Exam 1: Cervical & Thoracic Spine Flashcards
1
Q
What separates the physical therapy examination from other examination by other professionals?
A
- repeated, ongoing assessment
- “comparable sign”
- response to treatment
2
Q
T/F: The facet joints cannot refer pain past the knee?
A
True
3
Q
Anterior primary ramus
A
- referred pain from structures innervated by nerves of the plexus
- muscles: longus capitis, upper trapezius, intercostals, psoas, and quadratus lumborum
4
Q
Posterior primary ramus (medial)
A
- innervates the deepest back muscles (multifidi and rotatores)
- periosteum of posterior vertebral arch
- spinal ligaments - interspinous, supraspinous, ligamentum flavum, and intertransverse
5
Q
Posterior primary ramus (lateral)
A
- innervates erector spinae
- splenius capitis/cervicis, upper trap (?)
- overlying skin
6
Q
Posterior primary ramus (lateral)
A
- innervates erector spinae
- splenius capitis/cervicis, upper trap (?)
- overlying skin
7
Q
Recurrent meningeal n.
A
- periosteum of posterior aspect of vertebral bodies
- internal vertebral (epidural) veins and basi-vertebral veins
- epidural adipose tissue
- posterior aspect of intervetebral disc
- posterior longitudinal ligament
- anterior aspect of spinal dura mater
8
Q
Sympathetic trunk and ANS
A
- periosteum of anterior and lateral aspects of vertebral bodies
- lateral aspect of the intervetebral disc
- anterior aspect of the intervertebral disc
- anterior longitudinal ligament
9
Q
Dorsal root ganglion
A
the modulator of spinal nociception
10
Q
What is the difference between somatic referred pain and radicular pain?
A
referred pain is nociception generated by a skeletal or related structure and is perceived in an area distant to the structure generating the nociception
radicular pain arises from the dorsal root or dorsal root ganglia and is referred along a portion of the course of the nerve formed by the affected dorsal root
11
Q
Clinical feature of referred pain
A
- dull ache
- difficult to localize
- constant in nature
12
Q
Clinical feature of radicular pain
A
- sharp, shooting pain along the dermatomal distribution
- “long radiation” into the thoracic area
- pain coursing along a fairly thin band
- pain accompanied by paresthesia, hypesthesia, and decreased reflexes
- pain accompanied by motor weakness
13
Q
What are the two types of long radiation?
A
wrapping around the side or directly from back to front
14
Q
What is the mechanism of radicular pain?
A
- pressure on the dorsal root or DRG causes edema within the nerves
- prolonged edema and hemorrhage within the DRG results in decreased blood flow to sensory nerve and cell bodies
- ischemia of neural elements is perceived as pain
15
Q
Why are nerve roots more susceptible to injury than peripheral nerves?
A
- poorly developed epineurium
- no branching of nerve root fasciculi
- missing perineurium
16
Q
Dural stretch tests examine:
A
ALL tension within a nerve, including:
- the nerve as a whole
- the CT in the nerve (epineurium, perineurium, and endoneurium)
- the CT in the spinal canal (dura mater, arachnoid, and pia mater)
- neurons
- intrinsic blood supply of nervous system
17
Q
Where are the three vertebral levels that are sensitive during the slump test?
A
- C6
- T6
- L4
18
Q
Intraneural symptoms
A
- typically more chronic (longer Rx time)
- responds to pressure, tension, palpation
- neural Sx (burning, tingling, etc.); may persist after the release of neural tension
19
Q
Extraneural symptoms
A
- “catches” of pain
- non-neural tissue (tight mm.)
- neural Sx abate with the release of neural tension
20
Q
What are important considerations when performing neurodynamic tests?
