Examination of the Cervical Spine

Question 1

O que é uma lesão do coluna cervical?

Answer 1

Injury or pain to any structure (muscle, bone, or any other soft tissue) within the neck or head, superior to T1 Excludes traumatic brain lesions, concussion, etc.

Question 2

Apesar de não haver muita investigação acerca dos achados clínicos subjetivos, quais poderão ser os pontos-chave?

Answer 2

• Was trauma involved?
• Dizziness or other odd symptoms?
• Myelopathy, Radiculopathy, or Somatic Referred Pain?
• Irritability Status (como é que o estado da pessoa é alterado devido a ligeiro movimento; quanto tempo dura e; quanto tempo demora a passar)
• Headaches?
• Duration of Symptoms
• Behavior of Symptoms (How does movement affect pain?)

Question 3

Em caso de histórico de trauma, o que é preciso descartar?

Answer 3

Rule out Fracture;
Rule out Ligamentous Disruption;
Rule out Concussion or mild traumatic brain injury.

Question 4

Após trauma, quem não necessita de ser submetido a radiografia cervical?

Answer 4

1) cognitively in tact and have no neurological
symptoms; 2) are under the age of 65; 3) are not fearful of moving the head upon command; 4) no painful, distracting injury; 5) who demonstrate no midline pain are spared a radiograph.

Canadian C-Spine Rules (Sn = 99; LR- = 0.01)

Question 5

Quais são os 8 sintomas para suspeita de concussão?

Answer 5

A history of mild Traumatic Brain Injury and the presence of three or more of the following eight symptoms:

1) headache;
2) dizziness;
3) fatigue;
4) irritability;
5) insomnia;
6) concentration problems;
7) memory difficulty;
8) intolerance of stress, emotion, or alcohol.

Question 6

Após um trauma na zona cervical, quais são os sintomas que suspeitam dano ligamentar?

Answer 6

Fearful of moving head; Muscle Spasms; Pain; Spinal cord oriented symptoms.

Question 7

Quais os sintomas associados a disfunção de artéria cervical? (insuficiência vértebro-basilar)

Answer 7

Ataxia; Clumsiness and agitation; Diplopia; Dizziness; Drop attacks; Dysarthria; Dysphagia; Facial numbness; Hearing disturbances; Hoarseness; Hypotonia/limb; weakness (arm or leg); Loss of short-term memory; Malaise; Nausea; Nystagmus; Pallor/tremor; Papillary changes; Perioral dysthesia; Photophobia; Vagueness; Vomiting.

Question 8

Quais as alterações associadas a radiculopatia?

Answer 8

Muscle Weakness; Sensory Changes; Tendon Reflex diminished; unilareal.

Question 9

Quais as alterações associadas a mielopatia?

Answer 9

A mielopatia envolve a compressão ou distúrbio do sistema vascular da espinal medula (é como se fosse uma radiculopatia que afete a espinal medula em vez das raízes nervosas).

Muscle Weakness; Sensory Changes; Tendon Reflex Hyper-reflexic; Upper Motor Neuron Signs; Clumsiness; Bilateral; Loss of Vibration Sense.

Question 10

Quais as questões que ajudam a determinar a irritabilidade?

Answer 10

1. What do you have to do to set off this problem?
2. When it’s set off, how long does it last?
3. What do you have to do to calm it down to base levels?

Question 11

Quais as desordens associadas a irritabilidade mais comuns na cervical?

Answer 11

1. Whiplash;
2. Radiculopathy;
3. Acute Herniated Disc.

Question 12

Quais as desordens não irritáveis na zona cervical?

Answer 12

1. Postural Problems;
2. Cervical Spondylosis;
3. Clinical Instability;
4. Non-Acute Herniated Disc;
5. Cervicogenic Headache.

Question 13

Quais as outcome measures mais robustas para o seu uso em problemas cervicais?

Answer 13

Neck Disability Index (MID = 5; Minimal Clinical Importance Difference MCID = 18);
Numeric Pain Scale, VAS or NPRS (MCID is considered to be 1.3 to 2 for mechanical neck pain);
Patient Specific Functional Scale (Allows a unique activity limitation assessment, MCID = 2 points);

Headache Impact Scale.
Myelopathy Disability Index.

Question 14

Existe alguma relação entre a postura e a dor?

Answer 14

The posture is not necessarily predictive of neck pain. However, can influence neck pain when symptoms are currently present (e.g., Whiplash).

Question 15

Qual a relação entre a postura e ergonomia?

Answer 15

Faulty classroom ergonomics can lead to neck pain. Work postures, such as forward flexed position of head, neck, and shoulders; static loading of muscles; as well as repetitive motions can cause cumulative trauma disorders or aggravate pre-existing problems

Question 16

A anteriorização da cabeça está habitualmente associada a que achados clínicos?

Answer 16

Forward head posture is associated with Temporo Mandibular Disorders; Chronic headaches; Weakness of the anterior neck flexors; Weakness of the lower trapezius.

