Cervical Spine Pathology

Question 1

What are the two general categories of Cervicogenic Dysfunction?

Answer 1

1. Hypomobility of cervical spine
2. Hypermobility of cervical spine

Question 2

What types of problems are related to hypomobility of the cervical spine? (Give general categories and examples)

Answer 2

1. Postural syndromes (eg. chin poker or upper cross)
2. Trauma induced (eg. whiplash, blunt-force)
3. Genetic (Ankylosing Spondylitis)
4. Age related (OA, spondylosis, stenosis)

Question 3

What are the possible complications with hypermobility of the cervical spine? (General categories and examples)

Answer 3

1. Trauma induced ligamentous injury or bony fractures (eg. transverse and alar ligaments, dens fracture, capsular or ligamentous laxity)
2. Genetic (Down’s syndrome, RA)

Question 4

What are the alar ligaments?

Answer 4

The alar ligaments connect the sides of the dens (on the axis, the second cervical vertebra) to tubercles on the medial side of the occipital condyle.

Two little ligaments that go upwards 45 degrees, help to check rotation. Excessive rotation at the occiput you will put vertebral arteries at risk.

Question 5

What is the dens? What is the transverse ligament? What might happen if the transverse ligament is damaged?

Answer 5

Dens is part of C2, projects superiorly and atlas rotates around it. Dens kept in place by transverse ligament. Just behind that is spinal cord. If dens was allowed to move freely back in space toward posterior arch of atlas as it would do in flexion if transverse ligament was not holding it in place it would migrate backwards into the spinal cord? Atlas anterior which would bring dens posterior and that would impinge your spinal cord.

Question 6

What is the etiology and cause of whiplash?

Answer 6

Etiology: Sprain/strain of cervical spine (only refers to cervical spine)

Cause: High velocity forward flexion and/or extension of the cervical spine often from sports or MVA.

Question 7

What are the symptoms of whiplash?

Answer 7

• Concussion symptoms
• Decreased cervical ROM
• Headaches
• Muscle spasm
• Neck and shoulder pain
• Radiating symptoms down arm (radiculopathy)

Question 8

What specific part of the cervical spine is usually affected in whiplash?

What if you are hit from behind vs the one running into something?

Answer 8

Compression of facet joints. Not necessarily capsular laxity or ligamentous laxity, more of a compressive force so you get facet joint irritation or potentially fracture depending on head rest and how fast they were going. If you are the one behind who hits the person then you will have hyperflexion (will see transverse and alar ligaments affected) first and then possibly hyperextension.

Question 9

What ligaments and muscles are more affected if head is turned when the impact happens?

What will happen if you “see the accident coming” vs are “hit out of the blue”?

Answer 9

Alar ligament more on stress if head is turned when the impact happens. Suboccipital muscles on one side will be more stressed.

If you see the accident coming you tense up more which protects your spine but you will have more soft tissue injuries. If you do not see it coming you have a more chance of injuring bones and ligaments.

Question 10

What are some questions to ask after an MVA?

Answer 10

• Speed of collision
• Position of head
• Hit from behind or T-boned

Question 11

If the person’s muscles spasm and everything tightens up when you are doing ligament testing what should you do?

Answer 11

Send them back to doctor for imaging. Headaches could be from muscle, vertebral artery, ligaments.

Question 12

What is the cause and pathophysiology of a concussion?

Answer 12

Cause: Linear and/or rotational forces transmitted to the brain

Pathophysiology: “The Neurometabolic Cascade”: a complex cascade of ionic, metabolic and pathophysiological events that accompany microscopic axonal injury. The energy needed to re-establish homeostasis (disrupted ionic and metabolic balances) occurs in the presence of decreased cerebral blood flow and ongoing mitochondrial dysfunction, resulting in an imbalance of energy supply and demand.

Question 13

Majority of concussion symptoms resolve within _____ in severe cases they may persists for _____, _____, ______. The definition between concussion and post-concussion syndrome is therefore one defined by time: the presence of concussion symptoms lasting for _____ to ____ is post concussion syndrome.

Answer 13

7-10 days

weeks, months, years

weeks to months (basically if symptoms are lasting longer than a week you have post concussion syndrome)

Question 14

The concussed brain is ____ responsive to _______ __________. Therefore when ______ cognitive or physical activity occurs before complete recovery, the brain may be vulnerable to prolonged ________.

Answer 14

less; neural activation

premature

dysfunction

Question 15

What are some physical sn/sx of a concussion?

Answer 15

• Balance problems
• Dazed/stunned/fogginess
• Dizziness
• Fatigue
• Headache
• Nausea, vomiting
• Numbness, tingling
• Visual problems
• Sensitivity to light, noise

Question 16

What are the cognitive sn/sx of a concussion?

Answer 16

• Confusion
• Difficulty concentrating
• Feeling slowed down
• Forgetfulness
• Mental fog
• Repeated questions
• Slow verbal responses

Question 17

What are the emotional and the sleep sn/sx of a concussion?

Answer 17

Emotional:

• Irritability
• More emotional than usual
• Nervousness
• Sadness

Sleep:

• Drowsiness
• Difficulty falling asleep
• Sleep more or less than normal

Question 18

What is second impact syndrome and what is the pathophysiology of it?

