Head and Neck Diagnosis + Managment Flashcards
What are some history questions that should be asked for a cervical spine Exam?
- patient age b/c OA after 60
- mech of injury
- trauma
- losss of consciousness
- headache, dizziness nausea, trouble speaking, double vision
- numbness, tingling or weakness
- type of work, typical posture, sleeping posture
What regions do you inspect?
- head and neck
- posture of head neck and shoulder
What ROM should be tested in a cervical spine exam?
- Flexion
- Extension
- Lateral Flexion
- Rotation
- TMJ ROM
do AROM and PROM
What should be palpated during a cervical exam?
- mandible and TMK
- masseter/parotids
- submandibular gland
- submental; gland
- thyroid gland
- trachea/larynx
- lymph nodes
- clavicle and SC joint
- SCM and scalenes
- mastoid process
- carotid artery
- articular pillars
- facet joints
- spinous process
- upper trapezius
- levator scapulae
- splenius cervicalis/ capitis
- semspinalis capitis
- suboccipitals
- upper rib motion
- supraclavicular fossa
- clavicle
What ADL’s should be checked in a cervical exam?
- Breathing
- Swallowing
- looking up and down
- shoulder activity
What action tests C1 and C2 myotomes?
cervical flexion
What action tests C3 myotomes?
Cervical Side Flexion
What action tests C3 myotomes?
cervical lateral flexion
What action tests C4 myotomes?
Trpezius elevation
What action tests C5 myotomes?
Shoulder abduction
What action tests C6 myotomes?
Elbow Flexion and Wrist extension
What action tests C7 myotomes?
Elboe extension and wrist flexion
What action tests C8 myotomes?
Finger flexion
What action tests T1 myotomes?
Finger abduction
What DTR tests for C6 nerveroot?
Biceps and brachioradialis
What DTR tests for C7 nerve root?
Triceps
NO VBI TESTING during exam
DO NOT VBI test`
What cluster of test witll be used if a sprain or strain is suspected?
- cervical distraction
- cervical AROM/PROM and Muscle Test
- O’Donoghue maneuver (cervical AROM/PROM RROM)
- scalene cramp test (diff between scalene strain or scalene triggerpoint)
- kemps
What is the orthopedic cluster for Cervical joint disc and facet injury?
- cervical compression and distraction
- maximal cervical compression test
- spurlings
- jacksons
What cluster of orthopedic tests would be used for Cervical Instability?
- alar ligmanet stress test
- lateral shear test
- sharp-pulser test
- transverse ligament stress test (Rust sign)
- xray if suspect instability
What cluster of orthopedic tests for cervical radiculopathy/Nerve tension?
- cervical compression distraction
- brachial plexus compression test (compress supraclavicular fossa with patients arms out like roo’s test)
- bakody’s sign
- soto-hall test (like slump test but jsut for neck, also supine)
- upper limp tensioning tests
- cough, sneeze, valsava
What is the orthopaedic cluster for TOS?
- Adson’s
- Wrights
- Eden’s
- Roo’s
What are the coupled motions of the cervical spine?
- lateral flexion coupled with same side rotation
What is a cervical Sprain/Strain?
- soft tissue damage ass w/ ligament or muscle tearing or stretching
- ass. w/ Whiplash associated disorder
- facets affects
- reversal or straightening of the lordodic curve
What is damaged with an hyperextension cervical sprain/strain?
- anterior tissues
- ALL
- longus coli
- SCM
- scalenes
- TMJ
What is damaged with a hyperflexion sprain/strain?
- damages posterior neck tissue
- nuchaal ligament
- interspinous ligament
- trapezius
- levator scap
- suboccipitals
- TMJ
What are the different gradings of Cervical Sprains and Strains?
- Grade 1
Grade 2
- Grade 3
What is a grade 1 cervical sprain/Strain?
- mild swelling
- point tenderness
- no bruising
- mild stretch but no instability
- negative stress tests but pain at end of ROM
- Functionally better in 2 - 14 days
- Structural recovery takes 6 - 30 days
What is a grade 2 sprain/strain?
- mild/moderate swelling
- 11 - 90% of tissue damage
- some instability in stress tests
- Functional Recovery in 14 days to 2 months
- Structural healing in 1 to 3 months
What is a grade 3 cervical Sprain/Strain?