A
- peripherally vs. centrally evoked
- motor (autonomic effects)
- the pattern of Sx (mechanically vs. neurally dominated)
21
Q
Odontoid view
A
- A-A, A-O joints
- ligamentous instability
*superimposition artifacts often lead to misinterpretation
22
Q
A-P view
A
- the shape of vertebrae
- the presence of lateral wedging
- the presence of a cervical rib
- uncovertebral joint symmetry
23
Q
Lateral view
A
- cervical lordosis (increased, decreased, “flattened”)
- “kinking” of the spine (subluxation, dislocation)
- vertebral body fusion, wedging, the number
- displacement
- disc space, lipping, osteophytes
- articular facet joints
24
Q
Oblique view
A
- intervertebral foramen (sclerotic narrowing)
- facet joint overriding
- lipping of uncovertebral joints
25
Pillar (Weirs) view
- facet joints, articular processes
| - lamina, spinous processes
26
Swimmer's view
allows visualization of C7-T1/T2; a common site for wedge compression fractures
27
Where is the most common site of metastasis on the vertebrae?
pedicles
28
What are the three key features of the posterior lateral oblique view in the lumbar spine?
1. sense of joint integrity (joint space, parallel joint surfaces, smooth joint surfaces)
2. defect in pars interarticularis - "scotty dog sign"
3. SI joint - check for narrowing
29
Canadian C-Spine Rule
1. High-risk factors:
- age ≥ 65
- dangerous mechanism
- upper extremity paresthesia
2. Low-risk factors:
- simple rear-end MVA
- sitting position in ER
- ambulatory at any time
- delayed onset of neck pain
- an absence of c-spine tenderness
3. 45˚ ROM to the R/L
30
What are the dangerous mechanisms of the Canadian C-Spine Rule?
- MVA
- loss of consciousness
- fall of >3 ft. in an older patient
31
What are the three signs of degenerative disease?
1. narrowing of disc space
2. osteophyte formation
3. reactive sclerosis (facets, IV joints)
32
What are radiographic irregularities LIKELY to cause back pain?
- moderate or severe spondylolisthesis
- multiple markedly narrowed IV discs
- congenital kyphosis
- severe scoliosis
- osteoporosis
- ankylosing spondylitis
- Scheuermann's disease
33
Fryette's Law
1. With facets in neutral position, rotation is to the side opposite the direction of side-bending (for thoracic and lumbar spine)
2. With spinal segment in full flexion or extension, rotation and side-bending occur to the same side (for thoracic and lumbar spine, and ALWAYS true to the cervical spine)
3. Motion in any plane reduces motion in all other places (coupled motion)
34
Craniovertebral Joint
comprised of five joints (R/L O-A, R/L A-A, and articulation between anterior arch of C1 and odontoid process
responsible for 50% of cervical rotation and a fair amount of nodding/tilting
35
Concave-Convex Rule at O-A and A-A
- O-A: convex occiput moves rolls and glides in opposite directions
- A-A: atlas (and occiput) glide in the same direction as the axis
36
The ALL becomes the __________ in the cervical spine
anterior atlantooccipital membrane
37
The PLL becomes the __________ in the cervical spine
tectorial membrane
38
The ligamentum flavum becomes the __________ in the cervical spine
posterior atlantooccipital membrane
39
Lower Cervical Spine (C3 - T2)
two intervertebral joints at each segment and four facet joints; four uncovertebral joints
facet joints adhere to the concave rule (i.e. as superior facet moves the superior and inferior articular facets move in the same direction)
40
What are the MSK generators for headaches?
- upper four cervical vertebrae
- basiocciput and occipital conyles
- ANS
41
What are the common sites for compression of the vertebral aa?
- skeletal muscles and fascial bands at C6-7
- osteophytes at transverse foramen (C4-5 and C5-6)
- sliding motion of A-A or distortion at A-O joint
42
What are possible S/Sx of a cervical spine fracture or fracture dislocation?
- pain in the neck, occiput, shoulder
- headache
- LOC
- restricted movement
43
C-Spine fractures and dislocations occur from which types of force?
- compression
- shear
- tension
- combination
44
A pure flexion MOI produces which type(s) of fracture(s) and/or fracture dislocation(s)?
- wedge compression
| - odontoid fracture
45
A flexion w/ rotation MOI produces which type(s) of fracture(s) and/or fracture dislocation(s)?
