Clinical Presentation of Cervical Spine Flashcards
Name the 4 categories of neck pain
- neck pain w/ mobility deficit
- w/ headache
- w/ movement coordination impairment
- w/ radiating pain
If an individual has neck pain with mvmt coordination impairment, in which aspect of the ROM will they have pain?
they will have pain throughout the entire ROM
When moving the neck, motion occurs all the way to which thoracic vertebrae?
T4 - therefore upper thoracic mobility is important for patients with neck pain
Questions to ask if patient had a trauma
loss of consciousness, seatbelt, speed and direction
Special questions
functional/comparable postures (have pt demonstrate)
sleep position
headaches
strength changes
What are the 3 components of irritability?
- vigor
- severity
- duration
Name the red flags
constant pain night pain/sweats increase in symptoms w/ cough/sneeze extremity weakness bilateral UE sx LE sx signs/sx of VBI
4 categories of red flags
- non-musculoskeletal
- vertebrobasilar injury
- cranio-vertebral ligament injury
- Cervical myelopathy (cord damage)
Vertebrobasilar Artery Insufficiency (VBI) causes
compromised blood flow to the brainstem caused by atherosclerosis, stenosis, or trauma
may result in brain stem ischemia
VBI problem area
Acute angle C1 to foramen magnum (between C1 and C2)
rotation to the contralateral side will lengthen the artery and occlude it
VBI most common in:
patients with neck pain and history of trauma
Vertebrobasilar artery insufficiency can be diagnosed via:
5 D’s and 3 N’s (gold standard = ultrasound doppler)
5 D’s of VBI
dizziness drop attack diplopia dysarthria dysphagia
3 N’s of VBI
numbness
nausea
nystagmus
drop attack
patient loses muscular control of legs due to artery occlusion and they fall down but do not lose consciousness
diplopia
double vision
dysarthria
slurred speech
dysphagia
difficulty swallowing
nystagmus
eyes drift back and forth
“and” of 5D’s and 3N’s of VBI
ataxia (abnormal gait)
Cranio-vertebral ligament injuries are due to what and involve which 3 ligaments?
due to trauma or disease process
- alar ligament
- transverse ligament
- tectorial membrane
Alar ligament
runs from dens to occiput
transverse ligament
holds dens (c2) against C1
Tectorial membrane
attaches head to neck, continuation of anterior longitudinal ligament, prevents head from rolling forward
cranio-vertebral ligament injuries
risk to brain stem and upper cord, may be associated with dens fracture, may require surgical fixation
require radiographs with mouth open to see dens
signs/symptoms of cranio-vertebral ligament injuries
5D’s and 3N’s as well as mouth/lip numbness and feeling of lump in throat
atlanto-axial interval
space between dens and atlas
Cervical myelopathy
upper motor neuron lesion (injury to spinal cord)
signs/symptoms of Cervical myelopathy
UMN signs
spasticity, hyperreflexia, visual/balance disturbances, ataxia, bowel/bladder changes
multi-segmental paresthesia
tests = babinksi, clonus, hoffman’s
4 common clinical presentations (categories from the guide to be used in documentation)
- impaired posture
- connective tissue dysfunction
- localized inflammation
- referred pain syndromes; peripheral nerve entrapment
Impaired posture
muscle imbalances
- can be neck pain with headache or neck pain with movement coordination impairment
- check head on neck posture, thoracic posture, shoulder posture, etc
Muscle imbalances
muscle pain, tightness, trigger points (treat with SCS!)
examination for muscle imbalances
posture
muscle strength
muscle length
palpation
most common impairments (muscle) in the neck are located in which muscle group?
deep neck flexors
local vs global muscles
local muscles act on segments (segmental control) while global muscles do not have segmental control
Trap and SCM working together =
head on neck stability
if the trap dominates, what force occurs on the neck?
anterior shear
SCM and trap
global muscles; neither has segmental control on neck
longus capitis and longus colli
local muscles, provide stability for neck at the segmental level
suboccipital muscles
tight = neck will be extended
compensation for this is lower cervical spine will flex
Upper crossed syndrome
line of weakness and tightness
tight pecs, traps, levator scap
weak neck flexors, rhomboids, serratus anterior
upper crossed syndrome
tightness causes shoulder elevation and scapula protraction
inhibited deep neck flexors and lower scap stabilizers
Connective tissue dysfunction includes which 4 things?
- zygapophysial/facet joint dysfunction
- cervical spondylosis
- IV disc
- acute torticollis
Zygapophysial facet joints: typical cervical vertebral joints
close packed position = extension
facet glide during cervical ROM
disc compression/distraction
if facet issue, will have pain with extension
Motion of typical cervical vertebral joints: flexion
superior segment moves anteriorly and superiorly
Motion of typical cervical vertebral joints: extension
superior segment moves posteriorly and inferiorly
Motion of typical cervical vertebral joints: side bending (lateral flexion)
ipsilateral side closes and contralateral side opens
Motion of typical cervical vertebral joints: rotation
depends
retraction/protraction
don’t use as strengthening exercise!
coupled motion of typical cervical vertebrae
side bending (LF) and rotation occur in the SAME direction, regardless of the position
Atypical cervical vertebrae
OA joint
what motion occurs at OA joint?
flexion/extension
flexion at the OA joint is limited by what structre?
dens at foramen magnum
extension at the OA joint is limited by what structure?
bony approximation
what is the coupled motion at the OA joint? (atypical vertebrae)
side bending (LF) and rotation occur in OPPOSITE directions
OA =
occiput and C1
motion at AA joint (c1/c2)
rotation!
what is the reason for the rotation at the AA joint?
convex on convex movemnt (bi-convex)
roll without glide!
