Competency 2: Cervical Spine Examination Flashcards
Where do cervical nerve roots exit in relation to the numbered vertebra?
Exits above the numbered vertebra
The Atlas (C1) and Axis (C2) are considered atypical why?
- Atlas lacks a vertebral body and rotates around dens of C2
- Body of axis extends superiorly to form odontoid process
Upper cervical facets align in a plane pointing where; lower cervical facets point to?
- Upper cervical facets align in a plan pointing toward the eye
- Lower cervical facets point to opposite ASIS
What is the facet joint; type; where is it found?
- Zygapophyseal joint
- Synovial joint between articular processes
Biomechanics of the OA joint, AA joint, and C2-C7?
OA joint: flexion and extension primarily, minor SB and rotation Occiput rotates and SB to opposite sides (Type I like)
AA joint: primary motion is rotation. Atlast rotates around dens of C2
C2-C7: Rotation and SB typically occur to the same side (Type II like)
What do we observe and palpate for during cervical spine examination?
- Trauma, scars, masses, goiter
- Carrying angle
- Increased or decreased lordosis
- Distended external jugular vein (JVP): elevate head of bed 30°
- Tracheal deviation
- Masses in the neck, mediastinal mass, atelectasis, large pneumothorax
What makes up the Anterior and Posterior Triangle?
Anterior: mandible, SCM, midline
Posterior: SCM, trapezius, clavicle
- Omohyoid cross lower portion
What lymph nodes can we palpate for?
- Superficial and posterior cervical chain
- Occipital
- Pre/post-auricular
- Submandibular
- Submental
- Tonsillar
- Supraclavicular
Where is the Carotid pulse felt and what is the rule for feeling this pulse; what can we assess here with stethoscope?
- Medial to the SCM. Inferior to the corner of the jaw. Repeat on opposite side
- DO NOT assess BOTH pulses simultaneosuly. Could lead to fainting due to hypotensive reflex caused by baroreceptors
- Assess for thrills and bruits w/ bell of stethoscope
What does Jugular Venous Pressure assess and what is normal?
- Right atrial pressure, right internal jugular vein is in direct line w/ the SVC, assessment of the right IJV
- < 3-4 cm above the sternal angle = normal
Proper setup for assessing Jugular Venous Pressure?
- Place pillow under patients head to relax SCM’s
- Raise head of exam table to 30° and turn pt’s head slightly away from the side you are examining
- Identify the IJV using tangenitial lighting.
- Identify the highest point of pulsation. Extend object horizontally from teh apex. Place a ruler vertical from sternal angle ot create a right angle w/ the horizontal object
- Distance in cm above the sternal angle (right atrium) is the JVP
How is Low JVP’s vs High JVP’s best seen?
Low JVP is best seen in near supine position (hypovolemic pt)
High JVP is best seen sitting upright (hypervolemic pt)
Trachea should be where and what spaces are used as identification landmarks? Lateral displacement of trachea can occur with?
- Should be midline, use spaces between thyroid and SCMs as landmarks
- Lateral displacement of trachea can occur in tension pneumothorax
For thyroid palpation how do we locate, what do we have the patient do, where do we palpate?
- Isthmus overlies 2nd-4th tracheal rings
- Have patient flex neck slightly to relax SCMs
- Place fingers of both hands on pt’s neck so that index fingers lie just below cricoid cartilage. Have the pt swallow so thyroid rises up under finger pads.
- Observe for contour and symmetry
- Displace trachea to right and palpate right lobes. Repeat on left. Anterior surace of a lateral lobe is approximately the size of the distal phalanx of thumb and feels somewhat rubbery
When may a bruit be heard when listenings over lateral lobes of thyroid?
Hyperthyroidism
What is the normal ROM for flexion, extension, rotation, and sidebending of cervical spine; muscles involved with each movement?
Flexion: 45-90° (SCM, scalenes, paravertebral muscles)
Extension: 70-90° (Splenius capitus, cervicis, intrinsic spinal ms.)
Rotation: 70-90° (SCM, intrinsic spinal ms.)
Sidebending: 20-45° (Scalenes, intrinsic spinal ms.)
What is Central Neuropathy; common sites?
- Nerve entrapment by MSK or myofascial tissue producing paresthesias in area of the distribution of the nerve and creates sensory dysfunction/pain and may also decrease muscle strength.
- Common sites: intervertebral foramen and thoracic outlet
What is the Compression Test for central neuropathy and positive test?
- With head in neutral position, add an axial loading force caudally looking for UE pain, paresthesias, or numbness
- (+) test is reproduction of symptoms (pain/paresthesia in distribution of nerve root)
What is the Spurling’s Test for central neuropathy and positive test?
- Tests nerve root compression/irritation.
- Tested w/ axial force in neutral, then extension, then SB/rotation toward.
- Test of high specificity
- (+) test: reproduction of symptoms (pain/paresthesia in distribution of nerve roots)
What is a Valsalva Test, positive test, and what does it indicate?
