Cervical Spine Pathology & Radiology Flashcards
What are the Canadian C-Spine Rules
Get a radiograph if:
- Age >/= 65 yo
- Dangerous mechanism (fall from elevation, axial load to head, MVA)
- Paresthesia in extremities
- Low Risk Factor where Pt unable to actively rotate neck > 45 degrees
What do you look for in an AP View of the neck?
- alignment of the cervical vertebra
- SP midline
- Pedicles are equidistant on either side of midline
- space b/t vertebrae
What do you look for in a Lateral View of the neck?
- 3 parallel lines: Facets, Vertebrae, SP
- Disc Space
- Prevertebral soft tissue (< 7mm at C2, < 22mm at C6)
- Alantodens Interval (ADI): < 3mm in adult & < 5mm in peds
What is widening of the prevertebral soft tissue indicative of?
A cervical spine injury
What is the Atlantodens Interval (ADI) important for?
If you suspect cervical instability
What do you look for in an Oblique View of the neck?
- Intervertebral fOramina (as OVALS)
- Pedicles
- SP
What do you look for in an open mouth View of the neck?
- Position of dens b/t 2 columns of C1 vertebra
- position of the vertebra & C2 vertebra
- Bil. jt spaces should be equal
- TP of C1
What is a Lateral Flexion/Extension stress view of the neck
- Dynamic Motion Studies that help to elicit less than obvious instability of the C-spine
What do you see in a Swimmer’s View of the neck?
Helps demonstrate cervico-thoracic junction
What is a Jefferson Fracture?
A burst Fx of C1 caused by vertical forces compressing the lateral masses of C1 b/t the occiput and the axis
What are the 4 types of Jefferson Fx?
I - anterior arch
II - posterior arch
III - anterior & posterior arch double fx
IV - Lateral mass fx
Where in the cervical spine is there the greatest amount of flexion/extension?
Why is this important?
C5-6 = more likely to see degeneration
What is the resting position of the cervical spine?
Mid-way b/t flexion and extension
What is the closed packed position of the cervical spine
Bil: Full extension
What is the capsular pattern of the cervical spine?
Side flexion & rotation = limited, extension
What levels are the Upper Cervical Spine?
C0-C2
What levels are the Lower Cervical Spine?
C2-C7
What motions occur at the OA joint?
Primarily flexion/extension (24-30 deg) w/small amount of rot/SB
What are the arthrokinematics for flexion of the OA joint?
Bilateral condyles roll forward, glide posterior
What are the arthrokinematics for extension of the OA joint?
Bilateral condyles roll backward, glide anterior
What are the motions of the AA joint?
- Primarily Rotation, up to 40-45 deg
- some flexion, extension, & SB
What are the arthrokinematics for rotation of the AA joint?
- IPSI posterior glide
- CL anterior glide
Which motion segment places the most stress on the vertebral artery?
AA joint
Which motion segment may give a false test result on the alar ligament test?
C2-C3 if there is a motion restriction there
What angle are the superior facets of the lower cervical spine at?
45 degree angle upward, bkwd, and medially
In the lower cervical spine, what are the arthrokinematics of flexion?
Bilateral anterior-superior/ventral-cranial
In the lower cervical spine, what are the arthrokinematics of extension?
Bilateral posterior-inferior/dorsal-caudal
In the lower cervical spine, what are the arthrokinematics of SB/Rot?
IPSI dorsal-caudal, CL ventral-cranial
What is the a/b in the upper cervical spine?
A. Coupled movement
B. Non-coupled movement
A: opposite
B: Same
What is the a/b in the lower cervical spine?
A. Coupled movement
B. Non-coupled movement
A: same
B: opposite
Which levels do the nerves travel ABOVE their corresponding vertebra & which are BELOW?
C1-C7 ABOVE
C8 ABOVE T1
T1 & down is BELOW
What are uncovertebral joints
Present from C3-C7 they are a superior projection from the lateral aspect of the vertebral bodies that can reinforce the disc and provide protection from herniation
What % does the upper thoracic spine assist cervical motion?
Up to 25%
What is the common MOI for whiplash?
Flexion often combined with some rotation, followed by rapid extension or vice versa
What are some of the other factors you may want to consider about the MOI of whiplash?
- Position of head at impact
- awareness of impending impact
- condition of the neck tissues
Which direction of impact will cause the greatest whiplash disability?
Rear impact
What is a grade 0 whiplash
No neck symptoms of physical signs
What is a grade 1 whiplash
No physical signs except for pain, stiffness and tenderness only
What is a grade 2 whiplash
Neck symptoms and musculoskeletal signs (dec ROM, point tenderness)
What is a grade 3 whiplash
Neck symptoms w/neurological signs (dec or absent DTR, weakness, and sensory deficits)
What is a grade 4 whiplash
Neck symptoms and fx or dislocation
What is whiplash-associated disorders (WAD)
Whiplash that leads to a variety of clinical manifestations:
- Aching/stiffness of the neck
- difficulty swallowing
- H/A
- Pain into scapula, chest, and/or shoulders
- Concussion
T or F: WAD symptoms occur immediately
They can be immediate OR delayed
What are factors that can cause delayed recovery from whiplash?