Uncinate Processes
posterolateral
from uncovertebral joints or joints of Luschka
develop between age 6-9
degenerate early due to shear forces from rotation
neck pain with mobility deficit =
joint hypomobility
Facet joint dysfunction can be due to what 3 things?
trauma, degeneration, or insidious onset
Facet joint dysfunction
can refer pain - diagnostic blocks
pain is sharp and localized but can also be diffuse
pain between shoulder blades could be C4,5,6,7
Cervical Spondylosis
degenerative changes of disc, vertebrae, facets, or uncinate processes
nerve root compression, edema, cord compromise
cord compromise in cervical spondylosis occurs because of what?
facet hypertrophy which causes stenosis and therefore cord compression
Presentation of cervical spondylosis
stiffness, diffuse pain, dull ache, pain with movement, accessory motion limitations
Capsular Pattern : Bilateral at OA joint
equal limitation in extension and LF
capsular pattern: bilateral at typical vertebrae:
extension is most limited, follwed by equal limitations in rotation and LF
capsular pattern: unilateral at OA joint
contralateral LF is limited
capsular pattern: unilateral at typical vertebrae
contralateral LF and rotation are limited
capsular pattern
a pattern of limitation in those with degenerative changes
Central stenosis
cord compromise
degenerative!
lateral stenosis
nerve compromise
Stenosis
narrowing laterally in IV foramen where nerve exits
centrally in spinal canal
presentation of stenosis
sx of nerve/cord compression depending on degree of narrowing
stenosis can be caused by:
tumor, degeneration, or disc herniation (herniation is usually lateral)
68 yr old with neck stiffness and ache. gradual onset over past 3 months, AROM limited and painful into extension and rotation bilaterally
spondylosis! due to age, stiffness and ache
IV Discs
gelatinous nucleus pulposus becomes fibrous early
peripheral annulus fibrosus; concentric rings alternate direction
IV discs make up what % of the height in the c spine?
25 %
IV discs
no disc at OA joint
smaller than discs in vertebral bodies
thicker anteriorly than posteriorly!
contact uncinate processes laterally
IV discs are stressed via
rotation
IV disc dysfunction is caused by which 3 things/causes which 3 things?
- disc herniation
- disc degeneration
- rim lesions
the cervical spine is built for:
mobility (this is why IVD are not as large as in lumbar spine)
degenerate sooner than in lumbar spine
Disc herniation subjective findings
scapular, paraspinal sx with or w/o neck pain
pain increases w/ sustained postures and is better with activity
disc herniation examination findigns
relief with traction
pain with compression
pain with repeated flexion
possible neuro signs
most common location of disc herniation in cervical spine
C5/C6 because it is a common spot for hypermobility, causing shear forces in this area
Disc herniation pain
discs can refer pain - if disc herniates and compresses nerve, referral pattern will follow nerve not disc
DDD (disc degeneration)
spondylosis
in youth, proteoglycans and H2O are abundant
nucleus begins to resemble annulus and loses height
Disc herniation treatment
traction, posture, muscle imbalance
eval = neuro, flexibility, strength
goal of treatment for DDD
unload disc and increase mobility
same interventions as disc herniation
Rim Lesion
horizontal annular tear at anterior vertebral rim, w/o tearing the anterior longitudinal ligament
often a multisegmental injury
poor prognosis
rim lesions most often occur due to
hyperextension trauma - whiplash = most common
Predisposing factors to rim lesions
extension trauma
MVA hit from behind/poor headrest position
forward head posture
S/S of rim lesion
fear of movement
immediate pain after impact
highly irritable neck
same sx with compression and distraction!
difficulty lifting head off pillow (flexion)
Rim lesion xray
xray will appear normal, MRI must be done
rim lesion: avoid __?
extension
treatment for rim lesion
start with eye mvmts, isometrics, neurodynamics, leg/arm movemnts
Acute torticollis
contracture of SCM
Localized inflammation
whiplash-associated disorders (WAD) = an acceleration-deceleration mechanism of energy transfer to the neck
Prognosis in WAD
higher initial NDI score = higher likelihood of developing chronic neck pain
higher NDI score at 2-3 yrs post- injury is associated with what 4 things in those with WAD?
- higher initial NDI score
- older age
- cold hyperalgesia
- higher post-traumatic stress symptoms
what to exam for acute vs chronic
cranio-vertebral ligaments vascular structures soft tissue joints IVD nerves
Referred pain syndroms: peripheral nerve entrapment includes what 2 things?
- radiculopathy
2. thoracic outlet syndrome
Referred pain syndroms: peripheral nerve entrapment
pain relieved with distraction
examine ROM, sidebending, extension
treatment = traction and nerve mobs
classification = neck pain with radiating pain
Cervical nerve roots
exit laterally from spinal canal
IV foramen widens w/ flexion and narrows with extension!
Cervical radiculopathy
irritation of sensory nerve root causing pain and or paresthesia in the distal part of the dermatome
cervical radiculopathy clinical presentation
unilateral symptoms
neck/shoulder/arm/hand symptoms
worse with movements that narrow foramen (compress nerve)
examine sensory, motor, reflex changes
intervention for cervical radiculopathy
unload nerve, ROM to open forament
cervical radiculopathy sx are worse with
ipsilateral side bending and extension
Radiculopathy is present if these 4 s/s are present (tests are positive)
- nerodynamics
2. cervical rotation towards painful side is limited to
Spurling test
compression test – positive = pain increases with compression (closing lateral foramen)
Distraction test
positive = nerve pain in arm decreases with distraction
