Dr. Mincer C-Spine Exam Module 5

Question 1

The supraspinatus ligament is re-named as it continues to the cranium. What is the new name?

Answer 1

• Ligamentum nuchae (or nuchal ligament)

Question 2

What is the composition of the ligamentum nuchae?

Answer 2

• Fibroelastic (like the ligamentum flavum from the lumbar spine)

Question 3

What are two functions of the ligamentum nuchae?

Answer 3

1. It helps passively support the weight of the head in an upright position (fibroelasticity helps with this)
2. It is an important midline attachment for muscles

Question 4

What is the course of the vertebral artery?

Answer 4

• 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

Question 5

Why is the location of the vertebral artery in the neck particularly important for protecting it?

Answer 5

• 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)

Question 6

What is the vertebral artery’s relationship to cervical nerve roots?

Answer 6

• It is immediately anterior to the cervical nerve roots (inside the vertebral foramen)

Question 7

What are the classic symptoms of vertebral artery compression? (10)

Answer 7

1. 5 D’s
   
   • Dizzines,
   • drop attacks
   • dysphagia,
   • dysarthria, and
   • diploplia
2. fainting,
3. ataxia
4. nausea
5. numbness of the unilateral face
6. nystagmus

Question 8

Describe the general size and shape of the central (vertebral) canal in the C-spine

Answer 8

• Fairly triangular
• Large relative to the size of the segment

Question 9

The diameter of the central canal is greatest in what position?

Answer 9

Flexion

Question 10

The diameter of the central canal is least in what position?

Answer 10

Extension

Question 11

What is the overall incidence (not words, not numbers) of cancer, infection, and fracture in the C-spine?

Answer 11

• Cancer: relatively uncommon (more often than rare)
• Fracture: rare
• Infection: rare

Question 12

Who is the Canadian C-Spine Rule for?

Answer 12

• For alert and stable trauma pts where c-spine injury is a concern

Question 13

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?

Answer 13

• 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?

Question 14

Canadian C-Spine Rule: What is considered a dangerous mechanism? (5)

Answer 14

1. Fall from elevation equal or greater to 3 feet/5 stairs
2. Axial load to head, e.g. diving
3. MVC high speed (> 100km/hr), rollover, ejection
4. Motorized recreational vehicles
5. Bicycle collision

*MVC = Motor Vehicle Collision/Accident

** 100km/hr = 62 mph

Question 15

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?

Answer 15

Any Low-Risk Factor Which Allows Safe Assessment of Range of Motion?

1. Simple rearend MVC*
2. Sitting position in ED
3. Ambulatory at time
4. Delayed** onset of neck pain
5. 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

Question 16

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?

Answer 16

Able to Actively Rotate Neck?

• 45* left and right

Able, no radiograph

Unable, send for radiograph

Question 17

Canadian C-Spine Rule: What are four exceptions to the definition of Simple Rearend MVC?

Answer 17

Simple Rearend MVC Excludes:

1. Pushed into oncoming traffic
2. Hit by bus/large truck
3. Rollover
4. Hit by high speed vehicle

*MVC = Motor Vehicle Collision/Accident

Question 18

What is cervical arterial dysfunction?

Answer 18

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

Question 19

What are three forms of CAD?

Answer 19

1. Stenotic
2. Occlusive
3. Dissecting Aneurysms

Question 20

How does cervical rotation and extension affect the vertebral artery?

Answer 20

• 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 1^st two cervical vertebra

(I thought extension was one of the movements that the v-artery was mostly protected from)

Question 21

Describe the 3 main symptoms (with details) of internal carotid artery dissection?

Answer 21

• 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

Question 22

Describe the 2 main symptoms (with details) of vertebral artery dissection?

Answer 22

• 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

Question 23

What are the classic symptoms of vertebral artery insufficiency? (5 counting 5D’s as 1)

Answer 23

1. 5D’s (drop attacks, diplopia, dysphagia, dysarthria, dizziness)
2. Ataxia
3. Nausea
4. Numbness of the unilateral face
5. 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).

