Exam 1: C-spine Flashcards
What motions occur at the A-O joint?
flexion/extension
lateral flexion
What motions occur at the A-A joint?
rotation
flexion/extension
What is the facet orientation in the C-spine, and what motions does this orientation allow?
between vertical and horizontal planes; allows rotation, flexion/extension, and lateral flexion
Describe the joints of Luschka.
Uncinate process and the adjacent part of the superior vertebae; limits lateral flexion, guides flex/extension; provides stability
What is the effect of cervical motion on intervertebral foraminal size?
Flexion increases
Extension decreases
Describe intervertebral discs in the C-spine.
provide shock absorption and movement
no AA or AO discs
nucleus pulposus, annulus fibrosis on the outside
discontinuous rings and thickened anteriorly compared to other places in the spine
How does the disc:body ratio compare in the C-spine with other areas of the spine?
greatest ratio in cervical and lumbar spines, least in thoracic (bigger ratio=more movement)
What motions are coupled in the C-spine?
axial rotation and lateral flexion
BRAIN BREAK! Don’t forget to look in the C-spine review sheets you made for ligaments and muscles. Review dermatomes & myotomes please.
this was a brain break brought to you by Anna White
Mobility and stability in the cervical spine
C-spine is most mobile region of the spine; stability is critical for protecting nerves, BVs, etc
together-use mobility to position sense organs, then use stability to keep still so senses aren’t distracted by motion
Where does half of rotational movement of the C-spine come from?
A-A, O-A joints (upper cervical spine)
What is acute pain, and what is chronic pain?
acute 3 months
What are demographic risk factors of neck pain?
female, 45-49 years old
What are occupational/physical work risk factors of neck pain?
Heavy labor occupations, office and computer workers, health care (dentists, nurses), unemployed, sedentary work, repetitive work, working with neck flexed, working with arms at or above shoulder height
What hobby is a risk factor for neck pain?
cycling
What factors are negative for PT, and what are positive for PT?
People with neck pain who see PT’s have more severe pain, functional problems, worsening health status. Positive indicators for seeking PT: higher education, worker’s comp, and being in litigation.
Negative indicators: age, male
pain characteristics of non-MS neck pain
deep, nonspecific location
constant, not related to movement, night occurence
BRAIN BREAK!! review red flag symptoms on page 4 of C-spine hand out
Go ahead, Mark would want you to.
Tracheobronchial referral: conditions and symptoms
conditions: inflammation, infection (viral or bacterial), tumor
potential symptoms: neck pain, dyspnea, dysphagia, persistent cough, fever/chills, hemoptysis
bone tumors
benign: osteochondromas/blastomas, chondromas, hemangiomas, giant cell tumor
malignant: osteo/chondrosarcoma, multiple myeloma
symptoms of tumors in head/neck
neck pain, sore throat, dysphagia, growing mass, UMN signs (if SC involvement)
Pancoast’s tumor: pathology
lung cancer in upper lobe that invades lower brachial plexus
Pancoast’s tumor: symptoms
extrapulmonary: pain in shoulder/scapula, referred down arm; more common than
pulmonary: cough (isn’t typical initially), chest pain
Horner’s syndrome
mimics radiculopathy
Horner’s syndrome
if the tumor invades the sympathetic chain enopthalamos (protuding eye) ptosis miosis anhidrosis (dry eye)
Osteomyelitis in the neck
Staph and strep most common
Sx: neck pain, night pain, stiffness, may have a fever
Discitis
Osteomyelitis of vertebral body
Can be infectious
Sx: neck pain, stiffness, may have a fever
See disc space narrowing on imaging
In later stages, might have myelo- or radiculo- pathic signs
CV pain referral: Acute MI, carotodynia
MI: males-neck and jaw, females, back and neck
carotodynia: painful carotid artery; pain in front of neck, inflammation in arterial wall
GI referral
esophageal conditions (infection, tumor, varices (pouches that develop in esophagus) sx: anterior neck pain, dysphagia
disease conditions that can affect neck pain
Lyme disease, RA, ankylosing spondylitis, fibromyalgia, Klippel-Feil syndrome (congential fusion of cervical vertebrae), hypo- and hyper- thyroid
A-A joint ligaments
Alar, cruciform (includes transverse leg), apical, anterior atlanto-dental ligament, ALL/PLL, accessory A-A ligament
signs/symptoms of AA instability
suboccipital pain (C2), bilateral UE/LE paresthesias, nystagmus, UMN signs, headaches, blurry vision
causes of AA instability
congenital bony malformation, Down’s Syndrome (ligamentous laxity); inflammatory-RA, PA, ankylosing spondylitis, osteomyelitis; trauma; chronic corticosteroid use
radiculopathy
impingement of a nerve root; sensory and motor changes
myelopathy
impingement of the SC; UMN signs/sx
What’s the only outcome measurement for the C-spine?