Question 17

Como se caracteriza a Upper Crossed Posture?

Answer 17

• Shortening of the posterior cervical muscles;
• Alongamento e insuficiência ativa dos músculos cervicais anteriores;
• Encurtamento dos peitorais e músculos anteriores do peito;
• Alongamento dos músculos posteriores estabilizadores escapulares.

Question 18

Qual a relação entre a anteriorização da cabeça e a coluna torácica?

Answer 18

Forward Head Posture (FHP) mediated the relationship between thoracic kyphosis and cervical ROM, specifically general cervical rotation and flexion.
These results not only support the justifiable attention given to addressing FHP to improve cervical impairments, but they also suggest that addressing thoracic kyphosis impairments may constitute an “upstream” approach.

Question 19

Qual o impacto do stress, ansiedade e medo?

Answer 19

May be exacerbating the condition of the patient.
Stress is associated with mechanical neck pain and with headaches. Fear has a less definitive relationship but is likely are mediator for whiplash associated disorder.

Question 20

Já se sabe que os clínicos não são bons a detetar desordens psicológicas clinicamente relevantes para a condição. O que poderá ajudar a contornar essa limitação?

Answer 20

The use of outcome tools (scales).

Question 21

Quais são os agrupamentos de variáveis para a suspeita de uma fratura cervical fechada?

Answer 21

1) Idade inferior a 55 anos; 2) solteiro(a); 3) condição envolvendo trauma; 4) condição aguda; 5) condição que envolveu entrada no serviço de emergência.

Se o individuo não tiver nenhuma destas variáveis, é improvável que possua fratura.
2 em 5 variáveis - SN 72-99; SP 67-69.
3 em 5 variáveis - SN 85-89; SP 86-88.
4 em 5 variáveis - SN 21-53; SP 97-99.

Question 22

Quais são os agrupamentos de variáveis para a suspeita de Cervical Myelopathy?

Answer 22

(1) Gait deviation; (2) +Hoffmann’s test; (3) Hyperreflexia of the brachioradialis; (4) +Babinski test; and (5) age superior to 45 years.

1 em 5 variáveis - SN 0.94 (.89-.97); SP 0.31 (.27-32).
3 em 5 variáveis - SN 0.19 (.15–.20); SP 0.99 (.97–.99).
4 em 5 variáveis - SN .09 (.06–.09); SP 1.0 (.98-1.0).

Question 23

Quais são os achados clínicos da dor de cabeça que sugerem que a pessoa deva ser observada por um neurologista?

Answer 23

No prior history or Family History of Headaches;
Especially Headache onset after age 40-50 years;
Change in Headache pattern;
Progressive in frequency or severity;
Headache awakens patient from sleep;
Occipital or frontal focal Headache;
Provocative factors (Exertion, Cough or other Valsalva maneuvers, Sexual activity).

Question 24

Que outras red flags associadas à dor de cabeça podem sugerir a consulta com um neurologista?

Answer 24

– Vomiting, Persistent and Progressive
– Persistent Constitutional or Meningeal Symptoms (Fever; Stiff neck; Chronic malaise, myalgias or arthralgias);
– Focal neurologic signs (Progressive visual disturbance; Weakness, clumsiness, or loss of balance);
– Papilledema
– Photophobia or Phonophobia
– Seizure history
– Headache occurring after Head Trauma

Question 25

Quais são os princípios para encaminhar a utente com dores de cabeça?

Answer 25

SNOOP for Headaches:

• Systemic symptoms or illness (Fever; Altered Level of Consciousness; Anticoagulation; Pregnancy; Cancer);
• Neurologic symptoms or signs (Papilledema; Asymmetric Cranial Nerve function; Asymmetric motor function; Abnormal Cerebellar Function);
• Onset recently or suddenly;
• Onset after age 40 years;
• Prior Headache History that is different or progressive.

Question 26

Quais são os passos para testar os movimentos fisiológicos ativos da coluna torácica?

Answer 26

1. Baseline; 2. Move to First point of pain; 3. Move past First point Of pain to end range; 4. Assess if concordant; 5. No pain? Over-pressure (para descartar problemas articulares; 6. Repeat on Opposite Side.

Atenção: para testar a extensão da coluna cervical inferior, é necessário chin retraction - caso contrário iríamos incidir sobre a coluna cervical superior.

Question 27

With respect to the odd feelings in shoulders and arms, which technique that is best to consider and isn’t always used to assess the cervical spine?

Answer 27

• Anterior Posterior mobilization (an AP is useful when there are odd sensations in the arms or shoulders).

Question 28

Como realizar o Jull Test for Endurance?

Answer 28

• The test is performed in a supine position.
• Perform a chin retraction at 10 mmHg (com a cuff de um esfignomanómetro entre a marqueza e a cervical);
• Hold for 10 seconds;
• Record last value at 10 seconds;
• Repeat 10 times;
• Sum values.

Question 29

Como testar a Scapular Endurance?

