Common Clinical Presentation Flashcards
List some rare but serious C-Spine health conditions
- Neoplasm
- infection
- Ankylosing Spondylitis
- RA
- Klippel Feil syndrome
- CAD
list heightened risk factors for infection
- immunosuppresion
- DM
- Cirrhosis
- AIDS
- steroid use
- recent/current infection
What are a few s/s of meningitis?
fever, neck stiffness, Kernig’s Sign
What is Kernig’s sign?
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
define neoplasm
a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer.
List a few risk factors and s/s of neoplasm
prior Hx of cancer
fever and night sweats
what types of cancer are most commonly metasized to the spine?
think Lead Kettle (PB KTL)
prostate, breast, kidney, thyoid and lung
T/F: primary cancer is responsible for 75% of bone metastasis
TRUE
________ neoplasms metastazie to the vertebrae, pelvis, and proximal femur in 40% of cases
Kidney
RA has a greater risk for what?
- atlantoaxial instability (20-86% of pts with RA)
- basilar invagination
what is anklyosing spondylitis?
chronic inflammatory spondyloarthropathy
ossification of ligaments of spine, IV discs/end plates, and facet structures
anklyosing spondylitis increases a pt’s risk for what?
- spinal cord injury (11.4x greater)
- epidural hematoma
- low-impact trauma (most common in C5-C7)
- Osteoporosis (increases to 46-56%)
what population is anklyosing spondylitis more common in?
men (10x more likely)
most frequency observed in 3rd decade
a pt with anklyosing spondylitis will most likely have what complaints?
- back pain (worse at night and in morning, improves w/exercise and worsens w/rest)
- decreased chest wall expansion
- back stiffness
how will a pt with anylosing spondylitis present physically?
- visual inspection:
- chin on chest position
- excessive thoracic kyphosis
- flattened L curvature
- multi-directional ROM limitations of the spine
- diminished mobility of the spine
what would you expect to see on an imaging report for a pt with ankylosing spondylitis?
radiographic sacrolitis
what is Klippel Feil syndrome
congenital disorder in which there is failed C-spine segmentation
describe the clinical presentation of Klippel Feil syndrome
- < 50% short neck
- low posterior hairline
- limited C-spine ROM
- >50% have scoliosis
where is fusion most common in Kippel Feil syndrome?
list some complications to this syndrome
fusion of C2-3 most common
complication = instability, spinal stenosis
describe the pathophysiology of CAD
tear in vessel wall with circulating blood entering tear and forming an intramural hematoma
What are 2 triggering factors for CAD?
trauma
infection
List several potential consequences of CAD
- retinal or brain ischemia
- compression or stretching causes local symptoms
- subarchnoid or intra-cerebral hemorrhage
CAD accounts for ______ of all ischemic strokes
2-3%
There are many risk factors for CAD, list several
- past history of trauma to C-Spine/cervical vessels
- history of migrane-type HA
- hypertension
- high cholesterol
- Cardiac disease
- Diabetes
- blood clotting disorders and anticoagulant therapy
- long-term use of steroids
- history of smoking
- recent infections
- immediatly post partum
- trival head or neck trauma
- absense of a plausible mechanical explanation for the pt’s symptoms
List symptoms of CAD
- neck pain (6-80% report)
- face pain
- HA
- entire hemicranial or bilateral pain
- pain in neck, face, head simultaneously
- pain is severe (>70%)
- (Bilateral) extremity dysesthesia, motor dysfunction, pain
- Pulsatile tinnitus
List the 5Ds and 3 Ns of CAD
- Dizziness
- Dysarthria
- Dysphagia
- Diplopia
- Drop attacks
- Nystagmus
- Nausea
- Numbness (dysesthesia of face/lips/extremities)
what findings during a physcial examination could indicate CAD?
- Horner’s syndrome
- HTN
- Positional testing
- Neurological testing
What is Horner’s Syndrome?
Ptosis (dropping of upper eyelid)
Miosis (constriction of pupil) on one side
Enophthalmos (sinking of the orbit)
Anhydrosis (dry eyes)
what is a cervical spine myelopathy?
spinal cord compression as a result of impingement from surrounding structures
present in 90% of ppl in 7th decade
what are some common causes of cervical spine myelopathy?