- Pt holds breath and bears down (Valsalva maneuver), which increases intrathecal pressure
- (+) test is increased symptoms (pain/paresthesa in distribution of nerve root)
- Indicates: space occupying lesion in cervical canal
What are the boundaries of the thoracic outlet; best thought of a what 3 zone; structures inside; importance of thoracic duct and right lymphatic duct?
Boundaries: 1st rib, 1st thoracic vertebra, manubrium
3 zones: scalene triangl, costoclavicular space, retropectoralis minor
Structures: brachial plexus, subclavian V, subclavican A, thoracic duct (L side)
* Thoracic duct drains majority of body. Right lymphatic duct drains body’s RUQ
What is the Roos or EAST test; positive test; indicates what?
- Abduct shoulder to 90° and ER w/ elbow flexed to 90°
- Pt instructed to open and close fist for up to 3 mins.
- (+) test: reproduction of symptoms (pain/paresthesia)
Indicates: Thoracic outlet syndrome, specifically compression of subclavian A
What is the Adson test; positive test; indicates what?
- Locate radial pulse on affected arm. Physician ABduct, extends, and ER the shoulder while palpating radial pulse.
- First, pt’s head is extended and rotated toward affected side. Then the patient’s head is extended and rotated away from affected side
- (+) Test: Loss or change in pulse; reproduction of symptoms (pain/paresthesia)
Indicates: Thoracic outlet syndrome, specifically compression of subclavican artery between scalenes (when looking away from the affected side) or 1st rib/cervical rib (when looking toward affected side)
What is Wright’s Hyperabduction Test; positive test; indicates what?
- Physician locates and monitors the radial pulse on the affected side. ABDuct the patient’s arm above his or her head w/ some extension
- (+) Test: Loss or change in pulse; reproduction of symptoms (pain/paresthesia)
Indicates: Thoracic outlet syndrome, specifically neurovascular entrapment by pectoralis minor
What is the Costoclavicular Test (Military/Halstead Test); positive test; indicates what?
- Physician locates and monitors the radial pulse on the affected side. With the elbow extended and supinated, extend the shoulder.
- (+) Test: Loss or chanhge in pulse; reproduction of symptoms (pain/paresthesia)
Indicates: Thoracic outlet syndrome, specifically neurovascular entrapment between 1st rib and clavicle
What is the Nuchal Rigidity Test (Kernig Sign); positive test; indicates what?
- Pt supine. Place hands behind pt’s head, flex neck forward until chin touches chest.
- (+) Test: Marked neck stiffness/resistance to flexion
Indicates: Inflammation in subarachnoid space (i.e. meningitis or subarachnoid hemorrhage)
* Found in 57-92% cases of acute bacterial meningitis, and 21-86% of subarachnoid hemorrhage
What is Brudzinski’s Sign; positive test; indicative of what?
- Pt supine. Place hands behind pt’s head, flex neck forward until chin touches chest
- (+) Test: Flexion in both hips and knees
Indicates: Inflammation in subarachnoid space (i.e., meningitis or subarachnoid hemorrhage)
*Low sensitivity, specific data limited
What is Kernig Sign; positive test; indicates what?
- Place pt supine and flex hip and knee to 90°. Attempt to passively extend the leg at the knee
- (+) Test: Increases resistance to extension and pain behind knee, +/- back pain radiating to posterior thigh (sources vary)
Indicates: Meningeal/dural irritation
* Sensitivty is low (5%) and specific data is limited
Cervical spinal cord injuries can occur in ANY sport, but which 3 in particular; which kind of loading force accounts for over half of these injuries and what about this type of force increases injuries?
- Particularly football, hockey, lacrosse
- Axial load accounts for over half of c-spine inuries
- Neck flexion to 30° –> lordosis lost and protective soft tissues no longer protective
What is a Jefferson Fracture?
Axial Compression –> C1 fracture
What type of fracture is this?
- Wedge fracture
- Flexion and compression injury
What is a Dens Fracture?
C2 odontoid fracture at junction of process and body. Often requires surgery
What is a Hangman’s fracture; caused by?
Hyperextension injury —> C2 bilateral arch fracture
What causes a spinous process fracture?
Hyperextension or avulsion force from a muscle contraction
What is a Clay Shoveler’s fracture?
C6 or C7 fracture
What causes an Anterior Subluxation?
Flexion injury –> Facet dislocation w/o fracture
What causes a Teardrop fracture?
Flexion and compression injury –> Anterior-inferior teardrop fragment
Generalized lymphadenopathy (LAD) seen in what pathologies?
HIV/AIDS, infectious mononucleosis, lymphoma, leukemia and sarcoidosis
What is Scrofula?
Infectious cervical lymphadentitis
What will palpation of the thyroid feel like with Goiters, Graves’ disease, Hashimoto’s/Malignancy and Thyroiditis?
Goiters: simple (non-nodular) or multinodular
Graves’: soft
Hashimoto’s and malignancy: firm
Thyroiditis: tender
