CSP/TSP Flashcards
C1
The atlas
Has no vertebral body and no spinous process
Occiput-C1 articulation
Two superior concave facets that articulate with the occipital condyles (hold the skull)
3 ligaments provide stability
- Transverse
- Alar
- Apical
Makes up 50% of neck flexion and extension
C2
The Axis
Has odontoid process (dens) and body
C1-C2 (atlantoaxial) articulation
Diarthrodial joint that provides
50° (of 100) cervical rotation
10° (of 110) of flexion/extension
0° (of 68) of lateral bend
C1 to C7
Have a transverse foramen
C2 to C6
Have bifid spinous process
Curve of the cervical spine
Lordotic curve
Cervical ligaments - in general
Ligamentum flavum
PLL
ALL
Ligamentum flavum
Covers the dura
Connects under the facet joints to create a small curtain over the posterior openings between the vertebrae
PLL
Runs up and down behind the spine
Inside the spinal canal
ALL
On the front side of the vertebrae
Firmly unites with periosteum and annulus
Intervertebral discs
Accounts for 25% of spine height
Not present at C1-C2
Annulus fibrosus
Nucleus pulposus
Annulus fibrosus
Outer structure that encases the nucleus pulposus
Characterized by high tensile strength and its ability to prevent inervetebral distraction
Remain flexible enough to allow for motion
Nucleus pulposus
Central portion of the intervertebral disc composed of gel and approx. 88% water
Responsible for height of the intervertebral disc
Resist compression and distributes forces evenly to endplates of vertebrae
Nerve roots
Exit above corresponding pedicle through foramen (below in the TSP and LSP)
Travels horizontally to exit (in contrast to lumbar that descends before it exits)
There is an extra C8 nerve root that does not have a corresponding vertebral body
Exam - Inspection
Alignment in sagittal and coronal plane Skin defects Muscle atrophy Prior sx scars Fasiculations / tremors
Exam - Palpation
Know your landmarks
Exam - ROM
May document absolute degrees or relative to anatomic landmark (eg chin rotates to right shoulder)
Normal ROM of CSP
Flexion - 50
Extension - 60
Rotation - 80
Lateral bend - 45
Exam - Sensory
Document sensation to all dermatomes
Perform light touch in all pts - stroke lightly with finger
If a deficit, proceed with other sensory types
- pain
- vibration
- temperature
- two point discrimination
Motor
C5: Deltoid - Shoulder abduction C6: Biceps - Elbow flexion C6: ECR - Wrist extension C7: Triceps - Elbow extension C7: FCR - Wrist flexion C8: FDP - Flexion middle finger T1 - Hand interossei - spread fingers
Muscle grading system
1 - muscle contraction is visible but there is not movement to the joint
2 - active joint movement is possible with gravity eliminated
3 - Movement can overcome gravity but not resistance from the examiner
4 - The muscle group can overcome gravity and move against some resistance from the examiner
5 - Full and normal power against resistance
Reflexes
Biceps - C5, C6
Brachioradilais - C5, C6
Triceps - C7
Congenital Torticollis - in general
Most common position is lateral flexion and rotation
Rare - <2% incidence
May accompany clavicular fx, esp. in neonates
Up to 20% of children with congenital muscular torticollis have congenital hip dysplasia as well
Congenital Torticollis - causes
Birth trauma to the SCM M., results in fibrosis or compartment syndrome
Intrauterine malpositioning leads to unilateral shortening of SCM
May be associated with SCM tumor, called fibromatosis colli
Often have undergone breech or difficult forceps delivery
Congenital Torticollis - dx
Clinical
If refractive to tx or palpable mass, do neck US and CSP x-ray
Congenital Torticollis - Tx
PT
Home exercise program
positioning
Botox or sx for severe refractive cases >6-12m duration
Torticollis - in general
Common term for cervical dystonia
May also be static or a dynamic tremor
Torticollis - causes
Idiopathic
Inherited due to genetic mutation
Acquired - infection, vascular abnormality, brain injury, toxins
Drug exposure (levodopa, dopamine agonists, antipsychotic drugs, anticonvulsants, SSRIs, metoclopramide Reglan)
Neurological - CP, Huntington dz, Parkinson’s
Psychogenic
Torticollis - dx
Clinical but workup for cause
Torticollis - tx
Tx cause
PT
Botox - type A
Cervical Strain / Sprain - in general
The result of a stretch injury to the soft tissue elements of the CSP
Strain
Muscle or tendon
Sprain
Ligament
Cervical Strain / Sprain - causes
Acute - whiplash
Repetitive / chronic
Abnormal posture - carrying a heavy suitcase on one side of the body, computer work, weak core
Cervical Strain / Sprain - presentation
Axial pain Stiffness Muscle spasms Ha Neck fatigue
Cervical Strain / Sprain - exam
Tenderness with palpation
Painful +/- decreased ROM
No radicular signs
Cervical Strain / Sprain - imaging
XR +/- MRI
Cervical Strain / Sprain - Tx
Cervical collar is as short term tx - 1-2 wks
Modalities: ice, heat massage, topical analgesics, PT
Disc Herniation - in general
Most common is C5-6 and C6-7
Disc may compress either the SC or the exiting nerves or both
Pressure on an exiting cervical nerve root can cause changes in sensory, motor and/or reflex function in the innervated areas (radiculopathy)
Disc Herniation - exam
Weakness
Decreased sensation
Asymmetric reflexes
Special tests
Spurling’s test
Perform if you suspect nerve root compression
Place pt in slight extension & lateral flexion.