Answer 18

SIS: A second concussion is sustained before the effects of the first concussion have dissipated.

Pathophysiology: The exact cause is unconfirmed but it is thought to be a loss of autoregulation of the brains blood supply resulting in vascular engorgement and marked increase in intracranial pressure, brain herniation and ultimately coma or death may occur.

Question 19

What is the progression of activities before return to sports after a concussion?

Answer 19

• A progression in physical demands, sports specific activities and risk of contact.
• Patient must be symptom free at rest as well as during and after exertion before progressing to next step
• If patient experiences symptoms with a certain level of exertion, they are to be brought back to the previous level.

Question 20

Are helmets and/or mouthguards useful in preventing concussions? What is the primary form of prevention for concussion?

Answer 20

• Helmets (soft and hard) are best suited to prevent impact injuries but have not been shown to reduce the severity of concussions.
• There is no current evidence that mouth guards can reduce the severity or prevent concussions.
• Primary prevention comes in the form of modification and enforcement of rules of fair play as well as education regarding concussions and post concussion syndrome.

Question 21

Transverse Ligament Injuries Classification, Causes, Result?

Answer 21

Type I: Intersubstance tear

Type II: Bony avulsion

Causes: Trauma, Down’s syndrome, Rheumatoid Arthritis

Result: Dens (Odontoid) travels posteriorly into the spinal canal.

Question 22

Transverse Ligament injury sn/sx

Answer 22

• bilateral upper extremity parasthesia
• lump in throat
• having to swallow all the time
• upper motor neuron sign (Hoffmann’s sign)
• death!

Question 23

If you suspect a transverse ligament injury what should you do?

Answer 23

Send patient to doctor to get a lateral radiograph of the atlantodens interval (ADI)

Question 24

What is the normal atlantodens interval?

What is the interval after injury but with intact alar and apical ligaments?

What is the interval with injury to transverse ligament, alar and tectorial membrane?

Answer 24

< 3 mm = normal in adult (< 5mm normal in child)

3-5 mm = injury to transverse ligament with intact alar and apical ligaments

> 5 mm = injury to transverse, alar ligament, and tectorial membrane

Question 25

What segments of the population should you never do a transverse ligament test on?

Answer 25

* People with Down's syndrome * People with rheumatoid arthritis

Question 26

What is the etiology of a vertebral artery dissection?

Answer 26

A dissection (a flap-like tear) of the inner lining of the vertebral artery. After the tear, blood enters the arterial wall and forms a blood clot, thickening the artery wall and often impeding blood flow.

Question 27

What is the sequela of that may happen with a vertebral artery dissection?

Answer 27

Obstruction of blood flow through the affected vessel may lead to dysfunction of part of the brain supplied by the artery. This may be temporary (“transient ischemic attack") in 10–16% of cases, but many (67–85% of cases) end up with a permanent deficit or a stroke.

Question 28

What are common causes of a vertebral artery dissection? What underlying conditions may compromise this artery and make dissection more likely?

Answer 28

* May occur after physical trauma to the neck, such as a blunt injury (e.g MVA.), strangulation or manipulation. * Spontaneously. 1–4% of spontaneous cases have a clear underlying connective tissue disorder affecting the blood vesselss Compromising conditions: * Artherosclerosis can compromise the tunica intima of this artery. * Degeneration of the spine, osteophytes forming in the intertransverse foramen

Question 29

What amount of rotation of the neck creates stress on one side vertebral artery? Both sides?

Answer 29

Any time you rotate up to 45 degrees you are putting the side you rotate towards “on stress” because the vertebral artery is slightly kinked. 60 degrees both vertebral arteries are affected. People have anatomical variations such as only having one artery or having one that is smaller. Note: there are tests that we can do for vertebral arteries before doing spinal manipulations but they are not 100% so we do not do a cervical manipulation unless really necessary

Question 30

The vertebral artery supplies blood to ___ of the ___ cranial nerves. What type of test may pick up low blood supply?

Answer 30

Supplies blood to 11 of the 12 cranial nerves! Only one not fed by the vertebral artery is the olfactory nerve. If there is low blood supply we might be able to pick up a positive cranial nerve test.

Question 31

What are the cardinal signs and symptoms of vertebral artery dissection? What type of headache is a red flag?

Answer 31

Cardinal signs and symptoms: * 5 Ds – Dizziness, drop attacks, dysphagia, dysarthria, dysphasia * 3 Ns- Numbness (ipsilateral), nausea, nystagmus * 2 Vs – vertigo, vomiting * 1 A - Ataxia Red Flag: if the person has suboccipital pain pattern (back of the head that radiates to the eyes) and they get dizzy every time they get that headache Be careful with dizziness as it is not a cardinal sign on its own, it can by anemia, hypothyroidism, vertigo, medication reaction, inner ear problems etc. Drop attack: person will often faint with this, black out temporarily Dysarthria: slurred or slow speech Dsyphagia: difficulty swallowing Dysphasia: difficulty understanding language

Question 32

What are the other signs/symptoms of vertebral artery dissection? What are the characteristics of Horner's Syndrome?

