
difficulty breathing
when is an MRI indicated for kyphosis
if neurologic symptoms present
what is the treatment for postural kyphosis
treatment is observation, PT and NSAID as needed if pain
what is treatment for congenital kyphosis
typically` early surgical statement - spinal fusion
What is the treatment for scheurermann’s kyphosis
bracing if skeletally immature and 50-75 degrees
spinal fusion if >75 degrees or fail conservative management
What is the treatment for osteoporosis related kyphosis
symptomatic treatment vs spinal fusion depending on pt reference and impact on ADLs
What is thoracic outlet syndrome
compression of brachial plexus and/or subclavian vessels between neck and the shoulder - neurovascular disorder
likely anatomic predisposition with superimposed injury to that region (acute or chonic)
what is the typical patient population
usually thin females with long necks
F>M
peak onset 20-60 years old
what are the possible neurologic presentations of thoracic outlet syndrome
variable:
UE pain, non radicular with numbness/paresthesias/weakness
UE heaviness worse with overhead activities
nighttime symptoms (decreased pressure on brachial plexus, sensory return = pain)
What are the vascular symptoms of thoracic outlet syndrome
variable:
UE heaviness
cyanosis
swelling
deep pain in UE
Raynauds (primarily in hands associated with pain, numbness; worse in the cold)
what may you seen on a thoracic outlet syndrome phsyical exam
UE changes (cyanosis, edema, pallor)
Hair and nail changes
muscle atrophy
+/- tenderness to palpation over the supraclavicular area
+/- masses in the supraclavicular area
reduced skin temperature
What special tests are used for thoracic outlet syndrome
Adson test
supraclavicular pressure test
What are beneficial imaging for TOS
Xray, CT, EMG/NCS, vascular studies to identify underling anatomic cause
What is the treatment for TOS
non operative vs operative
- activity modification, pain control, PT, TENS, nerve block (anterior scalene)
- thoracic outlet decompression (failed 6 months conservative tx, progressive neurologic sx, worsening atrophy), vascular interventions (primary vascular etiology)
What is torticollis
one of the ‘packaging deformities’
most cases are congenital
contracture of the SCM muscle (head rotates away from affected side and tilts toward affected side- palpable mass)
typically not painful
often associated with other MSK disorders
What imaging is useful for torticollis
used to rule out other conditions
-xrays if no mass
US if mass present
CT to rule out atlantoaxial rotary subluxation
what is the treatment of torticollis
passive stretching (opposite of deformity)
surgical release of SCM (failure of 1 year of stretching or significant deformity)
what are the most common mechanisms for cervical fractures
result of a trauma
MVC
Fall
sports-related injuries
violence
what is the approach to a spine trauma patient
always be immobilized until cleared
treatment of life-threatening injuries ALWAYS trumps immobilization
what is being assessed for on the initial surgery for the exam of spine trauma
gross motor/sensory deficits
tenderness - especially midline (spinous process)
step-offs
palpable fluid collections/hematoma
bruising or abrasions/wounds
what is the later testing done in spinal injuries
still in the ED - neurologic exam - including perineal sensation and anal sphincter tone for SCI
what is the tertiary survey for spine traumas and when do they occur
within 24 hours of admit, again when awake/alert if not done during initial tertiary survey - neurologic exam
What does NEXUS stand for
national emergency x-radiography utilization study
when do c-spine patients not need x-rays
answer yes to all of the following:
Alert and stable
no focal neurologic deficits
no altered level of consciousness
not intoxicated
no midline spinal tenderness
no distracting injuries
what are the two c-spine clearance rules
NEXUS and Canadian C-spine Rules
What is the treatment for stable fractures
conservative management, usually with a brace for immobilization
what is the treatment for unstable fractures
ORIF, usually a fusion procedure
what medication do spinal cord injury patients get
steroids that are started immediately, thought to be neuroprotective
but not strongly supported in the literature, but widely used
what is the MOA for TP and SP fractures
flexion injury (whiplash)
how are TP and SP fractures treated
like a “bad sprain”
Treat conservatively: Rest, ice, NSAIDs, activity modification
soft cervical collar as needed for comfort
+/- follow-up
What is a Clay Shoveler’s fracture
C7 spinous process fracture
what is a occipital condyle fracture
compression into C1 or extreme rotation
for the most part these are stable (expect occipitoatlantal dislocation)
usually associated with head trauma
look for co-occuring C1 (atlas) fracture
what type of occipital fracture is almost always fatal
occipitoatlantal dislocation
what is the treatment for occipital condyle fractures
almost always rigid cervical collar (miami J)
What is the MOI for a C1 fracture
compression - force through the occipital condyles
what are the fracture classification pattern
levine classification - 5 types
What is Jefferson Fracture
C1 - burst fracture of C1 - comminuted atlas fracture
see widening of lateral masses on odontoid view
usually UNSTABLE - halo or operative fixation
what cervical fracture is unstable
jefferson fracture
what is the treatment of a jefferson fracture
Halo or operative fixation
what is the MOI for an odontoid/dens fracture
C2
high energy injuries - MVCs or falls
what imaging is used to see odontoid/dens fractures
CT or odontoid views
what is the treatment for odontoid/dens fractures
most are non-operative or at least get trail of non-op tx
high rate of non-union for type 2-3 fractures - may still heal with a relatively stable fibrous union and dont require surgery
What is Hangman’s fracture
traumatic spondylolisthesis of C2 - C2 pars interarticularis fracture
what is the mechanism of hangmans fracture
high energy injuries - MVCs or falls
hyperextension and distraction
how is a type 1 hangmans fracture treated
non-operative with cervical collar
how is a type 3 hangmans fracture treated
operative fixation
What is a teardrop fracture
fracture of the anteriorinferior vertebral body
what is the MOI for teardrop fractures
compression and flexion or extension - associated with ligamentous injury
how are teardrop fractures usually treated
usually non-op with cervical collar
what is a burst fracture
fractures through both superior and inferior endplates
what is the MOI for burst fractures
axial compression - fragments may displace into canal -> spinal cord injury
what is the typical treatment for burst fractures
generally require surgery due to instability
what is a facet fracture
often associated with facet subluxation/dislocation
what is the MOI for facet fractures
flexion distraction - often associated with SCI
what is the treatment for facet fractures
usually unstable and require surgery