Apply axial force
Closes the neuroforaminal space
Positive if pain in a radicular, dermatomal pattern on ipsilateral side
Specific, but not sensitive, in dx acute radiculopathy
Distraction test
Used when currently symptomatic Relieves symptoms Supine or sitting - place hands at occiputs and apply gentle distraction Positive if reduces symptoms Indicated a neuroforaminal compression
Disc Herniation - imaging
XR
MRI - test of choice
CT/Myelogram
Disc Herniation - tx
Nearly 90% can be tx conservatively - PT, rest, modalities, NSAIDs, oral steroids, CESI
Disc Herniation - sx
Pain management has failed
Intractable upper limb with imaging evidence of a correlating nerve root compression
Mechanical instability of the spine associated with disc herniation
S/s of neurological deficits are increasing
The disc herniation is massive and compresses the SC (myelopathy)
Myelopathy - in general
SC compression
Myelopathy - causes
Trauma Infection Inflammatory or autoimmune d/o Tumor Degenerative spondylosis Disc herniation
Myelopathy - presentation
Myelopathic or "upper motor neuron" findings Hyperreflexia Tremor Loss of fine motor control Babinski's Hoffman's Spasticity Ankle clonus Often painless May present with difficulty walking Coordination issues Incontinence or retention Loss of fine motor control
Hoffman’s sign
Hold and secure the middle phalanx of the long finger and then flick the distal phalanx
Positive is involuntary contraction of the thumb and index finger IP joints
Ankle clonus test
Rapidly flex the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius M.
Positive is tapping of the foot.
Only a sustained clonus (5 beats or more) is considered abnormal
Babinski reflex
Lateral side of the sole of the foot is rubbed with a blunt instrument or device from the heel along a curve to the metatarsal pads
Positive is when the hallux dorsiflexes and the other toes fan out
Myelopathy - imaging
MRI - preferred
CT/Myelogram, if MRI is CI
Myelopathy - tx
Involves decompressing the SC through various procedures depending on cause, spinal level and each pt
Sponylosis - causes
Dehydrated, shrinking discs
Aged herniated/cracking disc
Osteophyte formation
Contractures of ligaments and joint capsules
Sponylosis - in general
Degenerative condition
Typically begins to be seen at 40-50yo
M>W
Most commonly occurs at C5-6 > C6-7 levels
Sponylosis - RF
Frequent lifting
Smoking
Driving
Sponylosis - chronic changes
May lead to
- Radiculopathy
- Myelopathy
- Both
Sponylosis - tx
Symptom management
- PT
- Pain clinic
- NSAIDs
Odontoid fx - imaging
Seen on open mouth odontoid view XR
CT best next test for fx and stability eval
MRI if neurological symptoms exist
Odontoid fx - types
1 - avulsion of tip, rarely neurological s/s, usually stable - brace
2 - the waist , high non-union rate - halo or sx
3 - involves the body of C2 - brace
Hangman’s fx - in general
Fx of the pars interarticularis on the pedicle of the C2 verebrae
Most common of all CSP fx
Extreme hyperextension to the neck - MVA
May result in spondylolisthesis-slipping of C2 on C3
Hangman’s fx - imaging
Get CT to check for instability
Hangman’s fx - tx
Immobilization for 4-6 wks, if no displacement vs. sx
Burst fx - in general
Fall from a height, landing on one’s feet
Compressive failure of vertebral body
Most common at throacolumbar junction (T10-L2)
Less common in proximal TSP b/c the ribs help to stabilize
TSP canal is narrow in relation to the SC, so that thoracic SC injuries commonly are complete
Jefferson fx
Burst fx of C1
Diving accidents
Chance fx - in general
A flexion-distraction injury - lapbelt injury
Most commonly at the thoracolumbar junction
50% includ abdominal injuries
Burst fx - imaging
XR - AP, lat, obliques
MRI - important to eval for injury to the posterior elements