- subluxations
- dislocations
- fracture-dislocations of the facets and/or compression of wedge fractures
46
A hyperextension MOI produces which type(s) of fracture(s) and/or fracture dislocation(s)?
- neural arch fracture (C1-2)
- odontoid fracture
- spinous process fx (i.e Clay shoveler's fx)
47
A vertical compression MOI produces which type(s) of fracture(s) and/or fracture dislocation(s)?
- Atlas fracture (Jefferson's fx)
| - Burst fracture
48
A lateral flexion MOI produces which type(s) of fracture(s) and/or fracture dislocation(s)?
- lateral mass fx of the pedicles, vertebral foramina, or facet joints
49
Which two components determine the stability of a cervical spine fracture?
- middle column AND
| - posterior longitudinal ligament
50
What conditions are associated with A-A dislocation?
- Primary synovitis (RA, lupus, ankylosing spondylitis, etc.)
- Regional infections
- Primary or metastatic neoplasms
- Congenital anomalies
51
Odontoid Fracture
- Types I, II, and III
- the result of severe flexion or extension injury
- varying neurologic involvement
- non-union common (type II - poor blood supply)
- treatment includes hard collar or halo, Crutchfield tongs, or surgical fusion
52
Hangman's Fracture
- pedicle fracture at C2 results in slipping on C3, severing the phrenic n.
- fatal w/ displacement
- no neurologic damage w/o displacement
53
Cervicogenic HA (IHS Criteria)
1. localized pain to neck and occipital region
2. pain precipitated or aggravated w/ special neck position or posture
3. at least one of the following:
- limited passive neck movement
- changes in mm contour, texture, tone, or response to active/passive motions
- abnormal neck mm tenderness
4. at least one of the following on radiologic examination:
- movement abnormalities in flexion/extension
- abnormal posture
- fractures, congenital abnormalities, bone tumors, rheumatoid arthritis, or other distinct pathology
54
Klippel-Feil Syndrome
- gross limitations of neck motion
- low hair line
- bilateral neck webbing
- bilateral failure of scapular descent (Sprengel's deformity); most often unilateral
- radiographs demonstrate a congenital fusion of cervical vertebrae - usually 2 levels
55
Torticollis
- bony = uncorrectable
- acquired (spasm, post-traumatic) = Rx w/ Botox
- congenital muscular (correctable)
- usually minimal clinical presentation at birth
- SCM fibrous tissue hypertrophy noted at 3-4 weeks
- little growth in mm length
- progressive facial asymmetry (2˚ to above)
56
Why are herniated discs less common in the cervical spine than in the lumbar spine?
- the paucity of nuclear material
- joints of von Lushka
- strong PLL
57
What are the two questions posed by Wainner et al (2003) that are important to ask pts with suspected cervical radiculopathy?
- Where are your Sx most bothersome
| - Do your symptoms improve with moving your neck
58
Cervical Radiculopathy CPR
- ULTT (median)
- involved cervical rotation < 60˚
- distraction test relieves radicular Sx
- Spurling's test reproduces radicular Sx
59
Cervical Radiculopathy CPR
- ULTT (median)
- involved cervical rotation < 60˚
- distraction test relieves radicular Sx
- Spurling's test reproduces radicular Sx
60
Cervical Radiculopathy S/Sx
- pain level
- sensory deficit (dermatomal pattern)
- DTR disturbance
- Motor deficit (triceps, biceps, pronator teres, deltoid, and hand)
61
What is the most common reason for hand weakness?
brachioplexitis
62
Treatment of Cervical Radiculopathy
- Medication (NSAIDs, muscle relaxers, steroids, etc.)
- Soft collar
- Postural control/positioning
- Modalities
- Traction
- Exercise
63
What did Keating et al (2005) find in regards to patients' initial NDI scores?
patients with higher NDI scores are more likely to show improvement than individuals who had lower initial NDI scores
64
The CPR proposed by Cleland et al (2007) found that what four factors, if present, resulted in better short term outcomes in patients with cervical radiculopathy?