- dec. cervical spine mobility post injury
- pre-existing neck trauma
- female
- older age
- psychosocial factors
- pending litigation
What is congenital torticollis?
- SCM unilateral contraction that primarily effects females ages 6 mo to 3 years
- due to: Intrauterine injury or living situations
What is the presentation of acquired/acute torticollis?
- > = 20 yo
- unilateral pain, dec ROM, severe pain @ end ROM, strong but uncomfortable isometric strength testing
T or F: Acquired Tort is always the SCM
False, it can be SCM, splenius capitius, semispinalis capitus, or anterior scalene
What are possible causes of acute/acquired tort?
- Trauma/mm strain
- URTI
- Viral infection
- poor posture
- hearing problems
Treatment for acquired tort?
- 1st 24 hrs: rest, heat, ice
- after: STM, modailites, joint mobs, NSAIDs
What is cervical spondylosis?
Normal aging process (40+) with the loss of integrity of disc causing instability of affected segment
What % of radiographs for cervical spondylosis are asymptomatic?
- 50% by age 50
- 90% at age 65
Life of a disc
- Disc degenerates
- Loss of disc height = overriding zygoapophyseal joints = damage articular cartilage
- Translational instability & dec/loss arthrokin control
- Formation of protective osteophytes
- OA –> hypomobility
What conditions can lead to cervical hypermobility?
- whiplash
- OA/RA
- segmental degeneration
- trauma
- genetic predisposition
What are the main signs/symptoms of cervical hypermobility
- history of trauma
- catching/locking/giving way
- poor muscle control
- excessive EF
- signs of hypermob on x-ray
What clinical findings would you expect w/cervical instability
- neck pain & HA w/sustained WB (sitting)
- Catching or locking of neck
- weakness
- altered ROM (aberrant)
- hypermobility and soft end feel w/PPIVMs and PAVIMs
What is internal decapitation?
The transverse ligament breaks and a full force motion cuts the SC
What are the cause of upper cervical instability
- Trauma
- RA
- Down’s syndrome
- prolonged corticosteroid use
What are the s/s of upper cervical instability
- feels like head is falling off
- feels like lump in throat
- torticollis (cock robin position = cardinal sign of early phase)
- neurological signs/symptoms
What are the major concerns w/upper cervical instability?
Paralysis or death
What are the treatment options for upper cervical instability?
- Sx
What may indicate a facet joint pathology?
- A capsular pattern
- possible referred pain in head/shoulders
What is the progression for a disc herniation?
- degeneration
- prolapse
- extrusion
- sequestration
What is thoracic outlet syndrome?
Compression of neuroVASCULAR structures as they course from the cervical region to anterior chest/shoulder
What are some symptoms that would indicate thoracic outlet syndrome?
- vague shoulder pain/achiness
- sense of heaviness in the shoulder
- neurogenic signs (numbness, tingling, weak grip, loss of dexterity)
- Vascular signs & tests that reproduce symptoms w/diminished pulse
What are some common sites of compression for thoracic outlet?
- anterior/middle scales & first rib
- costoclavicular space
- pec minor/coracoid
- presence of cervical rib (rare)
What is cervical myelopathy?
Spinal cord compromise (compression & ischemia) from stenosis/spondylosis that disrupts normal neural transmission
What should you do if you suspect cervical myelopathy?
Refer for medical assessment so they can have a sx (ACDF)
What is the cervical myelopathy cluster?
3/5 must be positive to RULE in:
- gait deviation
- + Hoffman’s sign
- Inverted supinator sign
- Positive Babinski test
- Age > 45 yo
What is the inverted supinator sign
Reflex test of brachioradialis causes finger flexor hyperactive response
What is the common area for the vertebral artery to get kinked?
- C2 entering the skull
What is the presentation for a non-ischemic VA Dissection
Ipsilateral posterior neck pain
Occipital HA
What is the presentation for an ischemic VA Dissection
- Hindbrain TIA (Dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, facial numbness, ataxia, vomiting)
- Hindbrain Stroke (Wallenberg’s syndrome or locked-in syndrome)
- CN Palsies
What is the presentation for a non-ischemic Internal Carotid Art. Dissection
- Head/neck pain
- Horners syndrome (drooping of eyes)
- Pulsatile tinnitus
- CN palsies
What is the presentation for an ischemic Internal Carotid Art. Dissection
- TIA
- Ischemic stroke of MCA
- Retinal infarction
What is a common source of cervicogenic HA?
