Cervical Spine Pathology- Lecture

Question 1

Posture syndrome:

Answer 1

• Most common: Forward Head Posture (FHP), protracted shoulder girdle
• Lateral shifts secondary to: pain, scoliosis, discal dysfunction, muscle imbalance
• Upper cervical compensations to posture
  
  • Extension posture with FHP
  • Lateral bending/rotation with lateral shift/scoliosis

Question 2

Posture:

Answer 2

• Can have underlying deformity
• Need to determine need for imaging (e.g., Klippel Feil)
• Habitual poor posture is felt to lead to early degenerative changes
• Poor posture creates muscle imbalance
  
  • Shortened or overactive upper trap, levator scapula, SCM, Scalenes, suboccipital muscles, pectoralis minor
  • Weak middle and lower trap, deep cervical muscles (longus colli)
  • Weak deep cervical flexors is a consistent finding across many cervical pain syndromes and dysfunction
  • Tested with cranio-cervical flexion test (avoid substitution with SCM)
  • When using SCM for resisted neck flexion, head protrudes rather than flexes
• Mouth breathing
• Tongue position
• Elevated first rib
• Tight levator scapulae, pectoralis minor
• Weak lower and middle trap
• Scapular diskinesia leads to impingement at the GHJ with rotator cuff dysfunction
• Initially: pain (maybe HA) with poor posture, relieved with postural correction
• Chronic postural faults: Myofascial pain syndrome, ligamentous changes, discal pathology, thoracic outlet syndrome, thoracic dysfunction
• Upper cervical dysfunction

Question 3

Spondylosis / Spondylolysis:

Answer 3

• Condition of (losis) / degeneration of (lysis)
• Degenerative osseous and soft tissue of the vertebral column (spondy = spine)
• Affects the discs, joint, vertebral bodies, and ligaments when advanced
• In advanced stages can lead to stenosis and cervical myelopathy (myelo = spinal cord, pathy = pathology)
• Arthrotic change with disc degeneration
• Typically will see loss of cervical lordosis on x-ray
• Degenerative changes develop over time
• Leads to osteophyte production and secondary syndromes
  
  • Spinal stenosis – myelopathy
  • Discal disease
• Capsular pattern
  
  • Rotation (equally and bilaterally) and extension (equally and bilaterally) will be limited to varying degrees
  • Full flexion Lateral Bending and Rotation equally limited bilaterally
  • Extension limited
  • Flexion will be full

Question 4

Discogenic / Facet Torticollis (Acute Torticollis or “Wry Neck”)

Answer 4

• Acute onset
• Usually a previous history of neck pain
• Prefers a slight flexed posture, holds head looking to contralateral side
• Limited rotation, lateral bending to ipsilateral side > contralateral side. Extension limited > flexion
• Not a true“torticollis”(torticollis = lateral bending and rotation to opposite sides)
• Typically rotation limited and painful to the side of symptoms > side away from symptoms
• Postures away from symptoms: flexed, rotated away slightly
• Determining actual structures involved is difficult with clinical exam
• May palpate a kyphotic kink, or may be demonstrated with radiograph

Question 5

Nerve Root/spinal nerve Involvement

Answer 5

• Muscle weakness of a myotomal distribution
• Loss of sensation in a dermatomal distribution
• Diminished or a loss of deep tendon reflexes associated with that particular nerve root

Question 6

Neural Involvement

Answer 6

• Parasthesia
• Pain
• Response of the nerve to chronic compression or chronic stretch

Question 7

Tests for Neural Involvement

Answer 7

• Sensation testing (hot / cold discrimination lost first)
• Muscle testing
• Deep tendon reflex testing
• ULNTT
• Assess for autonomic nervous system involvement

Question 8

Acute Nerve Root Pain

Answer 8

• Lancinating / Shooting Pain
• Sharp / Burning Quality
• Well defined narrow borders
• Worse distally than proximally
• Spontaneous surges of pain

Question 9

Nerve Root Sleeve or Dural Involvement

Answer 9

• Can refer pain to the head
• Extrasegment referral of pain
• Pain is worse proximal but can be referred distal
• Vague distribution of pain

Question 10

Clinical Exam Radiculopathy
Test Item Cluster

Answer 10

• Ipsilateral rotation (<60 degrees) [closing motion]
• • Spurlings A
• • Distraction
• • ULNTT A
• Secondary findings:
  