Neck Disability Index
scoring of the NDI
least disabled=0, most disabled=5; higher number=greater disability
MCID=7pts (8.5)
0-4 no disability; 5-14 mild; 15-24 moderate; 25-34 severe; 35 and up complete disability
What do we do clearing exams?
To figure out if the neck pain is referred from somewhere else or not. Test other joints to see how that changes the neck paint (TMJ, shoulder)
symptoms of VBI
Dizziness, diplopia, dysarthria, dysphagia, drop attacks, nauseua & vomiting, sensory changes
What is the vertebral artery test for?
clearing test for VBI before doing upper c-spine manual therapy; can probably rule it, but not rule out
Wainner’s radiculopathy cluster
ULNT (median)
cervical rotation less than 60
Spurling’s test
cervical distraction test
BRAIN BREAK: page 12 has a summary of evidence
it’s probably important
standard series for radigraphs for C-spine
anterior-posterior
lateral
AP open mouth (odontoid)
other plain film views for C-spine
oblique
flexion-extension stress view
ABC’s of c-spine films
Adequacy: 7 vertebrae
Alignment: all 4 lines (anterior bodies, posterior bodies, spinolaminar line, SP line)
Bone: body and SP uniformity
Catilage: disc space
Soft tissue: prevertebral soft tissues C2 <22mm
CT
shows relationship of bones to neural canal in transverse plane
MRI
visualization of SC and soft tissues
myelogram
contrast solution into subarachnoid space; visualization of SC and nerve roots
discogram
injection of contrast material into discs
Child’s Neck Pain Clinical Practice Guidelines
Neck pain with mobility deficits
Neck pain with headaches
Neck pain with movement coordination impairments
Neck pain with radiating pain
Neck pain with mobility deficits
- younger individual (< 3 months)
- symptoms isolated to neck with no neuro-related pain patterns (may have trigger point)
- restricted cervical ROM, associated restricted segmental mobility
Neck pain with headaches
- unilateral HA associated with symptoms in neck/suboccipital area
- HA produced or aggravated with provocation of the ipsilateral posterior cervical myofasia & jts
- restricted cervical ROM & cervical segmental mobility
- abnormal/substandard performance on the cranial cervical flexion test (typically have weak deep flexors)
- acute or chronic
Neck pain with movement coordination impairments
- chronic pain
- abnormal cranical cervical flexion test
- abnormal deep flexor endurance test
- coordination, strength, and endurance deficits of neck and upper quarter muscles
- flexibility deficits of upper quarter muscles
- ergonomic inefficiencies with performing repetitive activities
Neck pain with radiating pain
- UE symptoms produced or aggravated with Spurling’s, ULT tests, and reduced with neck distraction test
- decreased cervical rotation (<60) toward involved side
- signs of nerve root compression
- success with reducing UE symptoms with initial exam and intervention procedures
- acute or chronic
Principles of Classification -McKenzie system
pain behavior
loss of ROM
presence of referred pain
effect of repeated movement
Postural Syndrome
caused by mechanical deformation or vascular insufficiency of normal tissue as a result of prolonged positioning
characteristics of postural syndrome
full painfree cervical AROM
no arm pain
neck pain with sustained end range positions
gradaul onset, dull, symmetric pain
dysfunction syndrome
caused by mechanical deformation or vascular insufficiency of abnormal tissue (shortened, fibrosed, lengthened)
characteristics of dysfunction syndrome
loss of cervical AROM
intermittent neck pain
neck pain at end range
no arm pain
derangement syndrome
caused by internal disruption or displacement of tissues
-thought to be disc related
characteristics of derangement syndrome
loss of cervical AROM
constant neck pain
pain radiates into UE
neck/arm pain affected by repeated movement
What’s the most common postural impairment?
forward head
What’s the effect of forward head on the c-spine?
increased facet loading, extension of upper c-spine
What’s the effect of forward head on muscle activity?
increased posterior cervical muscle activity
Upper crossed syndrome
Hyperactivity and shortness of levator, upper trap, pec major and minor
Hypoactivity and lengthening of deep neck flexors, middle and lower traps
deep cervical flexors
longus colli and capitis, rectus capitis anterior and lateralis
FHP and cervical mobility
variable, depends on when they present
Where do trigger points usually present in upper crossed syndrome
short and hyperactive muscles
-upper trap, SCM/scalenes, levator scapulae, masseter, temporalis
Child’s and McKenzie classifications of FHP
Childs: mobility deficits maybe, headaches maybe, movement coordination impairments maybe
McKenzie: postural syndrome, dysfunction syndrome
disc height/body ratio
2:5
cervical vs. lumbar discs
annulus: discontinuous, thickened anterior, posterior support is PLL, no alternating lamellae fiber directions
NP: 25% of disc (vs 50%), fibrosis an desiccation with age
4 classifications of disc pathology
annular tears
disc protrusion (contained)
disc extrusion (prolapse)
disc sequestration
Where do the most disc problems occur?
