Dr. Mincer C-Spine Exam Module 5 Flashcards
1
Q
The supraspinatus ligament is re-named as it continues to the cranium. What is the new name?
A
- Ligamentum nuchae (or nuchal ligament)
2
Q
What is the composition of the ligamentum nuchae?
A
- Fibroelastic (like the ligamentum flavum from the lumbar spine)
3
Q
What are two functions of the ligamentum nuchae?
A
- It helps passively support the weight of the head in an upright position (fibroelasticity helps with this)
- It is an important midline attachment for muscles
4
Q
What is the course of the vertebral artery?
A
- The vertebral artery is a branch of the subclavian artery
- It ascends through the transverse foramina to the foramen magnum
- It combines with the contralateral vertebral artery to form the Basilar artery
5
Q
Why is the location of the vertebral artery in the neck particularly important for protecting it?
A
- It runs at the axis of flexion/extension (mediolateral axis), which helps protect it from excessive stretching or pinching during flexion/extension (other movements can disrupt it more)
6
Q
What is the vertebral artery’s relationship to cervical nerve roots?
A
- It is immediately anterior to the cervical nerve roots (inside the vertebral foramen)
7
Q
What are the classic symptoms of vertebral artery compression? (10)
A
- 5 D’s
- Dizzines,
- drop attacks
- dysphagia,
- dysarthria, and
- diploplia
- fainting,
- ataxia
- nausea
- numbness of the unilateral face
- nystagmus
8
Q
Describe the general size and shape of the central (vertebral) canal in the C-spine
A
- Fairly triangular
- Large relative to the size of the segment
9
Q
The diameter of the central canal is greatest in what position?
A
Flexion
10
Q
The diameter of the central canal is least in what position?
A
Extension
11
Q
What is the overall incidence (not words, not numbers) of cancer, infection, and fracture in the C-spine?
A
- Cancer: relatively uncommon (more often than rare)
- Fracture: rare
- Infection: rare
12
Q
Who is the Canadian C-Spine Rule for?
A
- For alert and stable trauma pts where c-spine injury is a concern
13
Q
Canadian C-Spine Rule: What is the first question, and what are the three things that need yes/no answers?
What do you do next?
A
- Any High-Risk Factor Which Mandates Radiography?
- Age equal or greater to 65, or
- Dangerous mechanism, or
- Paresthesias in extremities
If yes, send to radiograph
If no to all, ask second question?
14
Q
Canadian C-Spine Rule: What is considered a dangerous mechanism? (5)
A
- Fall from elevation equal or greater to 3 feet/5 stairs
- Axial load to head, e.g. diving
- MVC high speed (> 100km/hr), rollover, ejection
- Motorized recreational vehicles
- Bicycle collision
*MVC = Motor Vehicle Collision/Accident
** 100km/hr = 62 mph
15
Q
Canadian C-Spine Rule: What is the second question, and what are the five things that need yes/no answers?
What do you do next?
A
Any Low-Risk Factor Which Allows Safe Assessment of Range of Motion?
- Simple rearend MVC*
- Sitting position in ED
- Ambulatory at time
- Delayed** onset of neck pain
- Absence of midline c-spine tenderness
If yes to any, ask question 3
If no to all, send for radiograph
*MVC = Motor Vehicle Collision/Accident
**Delayed: i.e. not immediate onset of neck pain
16
Q
Canadian C-Spine Rule: What is the third question, and what is the one thing that needs a yes/no answer?
What do you do next?
A
Able to Actively Rotate Neck?
- 45* left and right
Able, no radiograph
Unable, send for radiograph
17
Q
Canadian C-Spine Rule: What are four exceptions to the definition of Simple Rearend MVC?
A
Simple Rearend MVC Excludes:
- Pushed into oncoming traffic
- Hit by bus/large truck
- Rollover
- Hit by high speed vehicle
*MVC = Motor Vehicle Collision/Accident
18
Q
What is cervical arterial dysfunction?
A
CAD (cervical arterial dysfunction) describes potential adverse events involving both the
- vertebralbasial system supplying the hindbrain
- internal carotids (supplying the cerebral hemispheres and the retina)
* hindbrain is: Pons, Brainstem, Vestibular apparatus, Medulla Oblongata and Cerebellum
19
Q
What are three forms of CAD?
