Lower C-Spine Flashcards
What percentage of the population report neck pain?
20-30%
What are groups are more likely to get neck pain?
increases with age, most common in 5th decade of life
In order of importance what are the functions of the C-spine?
Mobility
Load bearing
Stability
(opposite of lumbar spine)
What is the muscle dysfunction associated with neck pain?
Less force production of neck muscles in people with neck pain.
Alteration in postural muscles
Reduced endurance of neck flexors (can use pressure cuff to examine)
How are postural muscles altered in neck pain?
Increased tone in: levator scap, lower trap, neck extensors
Decreased tone in: serratus ant, upper and middle traps
What is endurance test for neck flexors?
Place pressure cuff under neck. Inflate to 20 mmHg. Ask pt to tuck chin. Pressure should increase 10 mmHg. 10x10= 100% performance
How is the first rib implicated in the C spine?
serves as attachment site for neck muscles
What is MOI of first rib?
MVA, posture, poor breathing pattern (mouth breathers)
What are the joints of the CS?
IVJ
Z-jt: 45 degrees from horizontal, motion coupled in same direction
U-jt: post-lat part of column, superior is concave, inferior is convex, in C3-T1 vertebrae
What are the U joints
Saddle shaped, diarthrodial joints
Extend from C3-T1
Formed between the uncinated processes
Develop within first 12 years of life and fully developed by age of 30
What is function of U joints?
Prevent posterior lateral disc herniation
Helps with rotation
Weak evidence: having this joint takes stress off vertebral artery
Help with gliding motion of flex-ext segmental motion
What are pain generating structures in the C spine?
Disc, dura, NR, nerves, facet joints, U joints, muscles, ligaments
What is Cyriax’s examination concept called
Selective tissue tension technique
What is STTT for disc?
compression
flexion/extension: flexion if limited/painful because it’s stretching posterior structures and loading the disc
What is STTT for dura, NR, nerves?
Dura: slump test, passive neck flexion
NR: segmental neuro exam, side bent, unilateral PA, nerve glides, combined motion to close foramen
Nerve: neurodynamics, compression, nerve tapping, nerve palpation, segmental neuro
What is STTT for facet joints and U joints?
facet: unilateral PA, passive physiological motion, combined motion, flex/ext/rotation
U joints: passive segmental sidebend of neck
What is STTT of muscles and ligaments?
Muscles: MMT, palpation, length test
Ligaments: passive movement then overpressure
What is subjective like for CS patients?
Body chart: HA, neck, shoulder, upper back, radiating into UEs
Aggravating/easing factors
MOI: whiplash, pathological or mechanical
What are neck pain origins?
Whiplash/MVA, collisions, spondylosis, infection, tumor or disease processes, poor sleeping posture, excessive computer use, improper mechanics of c-spine, scapular mechanics, shoulder mechanics and/or poor posture
What must you screen for and rule out with CS?
Screen first!
Look for central and peripheral neurological deficits
Neurovascular compromise
Serious skeletal injury: fractures, instability
Rule out fractures and cervical myelopathy
What are the 3 big screening items for CS?
Vertebral artery, fracture, myelopathy
What are parts of the objective exam?
Observation/posture, AROM (OP), PROM, combined motion, repeated; sustained motion, neuro testing/segmental testing, muscle testing/endurance test, movement impairment, palpation, assessment of joint articulations (PPIVM, PAIVM)
What are things to look for with observation/posture of CS?
forward head, broad shoulders, torticollis, creases, rounded shoulders, normal lordosis, any depressions of segment
What are combined motion testing of CS?
Restriction of cervical extension, side bending, and rotation to same side as the pain is termed a closing restriction.
Restriction of cervical flexion, side bending, and rotation to opposite side of pain is termed an opening restriction.
What are special tests of CS?
Neurodynamics
Spurling Test (foramina compression)
Axial compression/axial distraction
Transverse shear
What are intervention strategies for CS?
Postural reeducation, ergonomic HEP, specific strengthening and stretching exercises, scapular muscle exercises, use of collars/head sets, modalities, mobilizations, soft tissue, TS manipulation
What is research on T spine manipulation?
patients with mechanical neck pain benefit from thoracic spine manipulation
What are the Cloward signs?
Referred pain areas of discs into the scapular region.
Deep, dull ache
Induced by local pressure
Associated with muscle spasms
What is referred pain for posterior and posterior lateral portion of discs?
Posterior: deep diffuse pain in back and spread out to both scapulas
Posterior-Lateral: scapula and down arm
What is referred pain for anterior and anterior lateral portion of disc?
Anterior: pain right on the spinous process
Anterior-Lateral: pain by vertebral border of scapula
What happens with ventral roots getting stimulated?
Causes trigger points/muscle spasms around scapula
What are differences between anterior/anterolateral and posterior/posterolateral disc stimulation?
Anterior is more focal pain in middle of back and scapular border. Posterior is more spread out over the scapula and into the upper arm
What happens when ventral versus dorsal roots are irritated?
Dorsal root= all sensory. Will have pain down arm
Ventral root: associated muscle spasms
What are the two types of herniations in the CS?
Soft disc: migration of nucleus
Hard disc: bulging of annulus
Who gets herniations and what are most common areas?
Less common than lumbar disc herniation
Up to 30 years of age
Common levels: C6-7 (60%) and C5-6 (30%)
What is a possible result of herniation?
Depending on nerve structures involved it can result in localized pain, referred pain, radiculopathy, or myelopathy
What is pain pattern for soft discs?