- severe brusinig and swelling
- fracture adn dislocation must be ruled out
- complete tearing of muscles and ligaments
- instability seen with testing
- almost complete loss of ROM
- Fucntional Recovery time 1 - 3 months
- Structural Healing time 6 months+
Risk Factors for Cervical Sprain Strain?
- prior cerviocal injury
- overuse
- postural
- sudden movement
- trauma
Cervical Sprain/Strain History?
- mechanism of injury
- prior injury
- pain, cervical and shoulder
- delayed onset muscle soreness (1 - 2 days)
- pain radiates into shoulder/arm nondermatomal
- Headache
- difficulty sleeping
- 5 D and 3 Ns
Cervical Strain/Sprain Physical signs?
- Observe: postural change, stiff neck, swelling brusing
- Palpation: local tenderness, joint dysfucntion, muscle spasm, hypertonicity
- ROM: Strain: pain with AROM and RROM
Sprain: pain with PROM and AROM
joint capsule: pain in multiple directions
DDx of Cervical Sprain/Strain?
- Stress/avulsion fracture/dislocation
- Cervical radiculopathy
- disc herniation
- Inflammatory RA
- Discogenic pain syndrome
- Spondylosis
- Hemarthrosis (vascular damage) or hematoma
- TOS
Orthopedic Cluster for cervical sprain/strain?
- cervical distraction/compression
- AROM, PROM, RROM
- jacksons
- spurlings
- mac formainal compression
* lcoal neck pain = sprain strain
- referal = radiculopathy or IVF encroachment
Imagin for Cervical Sprain Strain?
- reversal of lordotic curve
- need flexion and extension view for instability
- do quiclkly for injuries which may be grade 2 or higher
Treamtemnt for Cervical Sprain/Strain?
- PRICE
pain free ROM and isometrics
- myofacial release: scalenes SCM and posterior musculature
- cervical distraction
- scalene PIR
- manipulation contra when acute but can do in adjacent region (thoracic/shoulder), also adjacent to vertebrae which may be in lesion
Red flags to Cervical Sprain/Strain?
- non improvement or worsening after 1 week
- seeks drugs
- non-compliance
- more dysfucntional
- signs and symps of depression
- TENS IFC
- MED: NSAIDS, muscle relaxants
Rehab for cervical Sprain/Strain?
- control pain and inflam
- restore full ROM
- muscle strengthening
- proprioceptive retraining
- return to sport
How to monitor a patient wtih cervicla sprain/strain?
- questinaire (NDI)
- VAS
- ROM
- ADL
- Ortho Test
Prevention/Patient Education of Cervical Sprain/Strain?
- teach to protect and stabalize neck
- avoid aggravating loading positions
- sleep without pain
- erogonomic set up of chair and head rests
- strenghten neck muscles and maintain flexability
- take breaks if in poor posture
Prognosis of cervical sprain/strain?
- Grade 1: 2 days - 2 weeks should be function 90 % better, 6 dasy to a month to be structurally 90% better
- Grade 2: Fucntionally recover to about 90% in 14 days - 2 months, strucurally recover to 90% in 1 - 3 months
- Grade 3: Function back to 90% in 1 - 3 months, Structurally recover to 90% in 6 months to a year
What is Bell’s Palsy?
- iodiopathic unilatereal facial paralysis
- no known cause
- sudden
Key History in Bell’s Palsy?
- sudeen onset (<48 hrs) of single sided facial weaknessand unable to close one eye
Physical Signs of Bell’s Palsy?
- expressionless on single side
- must do a HEENT exam b/c potentially CN 7 involvement
- dropping of mouth
- can’t whistle or close single eye
DDx of Bell’s Palsy?
- stroke above facial nucleus in pons therefore forehead is sparred
- tumor
- Bilateral Bell’s Palsy occurs in: Guillian Barre, Chronic meningitis, Lyme Disease
- Do cranial nerve testing
Treatment for Bell’s Palsy?
- protect eye (eye patch)
- educate pateitn to report any additional finding (pain discharge or visual changes)
- lymphatic drainage
- manipulation for compensatory cervical spine dysfunctions
- meds: corticosteriods and antivirals
Prognosis for Bell’s Palsy?