- < 54 years old
- dominant arm not affected
- looking down did not increase Sx
- multimodal Rx used for ≥ 50% of visits
65
How much does it cost to treat patients experiencing WAD per year?
$29 billion
66
What are possible explanations for differences in WAD incidence between men and women?
- neck musculature differences
- canal size differences
- women are more likely to file insurance claims
67
Quebec Task Force Classification for WAD
0: no neck complaint or physical sign(s)
1: complaint of pain, stiffness, or tenderness only but no physical sign(s)
2: neck complaint and MSK sign(s)
3: neck complaint and neuro sign(s)
4: neck complaint and fracture or dislocation
68
Pavlov's ratio
the ratio of spinal canal and vertebral body should be just below 1; if significantly greater the pt is at a greater risk for WAD
69
Contributing factors to WAD
- forward head posture
- awareness of impending collision
- injury severity correlated with crash severity
70
What percentage of patients have a delayed onset of neck pain after WAD? Why?
22%; slow accumulation of blood/fluid in the paraspinals causing pain once the pain threshold is reached
71
Patients who complain of a headache following WAD most likely have a lesion in the:
posterior occipital musculature
72
Patients who complain of ulnar-sided hand numbness following WAD most likely have a lesion in the:
scalenes
73
Patients who complain of difficulty swallowing following WAD most likely have a lesion in the:
pharynx, esophagus, longus colli
74
Patients who complain of ringing in the ears following WAD most likely have a lesion in the:
vertebral/basilar aa., temporomandibular bone
75
Patients who complain of vertigo following WAD most likely have a lesion in the:
vertebral aa., inner ear
76
Mechanism of Flexion Injury
- posterior distraction
- anterior shearing
- anterior compression
77
Mechanism of Extension Injury
- posterior compression
- posterior shearing
- anterior distraction
78
WAD S/Sx
- alar ligament injury
- transverse ligament injury
- active perilymph fistulas
-
79
Early radiographic findings associated with WAD
- decreased cervical lordosis
- retropharyngeal hemorrhage
*motion films may be helpful
80
Late radiographic findings associated with WAD
- DJD of cervical spine
81
What may explain persistent Sx and chronic pain in patients following WAD?
- perturbations w/ ADLs
- internal neural fibrosis
- loss of normal muscle (i.e. fatty infiltration)
- involvement of ANS
- CNS re-connections or other alterations
82
What factors are associated with long-term disability in WAD patients?
- early Sx of UE pain and N/T; interscapular pain
- sharp cervical curve reversal
- women > men
- litigation pending
- Hx of LOC
83
Which ANTERIOR segments accounts for most of the displacement during cervical traction in neutral?
- C4-5 (12%)
| - C3-4 (8%)
84
Which POSTERIOR segments accounts for most of the displacement during cervical traction in neutral?
- C6-7 (37%)
- C3-4 (22%)
- C4-5 (19%)
85
What factors are suggestive of nonorganic signs in patients with neck pain?
1. tenderness - superficial, non-anatomic
2. simulation - head/shoulder/trunk rotation in sitting position; head/shoulder/trunk rotation while standing
3. ROM - R/L (C1-C2 segments)
4. regional disturbance - sensory loss; motor loss
5. overreaction - subjective!
86
Why is the diagnosis of thoracic spine disorders difficult?
