Neck and C spine Flashcards
Cervical nerve root exits ______ the numbered vertebra
Above
What are the atypical cervical vertebrae
C1 = atlas — lacks a vertebral body and rotates around the dens of C2
C2 = axis — body extends superiorly to form dens
Is the C2-C3 articulation considered typical?
Yes
From C2-C7, the upper cervical facets align in a plane pointing toward the _____
The lower cervical facets point to the opposite _______
Eye; ASIS
For C3-C7, the lateral aspects of the bodies have superior projections (uncinated processes) articulating with superadjacent vertebrae, what is the function of this articulation?
Helps support lateral sides of cervical intervertebral discs and protect from herniation
_______ joint = synovial joint between articular processes
Facet (zygopophyseal)
______ joint = vertebral bodies separated by fibrocartilaginous disc
Intervertebral
The 2 primary motions at the OA joint are ______ and ______, with minor motions being ____ and ______
The Occiput rotates and sidebends to the _______ sides
Flexion; extension; SB; rotation
Opposite
Primary motion at AA joint
Rotation
[atlas rotates around dens of C2]
How does sidebending relate to rotation in typical cervical vertebrae from C2-C7?
R and SB typically occur in same direction (type II mechanics)
What are some things to look for in your observation of the neck?
Trauma, scars, masses, goiter
Carrying angle
Increased or decreased lordosis
Distended external jugular vein (elevate head of bed 30 deg)
Tracheal deviation
Masses in the neck, mediastinal mass, atelectasis, large pneumothorax
What landmarks are associated with the neck and C spine exam?
Occiput Mandible Clavicle Manubrium SCM m. Trapezius m. Hyoid bone Thyroid cartilage Cricoid cartilage Trachea Spinous processes Vertebral prominens (C7) Interspinous ligament Transverse processes Facets Articular pillars Anterior and posterior triangles
What are the 3 borders of the anterior triangle?
Mandible
SCM
Midline
What are the 3 borders of the posterior triangle?
SCM
Trapezius
Clavicle
[omohyoid crosses lower portion]
What lymph nodes are associated with a typical neck exam?
Superficial and posterior cervical chain Occipital Pre/post auricular Submandibular Submental Tonsillar Supraclavicular
LNs are normally small, round or ovoid, and smooth. On exam you should note their size, shape, mobility, consistency, and tenderness. Increased size = lymphadenopathy. Generalized LAD is seen in what conditions?
HIV/AIDS Infectious mono Lymphoma Leukemia Sarcoidosis
______ = infectious cervical lymphadenitis
Scrofula
The ____ of the stethoscope can be used over the carotid arteries to assess for thrills and bruits
Bell
Assessing the ___________ assesses for the right atrial pressure as the right internal jugular vein is in direct line with the SVC
Jugular venous pressure
How do you assess jugular venous pressure?
Place pillow under pt head to relax SCM
Raise head of exam table to 30 deg and turn head slightly away of side you’re examining
ID the IJV using tangential lighting and table adjustments to identify the oscillation point/meniscus of IJV pulsations
ID the highest point of pulsation; extend an object horizontally from the apex. Place ruler vertical from sternal angle to create a right angle with the horizontal object
Distance in cm above sternal angle (right atrium) is JVP
What is a normal JVP?
Less than 3-4 cm above the sternal angle
Low JVPs are best seen in near ______ position — this would be a _______ patient
Supine; hypovolemic
High JVPs are best seen in ______ position — this would be a _______ patient
Upright seated; hypervolemic
The trachea should be midline in the neck. Use spaces between _____ and _____ as landmarks.
Thyroid; SCMs
Lateral displacement of the trache can occur in what condition?
Tension pneumothorax
The ______ of the thyroid overlies the 2nd-4th tracheal rings. Have the patient _____ the neck slightly to relax SCMs
Isthmus; flex
While examining the thyroid, once the neck is flexed, you place fingers of both hands on pt’s neck so that index fingers lie just below the ______cartilage. Have the pt swallow so that the thyroid rises up under finger pads. Observe for ____ and _____
Cricoid; contour; symmetry
While exampining the thyroid, displace the ______ to the right and left to palpate each individual lobe. The anterior surface of a lateral lobe is approximately the size of the distal phalanx of the ______ and feels somewhat _____
Trachea; thumb; rubbery
If the thyroid is noted to be enlarged on palpation, what is your next step in the exam?
Listen over lateral lobes to detect bruit - which may be heard in hyperthyroidism
A simple, non-nondular, or possibly multinodular thyroid enlargement may indicate what condition?
Goiter
A soft non-rubbery thyroid would indicate what condition?
Grave’s disease
A firm, non-rubbery thyroid may indicate what condition?
Hashimoto’s thyroiditis or mlaignancy
A tender thyroid may indicate what condition?
Thyroiditis
Muscles involved in C-spine flexion
SCM
Scalenes
Paravertebral muscles
Normal ROM of neck flexion
45-90
Muscles involved in C-spine extension
Splenius capitus
Splenius cervicis
Intrinsic spinal mm
Normal ROM of neck extension
70-90
Muscles involved in C-spine rotation
SCM
Intrinsic spinal mm
Normal ROM of neck rotation
70-90
Muscles involved in C-spine sidebending
Scalenes
Intrinsic spinal mm
Normal ROM for neck sidebending
20-45
______ ______ = nerve entrapment by musculoskeletal or myofascial tissue that produces paresthesias in the area of the distribution of the nerve and creates sensory dysfunction/pain and may also decrease muscle strength
Central neuropathy
What are 2 common sites for central neuropathy to occur
Intervertebral foramen
Thoracic outlet
Describe test — positive finding? — what does it indicate?