  • Predominant scapular pain
  • Arm pain with neck movement

Question 11

Differential: Pain Referral from Deep Somatic Structures

Answer 11

• Vague, deep pain
• Pain worse proximally, but spreads distally
• Hard to localize, can be nauseating
• In the limb rather than on the skin
• As the condition worsens the pain spreads distally

Question 12

Cervicomedullary Syndrome
Cervical Myelopathy

Answer 12

• Impingement on the spinal cord by bone, disc, tumor, etc.
• Leads to both lower and upper motoneuron signs
• Can be due to injury (trauma), displaced vertebra (listhesis), disc bulge/herniation, osteophyte, tumor, or stenosis

Question 13

Cervical “Instability”

Answer 13

• Craniocervical flexion test
• Feeling “head will fall off” with extension
• Headache is common report
• Difficult with returning to neutral from extension
• Manual support relieves symptoms with movement

Question 14

Examination for Upper Cervical Instabilities

Answer 14

• Sharps Purser
• Alar ligament test
• ADI on lateral radiograph
  
  • flexion ADI should be less than 3 mm
• Open mouth view radiograph (dens fracture, lateral displacement due to alar ligament failure)
• Life threating situation
• Management is surgical

Question 15

Vertebrobasilar Insufficiency

Answer 15

• No clear distinguishing symptoms
• Examining for features to fit
• Symptoms to head and face
• Headaches
• Dizziness
• Visual and / or hearing disturbance
• Drop attacks, syncope
• Paresthesia
• Autonomic disturbance
• Most common symptoms from the vertebral artery are: Neck pain and Headache

Question 16

Wallenberg syndrome

Answer 16

• Lateral medullary syndrome (Injury to lateral medulla; most commonly affects vertebral artery)
• Difficulty swallowing
• Difficulty speaking
• Contralateral sensory deficits in UE and trunk
• Loss of sensation of ipsilateral face
• Facial pain, numbness, Horner’s syndrome
• Nystagmus

Question 17

Screening for vertebral artery

Answer 17

• controversy regarding neck manipulation- No definitive clinical exam to predict vertebral artery status or chance for involvement

Question 18

“Whiplash” and Associated Disorders (WAD)

Answer 18

• Quebec Task Force
• Varying opinions on“whiplash”
• Determined that WAD is a self-limiting disorder
• Does not agree with the preponderance of the literature

Question 19

Trauma

Answer 19

• Acceleration / Deceleration Injuries, Whiplash, Flexion / Extension injuries
  
  • Fractures, occult fractures, facet joint fractures
  • Ligamentous involvement & other soft tissues
  • Discal involvement
  • Endplate slippage
  • Nerve root involvement
  • Dural involvement
  • Brachial plexus injury

Question 20

Key symptoms of possible intracranial pathology:

Answer 20

• Sudden onset of severe headache
• Headache increasing over a few days
• New or unaccustomed headache
• Persistently unilateral headaches
• Atypical headache or a change in the usual pattern of headache
• Headaches that wake the patient during the night or early morning
• Chronic headache with localized pain
• Stiff neck or other signs of meningitis
• Systemic symptoms (eg, weight loss, fever, malaise)
• Focal neurologic symptoms or signs
• Local extracranial symptoms (eg, sinus, ear, or eye disease)

Question 21

Cervicogenic headache

Answer 21

• Cervicogenic headaches are caused by abnormalities of the joints, muscles, fascia, and neural structures of the cervical spine
• Approximately 50% attributed to C2/C3 facet joints
• Outcomes from the literature
  
  • Several case series
  • Several randomized control trials comparing treatments
    
    • Manual therapy and exercise is the most effective PT treatment
    • Injections are the best diagnostic tool
    • Facet nerve ablation is the most effective medical treatment, has not been compared to manual therapy/exercise

Question 22

Syrinx, Syringomyelia

Answer 22

• Insidious onset between childhood and mid 40’s
• Reflex changes
• Loss of temperature and pain sensation bilaterally in some regions
• Weakness
• Axial pain
• Fasiculations, spasticity in the LE

Question 23

Chiari Malformation Symptoms:

Answer 23

• HA (occipital region common)
• Neck pain, tension
• Fatigue
• Dizziness
• Visual disturbance (spots, halos, nystagmus)
• Paresthesia in extremities and face/head
• Balance problems, clumsiness
• Memory loss
• Loss of neck motion
• Ears feel stopped up
• Cold hands and feet