Cervical Spine Pathology and Exam Flashcards
Canadian Cervical Spine Rule Low Risk
- able to sit in the ER
- simple rear-end MVA
- Ambulatory at any time
- delayed onset of pain
- do not have midline cervical spine tenderness
- AROM 45’ cervical rot B
Canadian Cervical Spine Rule-High Risk
need radiograph
>65 years old
-dangerous mechanism of injury
-paraethesias in the extremities
Observation
Forward Head? Protruded shoulders? Head in midline? --lateral shift Are the shoulders level? Normal Spinal Curvature? Posture?
Check for Instability
ALAR ligament Test
test position of C1 and C2 relative to occiput
when you S/B or ROT head, it tightens the alar ligament to make C2 move
–to perform
–fingertips on either side of C2
–S/B head or rotate head right and SP should move left
Positive test=no movement (immediate referral!)
Sharp Purser Test
Checks for instability between C1 and C2 (transverse ligament)
-To perform:
Hold C2 SP in a pincer grip
-Have pt bend head forward
-Hook their forehead with the palm of other hand or with elbow
-Compress two hands to push head straight back towards C2 with head still flexed
Positive test symptoms with flexion, relieved with AP or excessive movement
VBI Testing
Test the integrity of the vertebral artery on the opposite side of the direction that the head is S/B and ROT towards
–Testing position : the pt is supine with head supported off the edge of the plinth, eyes open
To perform VBI testing
- Head is brought into full passive EXT-hold for 10+ sec
- Then, add on head sideband hold for another 10+sec
- Pt is asked how he feels at the end of each step
- check on both sides
Examination Overview for Cervical Spine
Subjective Exam -area and behavior of pain -History Objective Exam -observation -ligamentous stability ---safety concern -VBI testing --safety concern Objective Exam Clear related joints AROM/ROM with OP Neuro Screen PPIVM's PAIVM's Special Tests Palpation
Pain Assessment
Area of Pain -location -referral sites Behavior of Pain -TIme of day -Irritability Numeric Rating Scale Neck Disability Index
Cervical Spine History
Occupation? Typical Positions? Mechanism of Injury? Radiation of pain? Paresthesia? Previous injuries? Aggrivating/relieving factors? Diagnostic imaging? Medications? General health? Sleeping Positions?
History
Headaches?
mouth-breather? occluded nasal breathing?
Pain with laughing, coughing, sneezing?
Swallowing or voice changes?
Vision problems> Dizziness? Faintness? Seizures?
Bilateral symptoms?
Sympathetic symptoms> Bowel/ Bladder function?
Systems Review
**Choice questions that are most relevant to the patient.
History Continued
Systems Review -Unexplained weight loss -evidence of 2-3 nerve root involvement Increasing number of painful regions -visual disturbances -Horner's syndrome--drooping of the eyelid, constriction of the pupil -gradual onset of symptoms
Canadian Cervical Spine Rule
Low Risk
- able to sit in the ER
- simple rear-end MVA
- ambulatory at any time
- Delayed onset of pain
- Do NOT have midline cervical spine tenderness
- AROM 45’ cervical rot B
VBI Testing Positive Signs
Dizziness Nystagmus Slurring of speech blurred vision Unconsciousness nausea numbness -Positive Signs-condraindication to traction or mobilization -Proceed in examination with caution-referral to physician may be required.