CT - important to eval degree of bone injury and retropulsion of posterior wall into canal
Columns of spine
Anterior column
Middle column
Posterior column
Anterior column
ALL
Anterior 2/3 of the vertebral body
Anterior 2/3 of the intervertebral disc
Middle column
Posterior 1/3 of the vertebral body
Posterior 1/3 of the intervertebral disc
PLL
Posterior Column
Everything posterior to the PLL Pedicles Facet joints and articular processes Ligamentum flavum Neural arch and interconnecting ligaments
Chance fx - tx (non-operative)
Immobilization in TLSO
Neurlogically intact pts
stable injury patterns with intact posterior elements
<50% vertebral height is lost
Minimal comminution
Must be followed for non-union and kyphotic deformity
Chance fx - tx (operative)
Sx decompression and stabilization
Hx three level above and two level below but modern pedicle screws have changed this to allow fewer levels
Compression Fx - in general
Osteoporosis is the most common cause
Estimated to affect 1/4 of all postmenopausal women in the US
W>M
People who have sustained one osteoporotic VCF have x5 risk of sustaining a 2nd one
Mets tumor for MM should be considered in pts <55 with no hx of trauma
Compression Fx - presentation
May be asymptomatic and incidentally found on XR
Present with midline back pain
May radiate to ribs
Typically neuro intact
Compression Fx - imaging
XR - dx the fx
MRI or bone scan confirms the acuity
Compression Fx - tx
Tx the osteoporosis
Conservative at least 2 week before considering sx
Kyphoplasty or verebroplasty with bx for failure
Thoracic Outlet Syndrome
Poorly categorized symptoms - vary
Similar s/s to other neuro or vascular condition like
- CTS
- Ulnar neuropathy (cubital tunnel syndrome)
- Cervical radiculopathy
- Brachial plexus injuries
- Myelopathy
Types of Thoracic Outlet Syndrome
Neurogenic
Vascular
Neurogenic Thoracic Outlet Syndrome - in general
Compression of lower brachial plexus, usally by tissue band that connects C7 to first rib
Most common type - 95%
W>M
Often mis-dx early on
Neurogenic Thoracic Outlet Syndrome
May present with Anterior shoulder pain Clavicular pain N/T in arm Weakness Angina May be asymptomatc at rest
Neurogenic Thoracic Outlet Syndrome - imaging
CXR / Clavicle XR to r/o cervical rib
Cervical rib
An extra rib
Present in <1% of population
May be normal bone structure or undeveloped fibrous tissue
Vascular Thoracic Outlet Syndrome - in general
If the subclavian A. is compressed, pts may notice color changes, claudication or a vague pain in the arm or hand
If the subclavian vein is compressed, there may be swelling of the arm, distension of the veins or a diffuse pain in the arm or hand
Makes the referral urgent as this may be thrombus
Pure TOS types aer rare and pts often present with s/s indicative of more than one type
Vascular Thoracic Outlet Syndrome - RF
Poor posture Hx of chest or clavicle trauma Kyphosis Large breasts Overhead athletes / workers
Vascular Thoracic Outlet Syndrome - exam
Work-up of CSP and shoulder are normal
Vascular Thoracic Outlet Syndrome - imaging
MRI of brachial plexus, NCS/EMG and doppler with angiogram is suspect vascular
Vascular Thoracic Outlet Syndrome - tx
PT/OT can help restore postural imbalances
Refer to ortho or CT surgeon
Adson test
A provocative test by compression of the subclavian A. by a cervical rib or tightened anterior and middle scalene M.
Passively extend, abduct and externally rotate affected arm while palpating the radial pulse
Ask pt to take a deep breath and hold it in
Ask pt to extend neck and rotate the head towards affected side
Positive if loss of radial pulse
Roos or East test
Have pt sit up with good posture
Shoulders abducted to 90° and externally rotated
Open and close fist for 1 min
Positive if reproduction of s/s