Question 24

What factors raise the index of suspicion that a pt may have cervical arterial dysfunction (CAD)?

Answer 24

• 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)

Question 25

What are some things that can increase the risk for cervical arterial dysfunction?

Answer 25

* 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,

Question 26

Should you do the end range CAD provocation test if the index of suspicion for CAD is high?

Answer 26

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

Question 27

Should you do end range CAD provocative test if pt’s index of suspicion for CAD is low?

Answer 27

No, there is no need.

Question 28

How successful are the CAD provocative tests for identifying arterial dysfunction?

Answer 28

* 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

Question 29

When are the 4 stages that the Australian Physiotherapy Association recommends assessing for the presence of s/s associated with VBI?

Answer 29

* History * Physical exam * During Tx * Following C-spine tx

Question 30

What are four subtypes of dizziness?

Answer 30

* Presyncope * Vestibular * Disequilibrium * Other Dizziness

Question 31

What are three characteristics of presyncope?

Answer 31

1. Lightheadedness 2. Impending faintness 3. Tiredness from altered blood supply, oxygen, or glucose

Question 32

What is a characteristic of vestibular dizziness?

Answer 32

Vertigo (spinning sensation)

Question 33

What are four characteristics of disequilibrium and three things it is associated with?

Answer 33

1. Unsteadiness 2. Imbalance 3. Weakness 4. Sense that fall will occur \*\*Associated with poor vision, peripheral neuropathy, or MSK disturbances

Question 34

What are four characteristics of “other dizziness” and something it is associated with?

Answer 34

1. Reports of floating 2. Anxiety 3. Depression 4. Fatigue (suggests a psychiatric disorder/cause)

Question 35

What kinds of dizziness can PTs often treat; which should be referred?

Answer 35

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.

Question 36

What is cervicogenic dizziness (CD)?

Answer 36

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).

Question 37

How is cervicogenic dizziness diagnosed?

Answer 37

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.

Question 38

What are 6 CAUSES of dizziness?

Answer 38

1. Cardiovascular 2. Neurological 3. Metabolic 4. Psychiatric 5. Vestibular 6. Cervicogenic (cervical MSK origin)

Question 39

What 10 ways dizziness (in general) may be described by pts?

Answer 39

1. Lightheadedness 2. Faintness 3. Heavy headedness 4. Falling 5. Weaving 6. Imbalance 7. Swimming sensation 8. Floating 9. Unsteadiness 10. Spinning

Question 40

Why is cervical spine ligamentous instability so important to identify?

Answer 40

* CSI may be a life threatening instability appreciated with imaging,

Question 41

What is CSI?

Answer 41

Cervical Spine ligamentous instability

Question 42

Cervical Spine Ligamentous Instability: What typical dysvascular or metabolic disorders may result in precautions or contraindications? (4-5)

Answer 42

* 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

Question 43

Why is rheumatic disease important to identify? (3 points)

Answer 43

* 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

Question 44

What are 6 risk factors for RA cervical disease?

Answer 44

1. Male 2. Seropositive rheumatoid factor 3. Rheumatoid nodules 4. Early bone erosion 5. Long standing disease 6. Prolonged steroid use

Question 45

How does ankylosing spondylitis affect the risk of cervical fracture?

Answer 45

* 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.

Question 46

What is ACS?

Answer 46

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.

Question 47

What can lead to ACS?

Answer 47

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.

Question 48

What is Angina? How is it described? (include percentages)

Answer 48

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.

Question 49

What are common signs that warn of heart attack? (4 points)

Answer 49

* 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

Question 50

What is a key sign of ACS in women?

Answer 50

A key sign of ACS in women is unexplained severe, episodic fatigue that interferes with performing daily activities. (emphasized in class)

Question 51

What can occur up to a month prior to an acute MI?