- ossification of PLL
- osteophyte complexes that come up with degenerative changes
- bulging discs
- soft tissue mass like a cancer
list symptoms of cervical spine myelopathy
- neck pain/stiffness
- shoulder pain
- imbalance/fal Hx
- UE dysesthesia
- multiple bilateral dematomes invovled usually
- non-dermatome pattern
- May also involve LEs first (gait deviations and weakness)
what things on a physical examination might lead you suspect cervical spine myleopathy?
- Neurologic signs:
- gait impairments
- spasticity
- pathologic reflexes
- hyper-reflexia
- dis-coordinated extremity movements
- radicular signs (usually bilaterally)
- balance impairments
list tests included in the clinical prediction rule for Cervical Spine Myelopathy
- Gait deviation
- Hoffman’s sign
- Inverted supinator sign
- Babinski Sign
- Patient age >45
what does the research say about the clincial prediction rules for cervical spine myelopathy? How many tests are needed?
- 1/5 = 94% sensitivity, -LR 0.18
- 3/5 = 99% specificity, +LR 30.9
- 4/5 = 100% specificity, +LR infinite
just need 3/5 to be pretty sure
what can cause upper cervical instability?
- ligamentous instability
- fracture (either by a trauma or fatigue fracture)
what things are associated with an increased risk for upper cervical instability (ligamentous)?
- history of trauma (whiplash, contact sport, etc.)
- throat infection
- congenital collagenous compromise
- Down’s Syndrome, Ehler’s Danlos
- inflammatory arthrides
- RA, anklyosing spondylitis
- recent neck/head/dental surgery
List symptoms of ligamentous upper cervical instability
- neck pain
- occipital HA/numbness
- limitation with activities performed at end-range C-Spine ROM
- radicular symptoms
- pt communicates the following:
- must support head w/hands
- tires easily in prolonged static upright positioning of head
what findings during a physical exam might suggest ligamentous upper cervical instability?
- multi-directional ROM limitations at C/S
- muscle guarding
- potential radicular signs
List several special tests that can be conducted for ligamentous upper cervical instability
- Modified/Sharp Purser
- Alar ligament Stability Test
- Tectorial Membrane Test
- Posterior A-O Membrane Test
upper cervical instability due to fractures is most commonly involving what structures?
- occipital condyles
- C1
- C2
what is a common mechanism of injury resulting in a cervical fracture and upper cervical instability?
axial loading
describe the clincial presentation of someone with upper cervical instability related to a fracture
- multidirection ROM limitations
- neck pain
- C-Spine spasm
- difficulty swallowing
- radicular pain
- CAD s/s
- Myelopathy s/s
what is a Jefferson fracture?
a specific type of fracture to the atlas
4-part burst fracture of atlas
*most common type of injury is a compression type injury
what is the difference between a spondylosis and a spondylolisthesis?
spondylosis → defect of pars interarticularis
spondylolisthesis → anterior displacement of vertebral body
a spondylosis often results from a fracture and is unilateral, but if it occur bilaterally it can progress into a sponydlolisthesis
how are spondylolisthesi graded?
by the % of vertebral body slip:
- 0-25%
- 25-50%
- 50-75%
- >75%
what are the Canadian C-Spine rules?
a clinical rule used to determine if a pt needs radiographic imaging done for the neck
has a really good -LR, very supported by research
what is the NEXUS low risk rule?
5 criteria in order to be classified as having a low probability of injury.
sensitivity ranges 0.83-1.00 (it’s good)
more suited for a traumatic setting
what are the 5 criteria in the Neux low risk rule?
- no midline cervical tenderness
- no focal neurologic deficit
- normal alertness
- no intoxication
- no painful, distracting injury
what is the most part of the screening process for upper cervical instability?
patient history
describe referral patterns for cervical spine arthropathies
can show up as a HA or in the anterior chest
List 2 types of degenerative arthropathies at the C-spine
- spondylosis → osteophyte complexes form around the margin of vertebral bodies and disc
- Osteoarthrosis → impacts the zygophysial joints and AA joints, osteophytes form narrowing the joint
what are some potential causes for central canal stenosis at the C-Spine
- Z joint hypertrophy
- bulging disc
- thickening/ossification of ligamentous structures
- spondylolysthesis
*central canal stenosis can cause cervical spine myelopathy but they are 2 distinct pathologies
what are some potential causes for lateral canal stenosis at the C-Spine?