VBI testing
To differentiate between dizziness related to VBI insufficiency or vestibular problem:
- with patient sitting/standing, hold the pt’s head still and have them rotate their body
- If dizziness still occurs, it is probably a vascular problem and not a vestibular problem
AROM
Flexion (45-50') -mouth should be closed Extension (85') -mouth should be relaxed Side-bending (40') Capsular Pattern ROT=SB>EXT>FL (full) Perform movement, apply overpressure if no pain If pain is not reproduced, consider combined motion testing
AROM
Differentiate between upper and lower C/S (see following slides for pictures) If no pain, apply overpressure:
- Upper C/S flexion
- Lower C/S flexion
- Combined C/S Flexion
- Upper C/S Extension
- Lower C/S Extension
- Combined C/S Extension
C/S Flexion
Upper c/s flexion
chin retraction with slight head nod
Lower C/S Flexion
Retract the Chin and bend whole head forward
Upper C/S Extension
Chin protraction with slight upward head nod
Lower C/S Extension
Retract chin and bend entire head backwards
Neuro Screen
Dermatomes
c4: tip of acromion
c5: radial styloid process or lateral epicondyle
c6 tip of thumb and index fingers
c7: tip of long and rin fingers
c8: tip of ring finger and little finger
t1: ulnar styloid process or medial epcondyle
Myotomes:
c4L shoulder shrugs
c5: shoulder abduction
c6: elbow flexion and wrist extension
c7: elbow extension and wrist flexion
c8: thumb extension
t1: finger adduction and abduction
DTR’s
c5: biceps reflex
c6: brachioradialis reflex
c7: triceps reflex
Passive Physiologic Inter-vertebral movements (PPIVMS)
Flexion Extension Rotation Side-Bending Side Glide
Passive Physiologic Flexion
– Headsupported posteriorly withfingers andanteriorly with thumbs – Headispassivelyflexed uptopointoffirstpain –Palpateinterspacesformotion
Passive Physiologic Extension
- Supported posteriorly with fingers and anteriorly with thumbs
- Head is passively extended
Passive Physiologic Rotation
-Head is passively rotated with one hand while the other hand aids rotation at the articular pilars
Passive Physiologic Side-Bending
- Cradle the occiput with on ehand
- Radial boarder if 1st digit on the other hand is held against posterior articular pillar (serves as a fulcrum)
- Head is passively sidebent over hand
Passive Physiologic Side glides
- Head is held with one hand on each side of the neck
- Radial boarder of 1st digit on other hand is held against posterior articular pillar (serves as a fulcrum)
- Head is passively sidebent over hand
Passive Physiologic Side Glides
- Head is help with one hand on each side of the neck
- Radial boarder of 1st digit on each hand is held against posterior articular pillar
- Translation forces are applied in alternating directions, working down the neck (can also do one side a ta time)
Passive Accessory Inter-vertebral Movements (PAVIMS)
CPA
UPA
Transverse Pressures
CPA’s
- method 1: patient is prone on low plinth. Start at c2 and work down to c7. Push on downward, diagonal direction (towards chin) with one thumb laid over the other, assessing amount of motion
- Method 2: (gentler technique): Patient is supine on plinth. C grip with index finger and thumb on articular pillars, palm supporting occiput. Shoulder is on forehead. Motion is into extension with downward pressure at forehead and upward pressure at articular pillars. Equal pressure is applied.
UPA’s
- Patient is prone on the plinth
- move muscle bulk either medially or laterally (don’t push directly through it)
- Apply pressure over lateral facet joints, by pushing in downward, diagonal direction (towards chin) with one thumb over the other
Transverse Pressures
- plinth is higher
- Stance with one foot forward
- arms are relatively extended with one thumb over the other on side of SP.
- Pressure is in horizontal direction, relatively parallel to the floor.