Answer 32

* Head pain occurs in 50–75% of all cases. It tends to be located at the back of the head, either on the affected side or in the middle, and develops gradually. It is either dull or pressure-like in character or throbbing. * A “Headache like no other” – this is with the acute vertebral artery tears * Suboccipital headache with dizziness * Neck pain * Intermittent or permanent stroke symptoms such as difficulty speaking, impaired coordination and visual loss. Horner’s Syndrome: The signs and symptoms occur on the same side as the lesion of the sympathetic trunk. It is characterized by miosis (a constricted pupil), ptosis (a weak, droopy eyelid), apparent anhydrosis (decreased sweating), with or without enophthalmus (inset eyeball).

Question 33

What are symptoms of cranial nerve dysfunction for the olfactory nerve?

Answer 33

* Anosmia (loss of smell) * Hyposmia (decreased sense of smell) * Parosmia (perversion of sense of smell) * Cacosmia (perception of an offensive odor that does not exist)

Question 34

What are symptoms of optic nerve dysfunction?

Answer 34

Visual field defects: * blurring * diplopia * blindness (partial/complete) * difference in the color red

Question 35

What are symptoms of oculomotor nerve dysfunction?

Answer 35

* Dilation of the pupil (ipsilateral) * Outward and downward deviation of the eyeball. * Ptosis (drooping of the eyelid)

Question 36

What does the trochlear cranial nerve do?Symptoms of trochlear nerve dysfunction?

Answer 36

* Eyeball ability to look in toward the nose * Vertical diplopia on looking downward

Question 37

Symptoms of trigeminal nerve dysfunction?

Answer 37

* Anesthesia of forehead, eyebrow and/or nose * Corneal drying and/or pain (decreased lacrimation) * Decreased salivation

Question 38

What does the abducens cranial nerve do?Symptoms of Abducens nerve dysfunction?

Answer 38

* Abducens nerve abducts the eyeball, ability to look out to the side. * Affected eye turns medially or has no lateral deviation

Question 39

Symptoms of facial nerve dyfunction?

Answer 39

* Complete or partial paralysis of the face * Hyperacusia (amplified sound) * Unusal or impaired sense of taste

Question 40

Symptoms of vestibulocochlear dysfunction?

Answer 40

* Positional vertigo (lasts about 30 seconds) * Tinnitus * Hearing loss

Question 41

Symptoms of glossopharyngeal nerve dyfunction?

Answer 41

* Dysarthria (trouble speaking) * Dysphagia (trouble swallowing)

Question 42

Symptoms of vagus nerve dysfunction?

Answer 42

* Aphonia (weak or hoarse voice) * Dysarthria (difficulty speaking) * Dysphagia (difficulty swallowing)

Question 43

Symptoms of dysfunction of the spinal accessory nerve?

Answer 43

* Weakness in trapezius and SCM

Question 44

Symptoms of hypoglossal nerve dysfunction?

Answer 44

* Dysarthria * Dysphagia * Protrusion of tongue to affected side

Question 45

Etiology and causes of temperomandibular joint dysfunction

Answer 45

_Etiology_: Dysfunction in the biomechanics of the TM joint: internal derangement (31%), OA osteoarthritis (39%), myalgia or myofascial pain disorder (30%) _Causes:_ Idiopathic or trauma induced (bruxism, whiplash)

Question 46

What is the usual natural course of TMJ?

Answer 46

transient, self limiting, frequently without long term effects

Question 47

What are primary symptoms of TMJ?

Answer 47

* Clicking in the TMJ during mouth opening * Deviation in mouth opening \*ipsilateral (same side) deviation which prevents functional opening = very diagnostic of hypo mobile arthritic joint.. * “Locked jaw” * Pain (will point specifically to TMJ) * Restricted mandibular movement

Question 48

What are some other associated symptoms of TMJ?

Answer 48

* Cervical headaches * Dizziness * Ear ringing * Eye pain * Loss of hearing acuity * Pins needles/numbness: face, palate, gums, tongue * Stuffiness, sinus pressure

Question 49

What does it mean if there is a C curve when person opens their mouth? S curve?

Answer 49

C curve when opening mouth – indicative of degenerative problem on that one side S curve – more likely to by myofascial

Question 50

What is happening when there is clicking or locking of the jaw?

Answer 50

In a normal TM joint the condyle should rest against a disc when the jaw is closed. The disc should also move with the condyle to cushion it when the mouth opens. If there is clicking it is usually because there is an anteriorly displaced disc such that the condyle does not sit in cartilage when the jaw is closed and has to click over it during opening. With a locked jaw the condyle is squishing into the disc and the disc is folding to an extent that it blocks the condyle from moving further.

Question 51

Why is it often helpful to do work on the lateral pterygoid to help with TMJ?

Answer 51

The lateral pterygoid directly connects to the cartilage of the TM joint. If it is inflamed or tightened it will pull the disc forward into that anterior displacement that is causing all of the trouble.

Question 52

How much jaw opening is needed for intubation?

Answer 52

35 mm