A
- Stenotic
- Occlusive
- Dissecting Aneurysms
20
Q
How does cervical rotation and extension affect the vertebral artery?
A
- It can cause Internal Carotid Artery Dissection.These movements compress the artery against the transverse process of the upper cervical vertebra
- Vertebral Artery Dissection is associated with contralateral cervical rotation that stretches or compresses the artery between the 1st two cervical vertebra
(I thought extension was one of the movements that the v-artery was mostly protected from)
21
Q
Describe the 3 main symptoms (with details) of internal carotid artery dissection?
A
- Ipsilateral frontotemporal headache
- Usually reported in the frontotemporal or hemicranial regions
- Neck Pain (upper/mid cervical or anterolateral neck)
- 9-20 percent of symptomatic patients
- Facial pain (I think it was anterolateral too)
- 34-53 percent of pts
22
Q
Describe the 2 main symptoms (with details) of vertebral artery dissection?
A
- Neck pain (34-46 percent of symptomatic pts)
- Usually sudden, severe, and sharp
- Ipsilateral
- upper posterior to middle c-spine
- Headaches sometimes accompany neck pain.
- Usually ipsilateral, constant ache in the occipital or parieto-occipital regions
**facial is not usually present
23
Q
What are the classic symptoms of vertebral artery insufficiency? (5 counting 5D’s as 1)
A
- 5D’s (drop attacks, diplopia, dysphagia, dysarthria, dizziness)
- Ataxia
- Nausea
- Numbness of the unilateral face
- Nystagmus
** strict use of theses s/s may be misleading and lead to poor understanding of the pt’s presentation (I think lightheadedness and syncope is one also a s/s that could occur).
24
Q
What factors raise the index of suspicion that a pt may have cervical arterial dysfunction (CAD)?
A
- Therapists should develop a high index of suspicion with acute onset of neck and head pain described as “unlike any other,” and consider the s/s associated with nonischemic and ischemic phases of CAD (cervical arterial dysfunction)
25
What are some things that can increase the risk for cervical arterial dysfunction?
* Careful history and review of
* cardiovascular risk factors\* including
* Diabetes Mellitus
* direct vessel trauma
* Hx of bacterial infection
* Hx of trauma (MVA, fall, lifting or coughing)
* Recent
* c-spine surgery,
* nerve blocks,
* radiation therapy,
* intubation,
* central venous catheterization ,or
* connective tissue disorders
\*such as HTN, hypercholesterolemia/dyslipidemia, hx of smoking, family hx of CVD, coagulation abnormalities,
26
Should you do the end range CAD provocation test if the index of suspicion for CAD is high?
If the index of suspicion is high based on the pt’s history, end range provocative test is not indicated and the pt is referred
27
Should you do end range CAD provocative test if pt’s index of suspicion for CAD is low?
No, there is no need.
28
How successful are the CAD provocative tests for identifying arterial dysfunction?
* In general, functional positioning tests have poor diagnostic utility as predictors of risk and will not assist the clinician with decision making related to the presence or absence of CAD
* Additionally, the Australian Physiotherapy Association recommends assessing for the presence of s/s associated with VBI during 4 stages
* History
* Physical exam
* During Tx
* Following C-spine tx
29
When are the 4 stages that the Australian Physiotherapy Association recommends assessing for the presence of s/s associated with VBI?
* History
* Physical exam
* During Tx
* Following C-spine tx
30
What are four subtypes of dizziness?
* Presyncope
* Vestibular
* Disequilibrium
* Other Dizziness
31
What are three characteristics of presyncope?
1. Lightheadedness
2. Impending faintness
3. Tiredness from altered blood supply, oxygen, or glucose
32
What is a characteristic of vestibular dizziness?
Vertigo (spinning sensation)
33
What are four characteristics of disequilibrium and three things it is associated with?
1. Unsteadiness
2. Imbalance
3. Weakness
4. Sense that fall will occur
\*\*Associated with poor vision, peripheral neuropathy, or MSK disturbances
34
What are four characteristics of “other dizziness” and something it is associated with?