Compression test
With head an neck in neutral position, add axial loading force caudally looking for upper extremity pain, paresthesias, or numbness
+ test = reproduction of symptoms (pain/paresthesia in distribution of nerve root)
Indicates central neuropathy
Describe test — positive finding? — what does it indicate?
Spurling’s
Tests nerve root compression/irritation. Tested with an axial force in neutral, then extension, then SB/rotation toward. Test of high specificity
+ test = reproduction of symptoms (pain/paresthesia in distribution of nerve root)
Indicates central neuropathy
Describe test — positive finding? — what does it indicate?
Neck distraction test
Doc places one hand under pt chin and places the other hand around the occiput, slowly distracting the head
+ test = alleviation of symptoms
Indicates = central neuropathy
Describe test — positive finding? — what does it indicate?
Valsalva test
Pt holds breath and bears down, which increase intrathecal pressure
+ test = increased symptoms (pain/paresthesia in distribution of nerve root)
Indicates = space occupying lesion in cervical canal
What are the boundaries of the thoracic outlet
1st ribs
1st thoracic vertebra
Manubrium
The thoracic outlet is best thought of as what 3 zones?
Scalene triangle
Costoclavicular space
Retropectoralis minor
What structures pass through the thoracic outlet?
Brachial plexus
Subclavian v
Subclavian a
Thoracic duct (L)
What is the difference between the thoracic duct and the right lymphatic duct?
Thoracic duct drains majority of body
Right lymphatic duct drains body’s right upper quadrant
Describe test — positive finding? — what does it indicate?
Roos or EAST test
Abduct shoulder to 90 and externally rotate with elbow flexed to 90. Physician instructs patient to open and close fist for up to 3 mins
+ test = reproduction of symptoms (pain/paresthesias)
Indicates = thoracic outlet syndrome, specifically compression of subclavian a
Describe test — positive finding? — what does it indicate?
Adson test
Locate radial pulse on affected arm. Physician abducts, extends, and externally rotates the shoulder while palpating the radial pulse. First, pt’s head is extended and rotated toward affected side; then, pt’s head is rotated away from affected side
+ test = loss or changes in pulse; reproduction of symptoms (pain/paresthesias)
Indicates = thoracic outlet syndrome, specifically compression of subclavian a. between scalenes (when looking away from affected side) or 1st cervical rib (when looking toward affected side)
Describe test — positive finding? — what does it indicate?
Wright’s hyperabduction test
Physician locates and monitors the radial pulse on the affected side. Abduct the patient’s arm above his/her head with some extension
+ test = loss or change in pulse; reproduction or symptoms (pain/paresthesias)
Indicates = thoracic outlet syndrome, specifically neurovascular entrapment by pectoralis minor m
Describe test — positive finding? — what does it indicate?
Costoclavicular test (aka military/halstead)
Physician locates and monitors the radial pulse on affected side. With the elbow extended and supinated, extend the shoulder and apply caudal pressure on the shoulder
+ test = loss or change in pulse; reproduction of symptoms (pain/paresthesia)
Indicates = thoracic outlet syndrome, specifically neurovascular entrapment between 1st rib and clavicle
What 4 special tests are used to detect central neuropathy?
Compression test
Spurling’s maneuver
Neck distraction
Valsalva test
What are the 4 special tests used to detect and differentiate thoracic outlet syndrome?
Roos (EAST) test
Adson test
Wright’s hyperabduction test
Costoclavicular test (military/halstead)
What are the 3 exam findings/special tests are used to detect subarachnoid irritation?
Nuchal rigidity on exam
Brudzinski’s sign
Kernig sign
Describe test — positive finding? — what does it indicate?
Nuchal rigidity
Patient supine. Place hands behind pt head, flex neck forward until chin touches chest
+ test = marked neck stiffness/resistance to flexion
Indicates = inflammation in subarachnoid space (e.g., meningitis or subarachnoid hemorrhage)
What PE finding is present in 57-92% of cases of acute bacterial meningitis, and 21-86% of subarachnoid hemorrhage?
Nuchal rigidity
Describe test — positive finding? — what does it indicate?
Brudzinski’s sign
Patient supine. Place hands behind patient’s head, flex neck forward until chin touches chest
+ test = flexion in both hips and knees
Indicates = inflammation in subarachnoid space (e.g., meningitis or subarachnoid hemorrhage)
T/F: for both brudzinski’s sign and kernig sign, the sensitivity is low and specificity data is limited
True
Describe test — positive finding? — what does it indicate?
Kernig sign
Place patient supine and flex hip and knee to 90. Attempt to passively extend the leg at the knee
+ test = increased resistance to extension and pain behind knee, +/- back pain radiating to posterior thigh (sources vary)
Indicates = meningeal/dural irritation
Cervical spinal cord injuries can occur in any sport, but particularly in what 3 sports?
Football
Hockey
Lacrosse
What type of injury accounts for over half of c-spine injuries?
Axial load — force transmitted to bone and disc
Cervical spinal cord injuries may occur when the neck is flexed to _______ degrees, because the lordosis is lost and protective soft tissues are no longer protective
30
Fracture of C1 due to axial compression
Jefferson fracture
Fracture due to flexion and compression injury
Wedge fracture
C2 odontoid fractures typically occur at the junction of _____ and ______, often requiring surgery
Process; body
C2 bilateral arch fracture due to hyperextension injury
Hangman’s fracture
Spinous process fractures may occur with ________ or ________ force from muscle contraction
Hyperextension; avulsion
At what vertebral level(s) would you see a Clay Shoveler’s fracture?
C6 or C7
Flexion and compression injury may lead to anterior-inferior _____ fragment
Teardrop
[this is a teardrop fracture]
Comminuted fracture that can result in severe spinal cord injury
Burst fracture
Flexion injury leading to facet dislocation without fracture
Anterior subluxation