Answer 29

The patient is instructed to place their elbows and shoulders at 90 degrees. They are then instructed to perform external rotation with a t-band as resistance. By performing against a wall (but not touching) the right performance is assured.

Question 30

Como se aplica a mobilização de C0-C1 para verificar se é causadora de dor de cabeça cervicogénica?

Answer 30

There are three testing positions. The C0-1 position is in prone with pressure placed on the lateral aspect of C1 downward toward the ispilateral eye. C2-3 and tested in the same manner as a C2-3 UPA. C1-2 involves 30 degrees of rotation to a side and a force applied toward the mouth of the patient.

Sn 62; Sp 87; LR+ 4.9; LR- 0.43.

Question 31

Se aplicarmos acessórios póstero-anteriores nas vértebras cervicais e não conseguirmos reproduzir o sinal concordante, o que podemos suspeitar?

Answer 31

Talvez o problema não esteja no pescoço. Poderá ter origem na coluna torácica, ATM, ombro, etc.

This test has 100% Sensitivity at identifying a lesion of any sort - Helps rule out presence of cervical pain on any origin.

Question 32

Que teste (com boas propriedades psicométricas) poderemos aplicar para ajudar a identificar dor de cabeça cervicogénica em C1-2? E como aplicar?

Answer 32

Flexion-rotation test (Sn .86; Sp 100; LR+ ~18+) - Rules in and out the presence of a cervicogenic headache with an origin at C1-2.

A flexão total da cervical estira o complexo ligamentar na coluna cervical inferior, permitindo acentuar os movimento em C1-2 com rotação.

The patient’s neck is placed in full flexion. The clinician then rotates the neck to each side looking for both reproduction of symptoms and a restriction of 15 degrees or more on the affected side.

Question 33

Qual o teste mais utilizado para identificar indivíduos com radiculopatia cervical?

Answer 33

Cervical Distraction Test (Sn 0,40; Sp 100).

Em decúbito dorsal, aplicamos tração (causando abertura do foramen lateral). Se a dor diminuir, desaparecer ou centralizar, é considerado um achado clínico positivo para radiculopatia.

Question 34

Para que são utilizados os Upper Limb Tension Tests (ULTTs)? E como realizar o do nervo mediano?

Answer 34

Estes testes são utilizados para colocar tensão sobre as raízes nervosas e ajudam a descartar a presença de radiculopatia cervical (Sn 0,97; LR- 0.14).

Median Nerve Bias - In a supine position the scapula is stabilized by the clinician. Then, the clinician performs movements into wrist extension, ulnar deviation, elbow extension, and shoulder abduction. A reproduction of symptoms is considered a positive finding.

Question 35

Qual é o teste que nos ajuda a descartar a presença de bloqueio ou restrição cervical? E como aplicar?

Answer 35

Palpation Side Glide (the study just identificates C2-3 restritions only, pelo que a utilidade é diminuta já que raramente temos problemas nesta zona) - Sn 0,98; LR- 0.02; LR+ 10.9).

The patient is placed in a sitting position. The clinician pushes the neck in extension and side flexion and feels for a block at a level.

Question 36

Que teste podemos realizar para nos ajudar a identificar a presença de radiculopatia cervical?

Answer 36

Spurlings Test (Sp 0,92; LR+ 4.87).

The patient side flexes their head to the side of arm symptoms. The clinician then applies a downward force to compress the intervertebral foramen. A positive test is referred symptoms.

Question 37

Qual a clinical prediction rule para diagnosticar radiculopatia cervical?

Answer 37

Spurlings; ROM inferior 60 degrees; Distraction test; and ULTT.
Sn 24, Sp 99, LR+ 30.3 (all 4 tests positive); QUADAS 10.

Question 38

Como se processa o Neck Flexor Endurance Test?

Answer 38

Adquire-se a posição do Jull Test for Endurance (upper cervical flexion movement). Porém, admitem-se algumas alterações: Hold as long as you can while maintaining chin retraction; Keep the crease in the neck; Timed test.
Não devemos utilizar em pessoas com dor cervical severa ou pós-whiplash porque pode ser agressivo. There is an association between weak anterior neck flexors and cervicogenic headache.

Question 39

Como Perform the Lateral Lift Test?

Answer 39

The patient is instructed to hold their neck in a lateral position (from the plinth) for as long as they can. Time the hold. Repeat on opposite side and compare ratio of side to side.

Question 40

Como executar Posterior Neck Endurance test?

Answer 40

Em decúbito ventral e com um cinto na zona torácica, the patient perform a chin retraction and hold the flattened neck position for as long as they can. Add a load to the head to increase the difficulty. Timed test.

Question 41

Quais são os problemas mais comuns da região cervical?

Answer 41

Cervical Disc Disorders (Herniated disc);
Cervical Degenerative Disorders (Spondylosis/Spondylolysis; Stenosis - Myelopathy and Radiculopathy);
Headaches (Cervicogenic headache);
Cervical Neck Injuries (Whiplash Associated Disorder).