in general: lumbar, then cervical, thoracic
in C spine- C6/7
Cloward’s areas
interscapular pain due to anterior disc irritation
Bakody’s sign
put arm on the top of their head and it relieves their symptoms
comfort posture for disc problems
may be sidebent or rotated away from the painful side
Childs and McKenzie classifications for disc problems
Childs: with radiating pain
McKenzie: derangement syndrome
disc tx
McKenzie repeated motion for centralization;
traction, though it’s not supported by evidence; mobes and manips, including T-spine; nerve gliding
Cervical spondylosis
degenerative spinal changes-OA
Radiographic hallmark signs of C spondylosis
decreased disc height (DDD), osteophytes (DJD) (jts of Lushka, facet hypertrophy)
common areas for c spondylosis
C5-6, C 6-7
unique exam findings
morning stiffness, neck crepitation; generally can’t centralize any nerve pain with bone pushing on the nerves; motion typically reduced in all directions; positive Spurling’s
Cervical Spondylitic Myelopathy
UMN signs (B neuro sx UE and LE, gait clumsiness, loss of hand dexterity, B&B changes)
test cluster for CSM
Babinski, inverted supinator sign, Hoffman’s, reflex testing (hyperreflexive)
Childs and McKenzie classifications for cervical sponylosis
Childs: movement coordination impairment or radiating pain
McKenzie: maybe dysfuction or derangement, but this really isn’t meant for disc pts
cervical spondylosis tx
FHP correction; traction; heat can help
facet dysfunction
crick in the neck
pain source from facet dysfunction
unknown; maybe synovial entrapment in facet, segmental muscle spasm maybe
Classifications of facet dysfunction
Childs: mobility deficits
McKenzie: dysfunction
Whiplash-associated disorder: common adverse prognosis predictors
female, severe pain, low professional status/low level of education
WAD classification table
Grade 0
no complaint about neck, no physical signs
WAD classification table
Grade I
Neck pain, stiffness, or tenderness only; no physical signs
WAD classification
Grade II
neck complaint and MS signs
WAD classification
Grade III
neck complaint AND neuro signs
WAD classification
Grade IV
neck complaint and fx or dislocation
exam findings
know details of accident, LOC; upper cervical instability assessment is critical; myelopathic signs are red flag
WAD classifications
Childs: mobility deficits if acute, could be radiating pain, chronic=movement coordiation impairments, could be headaches or radiating pain
McKenzie: acute in all directions=non-mechanical, after that dysfunction or derangement
WAD intervention
soft collar for 2&3, 72 hours; controlled rest 1-4 days for 2&3; stretching non-appropriate with pain
Myofascial Pain Syndrome
trigger points not inflammatory, not systemic; acute onset-trauma, stress, fatigue, posture, hormones; dully aching pain pattern; upper crossed syndrome
MPS trigger points
hyperirritable spot, taut and palpable band, local pain with compression, referred pain, twitch response with snapping palpation
MPS classification
Childs: maybe headaches, movement coordination impairments, NOT radiating pain
McKenzie: maybe dysfunction
MPS intervention
ischemic compression, myofascial release, spray n stretch
Jefferson fx
C1 fx from axial load
Hangman’s fx
C2 pedicle fx from sudden hyperextension
Odontoid
dens fx where it attaches to C2 body; from combined hyperextension/rotation
Clay Shoveler’s
lower c-spine SP fx from forced hyperflexion; typically C4 and below
Ferguson-Allen classification of c-spine fx
compresssion-flexion compression extension vertical compression distraction-flexion distraction-extension distraction
Do people with ORIF in their spine ever have normal range?
Nope. Sagittal and frontal motion are limited, can have about 50% rotation
fx classification
Doesn’t really fit any of them. Childs might be mobility deficits, movement coordination impairment.
general post-surgical rehab guidelines
collar 4-6 weeks, walking program, ROM at tolerance at 6 weeks, muscle strengthening at 8-10 weeks (isometrics->isotonics)
cervicogenic headaches-NM causes
cervical muscle tension, trigger points, greater occipital nerve impingement, convergence of C1-C4 afferents and trigeminal afferents
location of cervicogenic headaches
tend to be unilateral; occiput to forehead, orbits, temples, ears
BRAIN BREAK! page 21 of part 2: dx criteria
learn it. love it. know it.
CGHA exam findings
weak deep cervical flexors, scapular stabilizers; tight cervical extensors, suboccipitals; suboccipital region trigger points
CGHA classifications
Childs: neck pain with headaches
McKenzie: postural if range isn’t restricted, then its dysfunction; could be derangement
Congenital muscular torticollis
unilateral shortening of SCM muscles
potential causes of torticollis
muscle injury during fetal development, birth trauma, intrauterine malposition
JRA
persistent arthritis lasting more than 6 weeks in 1 or more joints in a child under 16
types of JRA
systemic, polyarticular (5 jts or more), pauciarticular (4 joints or less)
How is the c-spine usually involved in JRA?
loss of extension, rotation, lateral flexion; AA subluxation risk
one last BRAIN BREAK
read EBP section (23-24 of part 2)