- loss of disc height w/degenerative processes
- Z-joint and Uncovertebral joint hypertrophy
- Spondylolysthesis
what is a common cause of actue zygopophysial joint arthropathy?
commonly associated with extension mechanism
the lambda shaped meniscoids tend to get inflammed and injured
what findings during a physical exam might suggest acute zygopophysial joint arthropathy?
- pain w/joint compression ROM
- painful with segmental provocation
- CPAs and UPAs
- Cervical compression and Spurlings test likely provoke concordant pain, BUT
- pain observed in segmental distribution
- pain observed, NOT paresthesia/anesthesia
what is the difference between somatic referred pain, radicular pain, and radiculopathy?
- somatic referred pain → altered pain perception in CNS
- radicular pain → pain related to nerve root irritation
- radiculopathy → conduction block of motor and sensory axons
T/F: radicular pain only ever shows up with radiculopathies
FALSE
may occur with or w/o radiculopathy
describe the symptoms of radicular pain
- shooting/lancing pain traveling along nerve root distribution
- “band-like”
- pain w/activities that close the neuroforamen
- SB, rotation closing foramen
what findings during a physical exam suggest radicular pain?
- visual inspection → shifting position to open neuroforamen
- painful/limited ROM with motions/positions that compress foramen or place tensile load on nerve root
- relief with opening neuroforamen
what are common causes of radiculopathy?
compression or ischemia by:
- foraminal stenosis
- epidural disorder
- meningeal disorder
- neurologic disorder
- impingement by disc herniation
what region of the C-spine is most commonly effected by radiculopathies?
C6 and C7
spondylosis with foraminal encroachment in 70% of cases
what findings during a physcial exam might suggest a radiculopathy?
- natural Bakody’s sign
- painful/limited ROM w/motions that compress the foramen or place a tensile load on nerve root
- relief with neuroforamen opening
- Valsalva’s test +
- Wainner’s Cluster
what is a natural Bakody’s sign?
patient is resting hand on top of head
what is included in Wainner’s Cluster?
- Ipsilateral C/S rotation AROM < 60
- Spurling’s Test +
- Cervical Distraction test +
- ULTT +
what does research say about Wainner’s Cluster?
4/4 is good, less than that not so much
describe the pathomechanics of WAD
- trunk thrust forward
- lower C/S segment rotation into extension
- anterior annulus distracted, impaction on facet joints
- anterior annulus, ALL, and facet capsule strain
- Meniscoid contusion
- intra-articular hemorrhage of facets
- fractures of articular pillars/subchondral plates, dens, laminae C2, occipital condyles
list symptoms of WAD
- neck, shoulder, UE pain
- radicular vs referred symptoms
- glove-like distribution paresthesia
- weakness
- dizziness
- difficulty focusing vision
- tinnitus
what findings during a physical exam might suggest WAD?
- radicular signs
- C-spine motion limited
- weakness
- muscle guarding
- tinnitis
- must be tied to a traumatic event like MVA
what is a cervicogenic HA?
a HA referred from c/s
list the clinical criteria for the diagnosis of cervicogenic HA
- unilateral HA w/o side shift
- s/s of neck involvement
- pain episodes of varying duration or fluctuating continuous pain
- moderate, non-excurciating pain, usually a non-throbbing nature
- pain starting at the neck, spreading to oculo-frontal-temporal areas
- anaesthetic blockade abolishment of pain
- various attack-related events
what are s/s of neck involvement in a cervicogenic HA?
- pain triggered by neck movement or sustained awkward posture
- ipsilateral neck, shoulder, and arm pain
- reduced ROM
what are attack-related events?
- autonomic s/s
- N/V
- ipsilateral oedema and flushing in peri-ocular area
- dizziness
- photophobia
- phonophobia
- blurred vision in the ipsilateral eye