1. Reports of floating
2. Anxiety
3. Depression
4. Fatigue
(suggests a psychiatric disorder/cause)
35
What kinds of dizziness can PTs often treat; which should be referred?
Symptoms of presyncopal and other dizziness may indicate the need for a referral
Dizziness caused by cardiovascular or metabolic disorders may result in precautions or contraindications to PT and require medical referral, whereas dizziness related to the c-spine (such as non-vascular cervicogenic/disequilibrium dizziness?), MSK impairments, and the vestibular system may be appropriate for PT intervention.
36
What is cervicogenic dizziness (CD)?
A specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activities from the neck.
Dr. Mincer thought it best matched the disequilibrium type of dizziness, but later I think she said it could have a vascular cause too (but I don’t think she went as far as to say presyncope was cervicogenic dizziness). Maybe she meant just cervicaogenic dizziness that is appropriate to treat with PT (since we would not treat the vascular issues).
37
How is cervicogenic dizziness diagnosed?
It is considered a diagnosis of exclusion. When all other causes of dizziness have been ruled out, CD is considered. Therefore a thorough history and physical exam are necessary to identify pts with CD, MSK impairments, and vestibular disorders appropriate for PT.
38
What are 6 CAUSES of dizziness?
1. Cardiovascular
2. Neurological
3. Metabolic
4. Psychiatric
5. Vestibular
6. Cervicogenic (cervical MSK origin)
39
What 10 ways dizziness (in general) may be described by pts?
1. Lightheadedness
2. Faintness
3. Heavy headedness
4. Falling
5. Weaving
6. Imbalance
7. Swimming sensation
8. Floating
9. Unsteadiness
10. Spinning
40
Why is cervical spine ligamentous instability so important to identify?
* CSI may be a life threatening instability appreciated with imaging,
41
What is CSI?
Cervical Spine ligamentous instability
42
Cervical Spine Ligamentous Instability: What typical dysvascular or metabolic disorders may result in precautions or contraindications? (4-5)
* CSI is often related to the transverse ligament in
* RA
* AS
* Down Syndrome
* Klippel-Feil Syndrome
* Congenital absence of or immature dens leading to compression of neurovascular structures
43
Why is rheumatic disease important to identify? (3 points)
* RA is the most common inflammatory disease that affects the C-spine
* The diarthroidal joints (dens joints) are primarily affected, but extra-articular features manifest in the skin, eyes, lungs, and nervous system.
* These effects occur early in the disease process
44
What are 6 risk factors for RA cervical disease?
1. Male
2. Seropositive rheumatoid factor
3. Rheumatoid nodules
4. Early bone erosion
5. Long standing disease
6. Prolonged steroid use
45
How does ankylosing spondylitis affect the risk of cervical fracture?
* Neck pain can become more of a complaint than LBP in older individuals who have had the disease longer due to bony ankylosis and osteoporosis,and the c-spine is at increased risk of spinal fracture. Low energy falls such as trips and slips involving hyper-extension may result in neurological deficits from these unstable fractures.
46
What is ACS?
Acute coronary syndrome (ACS), caused by insufficient blood supply to the myocardium, is a spectrum of clinical presentations, ranging from unstable angina to myocardial infarction with non-ST segment elevation, or ST segment elevation.
47
What can lead to ACS?
Increased myocardial oxygen and nutrition requirements relating to exertion, emotional stress or physiological stress, such as dehydration, blood loss, and infection or surgery, can lead to ACS.
48
What is Angina? How is it described? (include percentages)
Angina is a typical symptom of myocardial ischemia often describe as a sensation of substernal or retrosternal chest pressure, squeezing, or heaviness during exertion of 70% to 90% incidence, but only 33% or less complain of chest pain.
49
What are common signs that warn of heart attack? (4 points)
* Prolonged uncomfortable pressure, fullness, squeezing, or pain in the center of the chest
* Pain that spreads to the throat, neck, back, jaw, shoulders, or arms
* Chest discomfort with lightheadedness, dizziness, sweating, pallor, nausea, or shortness of breath
* Prolonged symptoms unrelieved by antacids, nitroglycerin, or rest
50
What is a key sign of ACS in women?
A key sign of ACS in women is unexplained severe, episodic fatigue that interferes with performing daily activities. (emphasized in class)
51
What can occur up to a month prior to an acute MI?