Ache/stiffness
Cloward signs
May or may not have distal symptoms
What is pain pattern for UCS soft disc herniation?
base of neck, head, and face
What is pain pattern for C4-5 soft disc herniation?
base of neck and top of shoulder
What is pain pattern for C5-6, C6-7 soft disc herniation?
scapula, across the shoulder joint and post/lat aspect of upper arm
What his behavior of symptoms for soft cervical herniation?
Aggravating: looking down, turning head
ADLs may be limited
Speed of movement may be altered
Driving, sitting, work
What is history of soft disc herniation?
Not associated with incident
May be related to sustained posture
Slow onset or wake with pain
May have history of MVA
What are objective signs for soft disc herniation?
Posture: document deformity
ROM: limited flexion/extension
Painful ipsilateral ROM: side bend, rotation
Painful central PAs more than unilaterals
Positive spurling (rotation, SB, compression)
What is intervention for soft disc herniation?
traction, posture, modalities, ergonomics, body mechanics, McKenzie repeated motion
What is spondylosis?
Degenerative changes in the spine
What are time frames for degenerative changes in CS?
Discs: 30-55 years of age (degenerates before facets)
Facet joints: >55 years of age
U joints: >55 years of age
What is pattern of disc degeneration?
Natural phenomenon, common levels C4-5, C5-6, and C6-7
Lateral clefts at side of U-joints
Disapperance of NP by age of 40-45
Loss of disc height
Loss of normal lordosis
Results in intersegmental hypermobility and instability/subluxation
Why is there CS disc degeneration?
Happens because of large neck motions (motion > stability in CS)
Someone comes into your clinic with long history of neck pain, diffuse symptoms, and pain with sustained flexion and quick movements? what might be the problem?
CS disc degeneration
What are subjective signs of CS disc degeneration?
Cloward sign
Diffuse symptoms, unilateral or bilateral
Presence of radiculopathy
Agg: is sustained flexion, quick movements, end of range movements
Long history of neck pain
May have history of MVA
What are objective findings of CS disc degeneration?
Posture
ROM may be limited with pain
Palpation: central and unilateral
Segmental exam: sensory loss, motor loss, hyporeflexia
Upper limb neural tension
Diagnostic: X-ray show degenerative changes
What is intervention for CS disc degeneration?
Joint mobilization of UCS, CT junction, TS
Traction
Posture education
Ergonomics
Exercise: scapular stabilization, thoracic extension, thoracic mobility
What is cause of acute cervical facet syndrome?
Caused by sudden neck movement
Result of synovial capsule impingement within a facet
Localized pain with or w/o muscle spams
Acute torticollis
What is cause of chronic cervical facet syndrome?
chronic inflammation due to arthritis/injury
fibrotic changes in joint capsule
What are objective findings for cervical facet syndrome?
Limited ROM w/wo muscle guarding Side flexion is limited to both sides PPIVM: segmental motion limited PAIVM: limited, painful Lack of neurological signs Palpable point tenderness and muscle spasm
What is intervention for cervical facet syndrome?
Manual therapy: unilateral PA, contract relax, joint specific traction
HEP
Posture
Who gets acute cervical NR?
Usually occurs in older patients that have degenerative changes
May occur in younger individuals: trauma induced
What are subjective findings for acute NR?
Pain worse distally in dermatomal pattern
Possible Clowards
Can be constant and/or latent
A patient comes in and has constant numbness in thumb, deep sharp shooting pain in arm, deep intermittent ache in back, and constant stiffness in neck, and pain worse distally what might they have?
Acute nerve root
What is objective findings for ANR?
Posture: looks uncomfortable
Attempt to correct deformity increases symptoms
ROM: only able to test 1-2 motions
Palpation: may not be able to do this
Neuro: positive
X-ray: degenerative changes; nerve root encroachment
What is intervention of ANR?
Patient education: proper meds and sleeping posture
Ice/modalities
Manual traction
Joint mobilization: only when decreased severity and irritability
Who gets chronic nerve root?
middle age and older populations with already established degenerative changes
Long history of neck pain, post-surgical
What is subjective components of chronic nerve root?
Dermatomal pattern: not necessarily distal
Patchy distribution
Usually intermittent
Agg: sustained flexion, movements that narrow foramen
Can be nagging, able to sleep at night
What are objective findings for chronic nerve root?
Postural changes \+/- neuro signs ROM: limited in closing movements possible GH limitations Central PA \+ spurlings test \+ neurodynamic findings X-ray: possible degenerative changes of facets, or foraminal encroachment
Someone comes into the clinic and has intermittent pain that is patchily distributed and painful with sustained flexion, what might they have?
Chronic nerve root
What is intervention for chronic NR?
joint mobilizations traction neurodynamic treatment ergonomic modification of activities joint protection
Who gets stenosis?
Central (55 years of age
High contact sports injuries
What is common cause of stenosis?
mechanical compression and degenerative instabilities; a congenital condition
What are objective findings of stenosis?
Neck pain may be absent initially Neck and arm pain Painful and restricted ROM Presence of sensory and motor deficits Wasting of intrinsic muscles of hands resulting in loss of hand dexterity associated with cervical myelopathy Segmental neuro and central neuro exam Diagnostic must be used to determine extent of problem
What is intervention for stenosis?
Patient education: modify activity, sports participation discouraged
Exercise: posture, isometric strengthening, mobility exercises while avoiding end range motion
Manual: specific level traction, unilateral PA
Cervical collar
Surgery: if chronic