- 85 % of people recover within a 6 months
What is Trigeminal Neuralgia?
- facial pain syndrome in >1 divisions of the trigeminal nerve
- idiopathic
Key History of Trigeminal Neuralgia?
- sudden sharp stabbing intense pain
- triggered by chewing
- patients avoid rubbing face to avoid exaccerbating symptoms
Physical Signs of Trigemnial Neuralgia?
- fo full HEENT
- all other cranial exams are normal
DDX of Trigeminal Neuralgia?
- cluster headache or migrane
- stroke
- MS
- cavities, TMJ issues
- tumor
Tream of Trigeminal Neuralgia?
- massag b/w attacks
- maniopulation for cervical compenstaitons
meds: antiepileptics
Prognosis of Trigemninal Neuralgia?
- 75% of patient respond to medication and recover immediatly
What is Benign Positional Vertigo?
- abnormal sensation of moition caused by certain postions of the head resulting in nystagmus
Pathophysio of Vertigo?
- Canalithiasis: free moving densities in the posterior semicircular canal
- Cupulolithiasis: densities stick to the cupula, these left the posterior semilunar canal snesitivt to gravity
Demographics of Vertigo?
- occur in ages 50 - 57
Risk factors of vertigo?
- increasing age, head trauma, vestibular neuritis, migranes, inner ear surgery
Key History of Nenign Positional Vertigo?
- prior head trauma, ear disease or CNS disease
- prior episodes only when the head is kept in a certain position
- lasts from seconds to several minutes
- patients report nausea and vomiting with slight head movemnts
- notice vertigo when suddenly get up or into sudden extension
Physcial Signs of Vertigo?
- Dix HallPike maneuver is the gold standard for beinign paroxysmal positional vertigo
- Dx hall pike: patient sitting to supine quickly with ehad turned to side, wait 20 secoinds in this position, if no nystagmus repeat on the other side
- rotation nystagmus = pathogenic
- horizontal nystagmus = horizontal canal movement
- sustained nystagmus indicated cupulilithiasis
Differential Diagnosis of Vertigo?
- Meniere’s disease: reccurent vertigo, lasts hrs to days, ass with tinnitus and history of diabetes
- Migrane HA: vertigo may proceed headache
- Labyrinthitis: sudden onset constant dizziness, slowly improves over weeks, often ass. with hearing loss
- stroke: usually focal sensory and motor deficts
- vestibular neuritis: same as labyrinthitis without hearing loss
- vertebrogenic: history of neck trauma
When to use imaging in Vertigo?
- to rule out pathologies
Treatment for Vertigo?
- canalithiasis Repositioning Procedure
- Epleys maneuver: wait 10 mins before leaving the office, sleep supine for next 2 - 3 days, avoid rapidally oscilating movements
- suboccipital muscle release and distraction
- manipulation helps if the veritgo is cervicogenic
Meds are not as effecitve only temporary relief of the symptoms
Rehab for Vertigo?
- habituation exercises eye and head movements in triggers positions
- movements fatigue the response to positionall stimulation
- repeated passive and active rom
- hold vertigo provocative head position and hold for 30 seconds
Track patient progession for vertigo treatment?
- high visit frequency at first and lower gradually
- decreased episode of vertigo
What is the prognosis of Vertigo?
- BPPV responds spontaneously after a few weeks or months but reoccurances can occur months or years later
How does Semmont’s Maneuver help vertigo?
- patient seated
- turn head 45 away from affected side and practitioner helps patient lay down on to side
- maintain this position for 4 ish minutes
- Patient is brought to the other side quickly while keeping the head fadcing the same way also maintain for 4ish min
- slowly return to seated position
How is Epley’s Maneuver used in Vertigo?
- seated head away from affected side
- recline patient supine while keeping head rotated
- Now slowly rotate the patients head to the other side
- clinician and patient roll body so patient’s shoulders are aligned perpendicular to the floor with the affected ear now up
- patient is raised back to the sitting position while keeping head pointed at same rotation
- turn head midline
What is C1-C2 instability?
- excessive movement between atlas and axis
- usually secondary to rupture or laxity of the transverse ligament of the dens or a dens fracture
- congenital or trauma
- if patients have neuro symptoms they are at risk for progressive neuro symptoms and are at risk for death
What are the demographics of C1 - C2 instability?