Weakness, fatigue, trouble sleeping, and nausea may occur up to a month prior to an acute MI.
52
What are some less common warning signs of heart attack, especially in women? women? (9 points)
1. Unusual chest pain quality and location (ie. burning, heaviness; left chest), and stomach or abdominal pain
2. Continuous midthoracic or interscapular pain
3. Continuous neck or shoulder pain
4. Isolated right biceps pain
5. Pain relieved by antacids
6. Pain unrelieved by rest or nitroglycerin
7. Nausea and vomiting
8. Flu-like manifestations without chest pain/discomfort
9. Unexplained intense anxiety, weakness or fatigue, breathlessness, and dizziness.
53
What are the symptoms of cervical myelopathy?
Clinical features of CM varies, making early diagnosis difficult.
* The LEs may be affected first with weakness and spasticity, or hyperreflexia affecting gait, often producing a wide-based gait and balance problems.
* UE changes present as weakness, atrophy, and problems with finger fine motor control.
* Additional manifestations include neck stiffness or pain, pain in the upper quarter region (shoulder, scapula), widespread numbness, paresthesias in both arms or hands, and sensory and ataxic changes of the LE.
* Sensory changes, although inconsistent, may occur later rather than early in the UE and more than in the LE, but UE symptoms have also been an early presentation. Advanced CM findings may include paresthesias, quadriparesis and bowel and bladder changes.
54
How can the cluster of 5 tests be used to rule cervical myelopathy in/out?
1. Age \> 45 years (THIS CONFLICTS WITH 55 AND 70 ABOVE)^^^
2. Positive Babinski sign
3. Positive inverted supinator sign
4. Positive Hoffman
5. Gait dysfunction described as (**SAW)** Spastic, Ataxic or Wide-based gait
Absence of a + finding, or presence of 1 of 5 tests, provides a moderate level of confidence that the patient does not have CM, whereas 3 of 5 positive test findings assists with ruling in CM if CM is suspected. based on clinical examination, a referral for additional testing is warranted.
***Hoffman, Babinski’s, Clonus, and Deep tendon reflexes associated with hyperreflexia are more specific than sensitive, and therefore considered better tests for ruling in CM***. The inverted supinator sign (i.e. finger flexion or elbow extension during the brachioradialis reflex test) may be the most sensitive test for ruling out CM.
55
What are the two most common causes of cervical radiculopathy?
* Most common is ***degeneration of the c-spine*** (which includes loss of disc height, degeneration of disc, osteophytes) – 68%,
* second most common is due to ***disc herniation. – 22%***
56
What is the relative frequency of cervical radiculopathy by level?
* 7th spinal nerve most commonly affected (70%)
* 6th spinal nerve root next most common affect
* 8th spinal nerve root is the next most commonly affected
57
At what ages is cervical radiculopathy most common?
* Peak incidence occurs in the 4th or 5th decade
58
What are the typical symptoms of cervical radiculopathy? (General)
* Symptoms with this classification include
* Neck pain with an associated radiating or narrow band of lancinating pain in the involved upper extremity, upper extremity paresthesia, and related numbness and weakness
59
* What 7 clinical findings that assist with diagnostic classification of cervical radiculopathy?
* Clinical findings that assist with diagnostic classification are
1. Upper extremity symptoms
2. Radicular or referred pain produced or aggravated with Spurling’s test
3. ULNDTs
4. Decreased with neck distraction
5. Decreased cervical rotation of less than 60 degrees to the involved side
6. Signs of nerve root compression (hard neural signs)
7. Success in reducing UE symptoms using initial examination and intervention procedures, such as distraction.
60
Explain the 4 cluster test CPR for cervical radiculopathy
* **_4 cluster test CPR-**_ _**RUDS_**
* ULTT A (most useful test when used alone for ruling out CR)
* Cervical Rotation less than 60 degrees to the involved side
* Distraction test
* Spurling test A
* If 3 items are positive, the probability of CR increases 65%
* If all 4 items are present, the probability of CR increases to 90%.
* The test item cluster produces larger posttest probability changes for diagnosis of CR than any single test item.