- difficult to palpate
- no appendages to assess
- three level overlap
- referral pattern not as well defined as other regions
- an unusual constellation of Sx
87
Pain in or around the scapulae may be referred from:
the gallbladder
88
Pain in or around the shoulder may be referred from:
the diaphragm
89
Pain in or around the epigastric region may be referred from:
the heart
90
Pain in or around the abdomen may be referred from:
the lung or pleura
91
Pain in or around the umbilicus may be referred from:
appendix or pancreas
92
Pain in or around the left chest area may be referred from:
spleen
93
Facet orientation follows the _______ ____
concave rule
94
Cervical facet joints can cause referred pain:
- C3-4: T1
- C5-6: T1-7
- C7: inferior angle of the scapula
95
Sources of thoracic pain (muscular):
- intercostals
- serratus anterior
- interscapular
- thoracolumbar fascia
- diaphragm
96
Rib motions:
T1-T6: pump handle motion
T7-T10: bucket handle motion
T11-T12: caliper motion
97
Rib Fractures
- breathing difficulty
- heals within 6 weeks
- may damage the lung, spleen, or kidney
98
Causes of acute costochondritis
- traumatic or associated with fibromyalgia
- myofascial syndrome
- thoracic spine pain
99
Causes of chronic costochondritis
- Tietze's disease
| - Low-grade inflammation and disease
100
Sources of thoracic pain (ribs):
- fracture
- costochondritis
- slipping rib tip
- site of metastasis
101
Sources of thoracic pain (nerves):
- Herpes zoster
| - Nerve lesions (long thoracic, spinal accessory, suprascapular)
102
Where are the most common sites for facet joint DJD?
C7-T1 and T4-T5
103
Where are the most common sites for costovertebral DJD?
Ribs 6-8
104
What were the findings of the study regarding thoracic back pain and denervation?
- Pts with thoracic back pain from T2-5 had a joint problem, while pts from T8-L1 had a denervation problem
105
Causes of Kyphosis
- osteoporosis
- metabolic disease
- microfractures
- disc degeneration
- Paget's disease
106
Scheuermann's Disease
- rigid kyphosis
- osteochondrosis of several vertebrae
- affects the younger population
- Schmorl's nodes
- anterior vertebral body fusion (2-5 levels)
107
Pott's Disease
- TB of the spine
- insidious onset
- vague ill health
- angular kyphosis
- gibbus deformity
- pain, dull ache
108
Types of Scoliosis
- postural: decreased with Adam's forward bend test
- short-leg: decreased with sitting or correction
- sciatic: decreased with cause or pain is treated
109
What are the most common types of scoliosis?
- right thoracic curve - 22%
- right thoracolumbar - 16%
- left lumbar curve - 24%
- double major curve - 37%
110
What are two key features to measure scoliosis?
- Risser sign
| - Cobb angle
111
What effect might the loss of muscle spindles play in the development of scoliosis? Pineal gland?
muscle spindles play an important role in proprioception, kinesthetic input, and postural tone; loss of muscle spindles may cause the development of scoliosis
the pineal gland releases serotonin, which is important in the metabolism of spine growth
112
Conservative Management for structural scoliosis
- orthotic bracing
- Milwaukee brace, Boston brace system, Wilmington Brace
- 74% success rate (i.e. prevention of further progression)
113
Milwaukee Brace
>5˚ progression per 6 mos. OR angle = 20-30˚
114
Conservative Management (Exercise) for structural scoliosis
- posture
- strength - trunk, extremities
- ROM
- leg length
- breathing pattern (i.e. diaphragmatic)
- functional activity method
- SCHROTH METHOD
115
Appropriate candidates for surgical management of structural scoliosis:
- failed conservative treatment
- > 40˚ curve in patients who are still growing
- > 50˚ curve following bone growth cessation
116
What two factors determine the stability of thoracic spine fractures?
- the integrity of the PLL
| - the degree of collapse; > 50% collapse are generally considered unstable
117
Thoracolumbar Fractures
- T1 - T9: rare d/t increased stability from ribs
- Above T10: cord transection
- T10 - L1: cord and nerve root lesion combination
- Below L1: nerve root injury/lesion only
118
Chance Fracture
vertebrae fracture that transects the cord and all abdominal organs; patients often expire from internal bleeding
119
Lamina Fracture
- usually from a missile or fracture
- neural damage possible
- no articular problems
- function (no loss of motion)
120
Pedicle Fracture
movement may lead to paraplegia
121
Transverse/Spinous Process Fracture
direct blow, but usually have a quick recovery
122
When is myelography indicated?
- confirm or exclude intraspinal lesions
- establish the size and location of a known lesion
- medicolegal reasons
123
Abnormal myelographic results
- ruptures of IV disc
- spinal cord compression
- stenosis
- tumor
- nerve root injury