- Trauma: fracture of dens or ligament rupture
- down syndrome: asymptomatic in 10 - 20% of pop
- RA: b/c erosion of the transverse lig of the dens
- AS, psoriatic arth, reactive arth, pharyngeal infection
Key History of C1-C2 instability?
- usually asymptomatic
- clicking or grinding sensation
- Potential Neuro signs of brain stem compression
- babinski, clumsiness or lack of coordination
DDx for C1-C2 instability?
- cervical disc syndrom
- cervical DJD
- cervical subluxation
- congenital dens malformation
- vertebral canal stenosis
- vertebral artery ischemia
- SOL
- B12 deficiency
Imaging for instability?
- flexion and extension views
Treatment for Cervical Instability?
- treat patient for discomfort and protect patient from future c-spine injury
- if neuro symps stabalize cervical spine and refer to ER
- upper cervical manipulation mob and ROM are contraindicated
What is a Cervical Spondylosis (DJD)?
- progressive loss of articular cartiage and reactive changes at the joint margins and subchondral bone
- usually occurs after the age of 50, 96 - 100% of people will have this condition after the age of 70
Key History point of cervical DJD?
- slowling developing achy neck pain
- chronic suboccipital headache
- morning stiffness and pain, aggrevated by repetitive or heavy use
- possible radiculopathy with nerve root compression (C6 or C7)
Physical Signs of cervical DJD?
- palpation shows neck stiffness
- ROM decreased (if >50% decrease then DISH suspected)
- increased pain with flexion if anterior anatomy involved ex. disc or posterior herniation)
- increased pain with extension if facet or IVF encroachment
- Neurological exam is usually WNL unless there is vertebral canal or IVF stenosis
DDx of Cervical DJD?
- AS
- cervical sprain or strain
- RA
- HA migrane or cluster
- disc herniation
- TOS
- meningitis
Orthopedic Test Cluster for cervical DJD?
- cervical compression/distraction test
- kemps
- spurlings
- jacksons
- max foraminal compresion
- slump
Imaging for Cervical DJD?
- decreased disc height
- osteophyte formation
- loss of cervical curve
- subchondral bone/end-plate sclerosis
- subchondral cysts
- subluxation
- IVF enchroachment
*CT better for bony iamge
* MRI better for SOL
Treatment of Cervical DJD?
- PRICE
- pain free ROM and pain free isometric holds
- Massage
- adjustments: long axis traction, adjust hypo mobile segments,
- Meds: NSAIDs
Rehab for Cervical DJD?
- pain free ROM
- aerobic and cardio
- postural retraining
- continue ROM and aerobic exercises add in parascapular stabilizer and rotator cuff exercises
Prognosis of Cervical DJD?
- symptom relief occurs within a few weeks in most individuals
- no cure but can help manage pain and alter biomechanics to decrease the increased incidence of the pain
- surgery does not mean a cure
What is cervical Facet Syndrome?
- cervical facet or zygapophyseal joint irritation or damage that may cause cranial cervical or upper shoulder and back pain and referal
- usually after a cervical injury (disc injury at same level, or WAD, OA or RA)
- also caused by repetitive stree or poor posture
Key History points of Cervical Facet Syndrome?
- dull achy pain often pinpointed by patient
- neck muscle spasm and torticollis
- radiates to shoulder or mid back, does not radiate beyond elbow or upper thoracic spine
- history of whiplash
- pain releived when supine
Physical signs of Facet syndrome?
- Increased pain on extension and rotation
- antalgia can be seen as patient flex away from the pain
- no neuro
DDx of Facet Syndrome?
- Cervical discogenic pain syndrome
- cervical radiculopathy
- cervical sprain/strain
- fibromyalgia
- myofascial pain syndrome
- infection neoplasm, aneurysm
Orthopedic cluster for cervical facet syndrome?
- compresion/ distraction
- jacksons
- spurlings
- max foraminal compresion
- kemps
- no nerve root signs
Treatment for cervical facet syndrome?
- reduce muscle spasm and inflammation
- immobilization
- pain free ROM and pain free isometrics
- myofacial release
- Adjust