61
What is the NDI? (name, number of items, highest score, etc)
* Neck Disability Index
* Used Oswestry Low Back Pain Index as a template
* Consists of 10 items (4 pain intensity, headache, concentration and sleep; 4 inquire about lifting, work, driving, and recreation; 2 about personal care and reading activities).
* Each item is scored 0-5
* Scored as a percentage out of 50 (total score/50 x 100)
* If one item is left blank score is out of 50
* Higher scores represent higher perceived disability
* Scores of 40-50 and 0-10 approach a ceiling and floor effect, respectively in which case use of the PSFS should be considered.
62
NDI: What is the non-validated interpretation of scores (5 levels)
* Non-validated interpretation of scores
* 0-4 no disability
* 5-14 mild disability
* 15-25 moderate disability
* 25-34 severe disability
* \> 35 complete disability
63
**Subjective Exam/Body Map: What body areas should be cleared when examining a patient with neck pain? (6)**
1. Head
2. Neck circumferentially
3. Thoracic spine
4. Both UE circumferentially
5. Chest
6. Abdomen
64
Subjective exam/body map: What would you specifically ask about when clearing body areas? (4 ish)
* Numbness,
* tingling
* Other sensory symptoms like: cold, heaviness, dizziness, unsteady nausea, visual disturbances
* Areas that do not feel normal
65
**What is the MCID for neck pain on the NPRS?**
* MCID of 1.3 = meaningful improvement has occurred from the pt’s perspective
* In a population with CR the MCID is 2.2
66
What is the general somatic referral pattern of the zygapophyseal joints in C2-C7? General referral pattern of the AO and AA joints?
Zygapophyseal joint referral (general)
* C2 - C3 refers superiorly to the head
* C3 - C4, C4 - C5 referral is primarily over the posterior neck
* C5 - C6 spreads across the supraspinous fossa of the scapula
* C6 - C7 spreads more inferiorly over the scapula
AO and AA joints can produce neck pain in the suboccipital region and headache.
67
What are the borders of neck pain (by definition)?
Neck pain, by definition, is located in an area bound by the T1 spinous process, the superior nuchal line, and laterally by the lateral margins of the neck. However, persons with neck pain report symptoms from the inferior border of the scapula to the head and face, with or without referral to the UE and trunk.
68
How do pts describe somatic referred pain?
Pts describe somatic referred pain as deep, dull aching and expanding into wide areas that are difficult to localize
69
Are neurologic signs absent in somatic referred pain?
Somatic referred pain does not involve spinal nerve or nerve roots, so neurological signs are absent.
70
How does 24 hour behavior: When is pain at night mechanical; when is it concerning?
* **Pain at night** is mechanical in origin when:
* Pt reports inability to lie on the involved side
* Symptoms relieved by change in position
* If the pain is most intense at night and the patient is unsure of what wakes her, reports she must get up and walk around, and has difficulty returning to sleep consider:
* Active inflammatory component
* Neoplasm
71
Most musculoskeletal conditions are (better/worse/the same) in the morning?
Most musculoskeletal conditions are better **in the morning**
72
**What should we determine if a pt reports night pain? (3)**
**Need to determine:** frequency, provocative position and symptoms produced
73
What do the following suggest about morning pain?
* Worse in morning
* Unchanged in morning
* improved in morning and remain better with movement
* improved in morning but worsen with activities of the day
* Worse in morning - may be due to poor sleeping posture
* Unchanged in morning - nonmechanical or minor mechanical
* improved in morning and remain better with movement - mechanical with good prognosis
* improved in morning but worsen with activities of the day - mechanical with limited prognosis
74
What is a role of the coordination deficits classification in relationship to other classifications?
* Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery
75
What is a role of the coordination deficits classification in relationship to other classifications?
* Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery
76
FABQ: What are the cut-off scores for neck? What were lumbar cut-off scores? (for comparison)
* Cut-off scores for neck
* FABQ-Total = 48
* FABQ-Work = 18
* FABQ-PA = 15
* Cut-off scores for lumbar (for comparison/review)
* FABQPA = \>14 (score range 0-24)
* FABQW =\> 29? or \>20 (score range 0-42)
77
How was FABQ adapted for the neck?
The word “neck” is substituted for the word “back” when used in patients with neck pain