Special Test
Quadrant Spurling Cervical Compression and Distraction Swallowing Tests Thoracic OutletL Adson/ Roos/ Allen Tests Cervicogenic Headache -Flexion Rotation -Segmental Differentation
Quadrant Test
To perform LOWER quadrant test:
- Assess for VBI id not performed previously
- Patient is sitting
- Head is passively extended, S/B and ROT (to the same side) with added axial compression at the exd (10 sec pause between each movement)
Spurling’s Test
- Pt is sitting
- Axial Load is applied through spine to assess for increase in symptoms
- If negative, the patient is then asked to sidebend, if no symptoms then an axial load is applied and symptoms re-assessed
- Positive Sign=Radicular symptoms into UE
- Indicates: spondylosis, HNP, osteophytes
Cervical Compression
TO perform
-Pt is in supine or sitting
-Press down on the top of the patient head
May send referred symptoms into the UE’s
(+)sign is pain in the cervical refion or UE’s
Painful test may indicate: nerve root irritation, disc herniation, facet inflammation, fracture
Cervical Distraction
Positive test = minimize-pain relieves numbness/tingling
To perform=
-patient is sitting
-grip mastoid process using thenar eminences
-pull upward maintaining firm pressure
Increase symptoms may indicate: large HNP, dural irritability, muscle spasm, ligament tear
Upper Limb Tension Test
Pt: Supine Depress the shoulder girdle Extend the wrist and fingers Supinate the forearm Abduct the shoulder 110' the externally rotate Extend the elbow
Wainner’s Clinical Prediction Rule
Highest specificity with cluster of 4 tests:
-medial nerve symptoms with neural tension testing
-Increased sighs with Spurling’s Test
-Decreased signs with distraction
-Ipsilateral c-spine rotation less than 60’
4 out of 4 SN=24’ SP=99’
3 out of 4 SN= 39’ SP= 94’
Swallowing Test
Ask the patient is they have difficulty swallowing
- (+) sign=difficulty or pain while swallowing (indicated C/S pathology sich as boney protuberances, osteophytes, or soft tissue swelling)
Palpate hyoid bone for lack of elevation or excessive protraction during swallowing
Thoracic Outlet Syndrome
Adson’s Test
Pt is seated with arm at 15’ of ABD
PT palpates radial pulse
Pt inhales and holds breath
Pt tilts head back and rotates head toward ipsilateral side
(+) Sign=Diminished/Absent pulse or Parethesia
Thoracic Outlet Syndrome Roo’s Test
- Pt is seated with arm in 90 deg of shoulder ABD and 90 deg of elbow flexion
- Pt performs finger FL/EXT for 3 minutes
- (+) sign=diminished/absent radial pulse, pain, heaviness, numbness, tingling, inability to maintain position
Thoracic Outlet Syndrome (Allen’s Test)
- Pt is seated
- Elbow is flexed to 90deg and shoulder is ABD and ER
- Patient turns head to contralateral side
- (+) sign= diminished/absent pulse
First Rib Spring Test
- Pt lies supine
- Passively rotate the pt’s head toward side to be tested
- contact the first rib with 2MCP and apply a inferior /anterior force toward opposite hip
- Positive test decreased mobility, concordant symptoms
Cervical Rotation Lateral Flexion Test
Pt is seated
-Passively rotation the pt’s head away from side to be tested
-Sidebend the head (ear to sternum)
Positive test=restricted motion, tests contralateral rib
Cervicogenic Headache
Ask patient if they have a headache
-is it in suboccipital muscles?
-does it radiate up behind the eye?
Perform flexion/rotation test (see following slides)
–Helps determine which c/s level is causing the problem
Flexion Rotation
Tests mobility at the C1-2 level
- Pt is supine
- Passively flex head until the chin is near manubrium (both upper and lower C/S flexion)
- Grip head and rotate it in both directions
- (+) Sign restricted motion on one side (>10 deg) or headache on ipsilateral side
Upper Cervical Segmental Differentiation
Determine which UCS level is symptomatic:
- first, find the posterior arch of c1 (3finger widths lateral from external occipital protuberance) Perform a UPA over this arch to assess O-C1
- Perform a UPA over the C2 articular pillar. This assesses the C2-3 level
- Have the pt rotates their head 30deg. Perform a UPA over the C2 articular pillar on the ipsilateral side. This assesses the C1-2 level (the rotation takes up the slack at that level which causes the movement to occur at c1-c2)
- (+) SIGN=pain and hypomobility (the problem may be at multiple segments!)
Palpation
Anterior
- hyoid bone
- cricoid cartilage
- sternoclavicular joint
- manubrium
- sternocleidomastoid
Palpation
Posterior
- External Occipital Protuberance
- Superior Nuchal Line
- Mastoid Process
- Transverse Processes
- Posterior Arch of C1
- Articular Pillars and facet joints
- Spinous Processes
Palpation
Musculature
- Trapezius
- Suboccipitals
- Levator Scapulae
- Anterior and Middle Scalenes