C2-3 pain referral
What are the classic findings w/Cervicogenic H/A
- Unilateral symptoms usual after strain/mvmt to c. spine
- pain in neck/suboccipitals that radiates to frontotemporal & orbital regions (throbbing)
- Presents w/limited ROM
- Relieved w/lying down or blockage to cervical jts/nerves
Migraine S/S
- unilateral H/A
- throbbing
- Autonomic systems
- changes w/food/light/stress
- Response to medication
- NOT related by neck movement & NO ROM changes or blockage of cervical jts/nerves
Tension-Type HA S/S
- bilateral
- Pressure/tightening
- Presence of Trigger points
- NOT autonomic
- NOT changed by mvmt, routine activity, NO ROM changes
What is the most painful type of headache that can last from weeks to months?
Clusters headache
What are the s/s of a cluster headache
- tearing
- redness in eye
- stuffy/runny nose
- sweating
- drooping eyelid
When would a cervical sx be indicated for…
Radiculopathy
- Persistent/recurrent arm pain > 3mo
- neuro deficits that interfere w/function
- failed conservative treatments
When would a cervical sx be indicated for…
Myelopathy
- Mod–>Severe sympt altering QOL
- Unsteady gait
- hand dysfun
- neurogenic bowel/bladder
- spinal stenosis
What are the 3 primary cervical surgeries
Anterior cervical discectomy and fusion
athroplasty
framinotomy
What is the purpose of an ACDF Sx?
- Halt further osteophyte formation
- lead to regression & remodeling of existing osetophytes
- distract the disc space to reduce bulking of the ligamentum flavum & enlarge the neuroforamen
How is an ACDF done?
Anterior approach w/removal of disc and endplate cartilage to the uncovertebral jt and to PLL w/graft taken from iliac cret
What do they need to be cautious of when doing an ACDF?
overdistraction as it can lead to collapse
How much of the facet jt should be preserved to prevent segmental instability during a posterior laminectomy?
- 50-75%
Why might a disc arthroplasty be the best procedure?
Maintains cervical motion at the segment and is friendlier to the neighbouring segments by doing so
ICF: Neck pain w/mobility deficits
What are the ICD Dx?
Cervicalgia
Pain in T spine
ICF: Neck pain w/mobility deficits
Clinical findings for classification?
- Younger < 50
- acute neck pain duration
- symptoms isolated to neck w/UE symptoms only caused by provocation of involved cervical/thoracic segment
- restricted cervical ROM
- neck pain @ end range
ICF: Neck pain w/mobility deficits
Interventions
- Cervical & thoracic mobs/manips
- Stretching & mobility exercises
- coordination, strength & endurance exercises
ICF: Neck pain w/H/As
ICD Dx?
- H/A
- Cervicocranial syndrome
ICF: Neck pain w/H/As
Clinical findings?
- Unilateral H/A aggravated by neck mvmts
- HA produced w/provocation of IPSI posterior cervical myofascia and jts
- Restricted cerv ROM
- Upper cervical (C1-2) segmental mobility defecits w/flexion rotation test
- Restricted cervical segmental mobility
- abnormal performance on cranial cervical flexion test
ICF: Neck pain w/H/As
Interventions
- Cervical/thoracic mobs/manips
- strength endurance and coordination exercises for neck and postural mm
- postural education
ICF: Neck pain w/Mvmt Coordination Impairments
ICD Dx?
Sprain and strain of the cervical spine (hypermobile)
ICF: Neck pain w/Mvmt Coordination Impairments
Clinical Findings?
- Longstanding neck pain
- abnormal performance on cranial cerv flexion test and deep flexor endurance tests
- coord, strength & endurance deficits of neck/UQ mm
- flexibility deficits of UQ mm
- ergonomic inefficiencies w/repetitive activities
- Hypermobility & loose end feels
- Aberrant AROM w/greater AROM in supine
ICF: Neck pain w/Mvmt Coordination Impairments
Interventions
- coord, strength & endurance
- stretching
- mobs/manips above & below hypermobilities
- ergonomic corrections
Acute Pain symptoms
- high pain and disability scores
- recent hx of trauma
- referred sympt into UE
- limitied cervical AROM
- poor tolerance to manual exam
Acute pain includes what dx?
WAD
Acute pain interventions
- gentle AROM w/in Pt tolerance
- activity mod to control pain
- relative rest
- physical modalities
- intermittent use of C. collar
- gentle manual & exercises
ICF: Neck pain w/radiating pain
ICD Dx?
Spondylosis w/radiculopathy
Cervical disorder w/radiculopathy
ICF: Neck pain w/radiating pain
Clinical findings
- UE symptoms produced w/the TIC
- Dec. cerv rot.
- signs of nn root compression (sensory, strength, reflex deficits)
ICF: Neck pain w/radiating pain
Interventions
- UQ and nerve mobs
- traction
- craniocervical flexion exercises
- postural exercise
- thoracic mobs/manips