Answer 51

Weakness, fatigue, trouble sleeping, and nausea may occur up to a month prior to an acute MI.

Question 52

What are some less common warning signs of heart attack, especially in women? women? (9 points)

Answer 52

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.

Question 53

What are the symptoms of cervical myelopathy?

Answer 53

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.

Question 54

How can the cluster of 5 tests be used to rule cervical myelopathy in/out?

Answer 54

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.

Question 55

What are the two most common causes of cervical radiculopathy?

Answer 55

* 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%***

Question 56

What is the relative frequency of cervical radiculopathy by level?

Answer 56

* 7^th spinal nerve most commonly affected (70%) * 6^th spinal nerve root next most common affect * 8^th spinal nerve root is the next most commonly affected

Question 57

At what ages is cervical radiculopathy most common?

Answer 57

* Peak incidence occurs in the 4th or 5th decade

Question 58

What are the typical symptoms of cervical radiculopathy? (General)

Answer 58

* 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

Question 59

* What 7 clinical findings that assist with diagnostic classification of cervical radiculopathy?

Answer 59

* 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.

Question 60

Explain the 4 cluster test CPR for cervical radiculopathy

Answer 60

* **_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.

Question 61

What is the NDI? (name, number of items, highest score, etc)

Answer 61

* 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.

Question 62

NDI: What is the non-validated interpretation of scores (5 levels)

Answer 62

* Non-validated interpretation of scores * 0-4 no disability * 5-14 mild disability * 15-25 moderate disability * 25-34 severe disability * \> 35 complete disability

Question 63

**Subjective Exam/Body Map: What body areas should be cleared when examining a patient with neck pain? (6)**

Answer 63

1. Head 2. Neck circumferentially 3. Thoracic spine 4. Both UE circumferentially 5. Chest 6. Abdomen

Question 64

Subjective exam/body map: What would you specifically ask about when clearing body areas? (4 ish)

Answer 64

* Numbness, * tingling * Other sensory symptoms like: cold, heaviness, dizziness, unsteady nausea, visual disturbances * Areas that do not feel normal

Question 65

**What is the MCID for neck pain on the NPRS?**

Answer 65

* MCID of 1.3 = meaningful improvement has occurred from the pt’s perspective * In a population with CR the MCID is 2.2

Question 66

What is the general somatic referral pattern of the zygapophyseal joints in C2-C7? General referral pattern of the AO and AA joints?

Answer 66

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.

Question 67

What are the borders of neck pain (by definition)?

Answer 67

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.

Question 68

How do pts describe somatic referred pain?

Answer 68

Pts describe somatic referred pain as deep, dull aching and expanding into wide areas that are difficult to localize

Question 69

Are neurologic signs absent in somatic referred pain?

Answer 69

Somatic referred pain does not involve spinal nerve or nerve roots, so neurological signs are absent.

Question 70

How does 24 hour behavior: When is pain at night mechanical; when is it concerning?

Answer 70

* **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

Question 71

Most musculoskeletal conditions are (better/worse/the same) in the morning?

Answer 71

Most musculoskeletal conditions are better **in the morning**

Question 72

**What should we determine if a pt reports night pain? (3)**

Answer 72

**Need to determine:** frequency, provocative position and symptoms produced

Question 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

Answer 73

* 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

Question 74

What is a role of the coordination deficits classification in relationship to other classifications?

Answer 74

* Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery

Question 75

What is a role of the coordination deficits classification in relationship to other classifications?

Answer 75

* Most patients with neck pain, regardless of the initial classification, require assessment and intervention or muscle performance deficits for optimal recovery

Question 76

FABQ: What are the cut-off scores for neck? What were lumbar cut-off scores? (for comparison)

Answer 76

* 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)

Question 77

How was FABQ adapted for the neck?

Answer 77

The word “neck” is substituted for the word “back” when used in patients with neck pain