Neck Pathology

Question 1

dens fracture defn and complications

Answer 1

fracture at base of dens

causes posterior displacement which leads to spinal cord injuries in 15% of patients

delayed healing or nonunion common d/t poor blood supply

Question 2

cervical muscle strain defn and complications

Answer 2

exertion, overstretching, overuse injury –> tight muscles and tight paraspinals. most resolve spontaneously.

causes tension headaches d/t compression of greater occipital nerve by tight paraspinals

loss of lordosis due to paraspinal spasm and associated shortening

Question 3

dens fracture causes and dx

Answer 3

most common upper cervical spine fracture
car accidents and falls

open mouth X-ray most sensitive, lateral for posterior displacement

Question 4

dens fracture tx

Answer 4

surgery and bracing

Question 5

cervical muscle strain causes and dx

Answer 5

most common cause of cervical muscle pain, caused by stress, awkward positions, repeatedly looking up and down, overstretching

physical exam - tightness/spasm, paraspinal tightness/spasm, loss of lordosis

Question 6

cervical muscle strain tx

Answer 6

ice, NSAIDs, and bracing for acute. heat for subacute. PT and ergonomics for chronic.

Question 7

atlantoaxial instability defn and complications

Answer 7

increased motility of atlantoaxial joint (arch and dens) d/t ligament laxity (usually transverse ligament)

posterior displacement of dens, may compress spinal cord (cervical myelopathy)

even relatively minor neck injuries can cause total displacement, paralysis or death - must catch early in high risk patients

Question 8

atlantoaxial causes and dx

Answer 8

structural damage from trauma or chronic inflammation (e.g. rheumatoid arthritis)

connective tissue disorders (EDS, Down’s, Marfan’s…)

should be suspected in high risk patients and those with progressive neuro deficits

dx by X-ray (lateral)

risky activities: intubation, high impact exercises, neck manipulations…

Question 9

atlantoaxial tx

Answer 9

surgery with rigid bracing while awaiting surgery

pain relief

***early detection

Question 10

scoliosis defn and complications

Answer 10

lateral curvature of spine, mainly in thoracic and lumbar regions. C or S shape

Question 11

scoliosis causes and dx

Answer 11

usually idiopathic, commonly onsets in early adolescents, 7x more likely to progress and require surgery in women

may onset in adults d/t bone injury or ddd

spinal asymmetry especially noticeable on bending, pain on affected side, higher ribcage and scapula on affected side, reactive muscle spasm

Question 12

scoliosis tx

Answer 12

pain management
intervention needed at >10% deviation

in kids, brace at 20-30% and monitor progression until bones are fully developed (only prevents progression)

> 40% deviation, breathing impairment, rapid worsening –> surgical fixation

Question 13

ddd defn and complications

Answer 13

aging/loss of flexibility of intervertebral disks - fewer proteoglycans and more collagen in the nucleus pulposa (center bit) –> excessive pressure on vertebral endplates

sclerosis of vertebral endplates –> osteophytes, tears in annulus fibrosis (bit surrounding he nucleus pulposa)

facets don’t align properly due to uneven pressure, ligament weakening, muscle spasm to make up for it

complications: radiculopathy, disk herniation

Question 14

dermatomes relevant in cervical radiculopathy

Answer 14

C5, C6, C7: lateral parts of upper limbs (+C5 clavicles)

C6, C7, C8: hand
C6: Thumb
C7: index and middle finger
C8: ring and little finger

C8, T1: medial parts of upper limbs

Question 15

ddd causes

Answer 15

aging, excess pressure or activity, leaning head, trauma

for lumbar- excess weight, sitting

Question 16

ddd dx: clinical presentation, physical exam, imaging and how these differ from similar conditions

Answer 16

midline pain worsened with activity
if facet involvement, pain worse on extension
loss of lordosis
paraspinal spasm and tenderness - no tenderness directly over spine
normal to limited ROM
no special exam

plain films - narrowed disk space, osteophytes, endplate sclerosis
MRI - desiccated disks

Question 17

ddd tx

Answer 17

NSAIDs
opioids if severe
if severe pain with any movement, consider spinal fusion
PT focused on releasing and strengthening paraspinals

Question 18

cervical disk herniation defn and complications

Answer 18

nucleus pulposa breaks through annulus fibrosis
usually posteriolateral due to typical anterior head movements

complications: radiculopathy or myelopathy (spinal cord compression)

Question 19

cervical disk herniation causes

Answer 19

…

Question 20

cervical disk herniation dx: clinical presentation, physical exam, imaging and how these differ from similar conditions

Answer 20

midline and/or paraspinal tenderness
paraspinal spasms
loss of lordosis
decreased ROM
if no radiculopathy or myelopathy, normal neuro exam

cervical radiculopathy to upper extremities, along a specific myotome and causing muscle weakness and diminished reflexes

if myelopathy: weakness to upper extremities, weakness and/or spasticity/increased tone to lower extremities –> abnormal gait. hyperreflexia below level of compression.

if nerve root compression, positive spurling’s compression test (turn head and push down)

CT and MRI to confirm

Question 21

cervical disk herniation tx

Answer 21

surgical

Question 22

cervical radiculopathy defn and complications

Answer 22

compression or injury to spinal nerve roots, most commonly due to osteophytes or herniated disk
compression within spinal canal due to inflammation also possible

dorsal vs ventral involvement determines dermatome (paresthesias), myotome (weakness), or both

Question 23

cervical radiculopathy causes

Answer 23

…

Question 24

cervical radiculopathy dx: clinical presentation, physical exam, imaging and how these differ from similar conditions

Answer 24

paresthesias and/or weakness (w/ possible loss of reflexes)
paraspinal spasms
limited ROM d/t pain or abnormal sensation
local tenderness to paraspinals but not to affected extremities

Spurling’s compression test: turn head and push down to reproduce symptoms
EMG to determine degree and root level of involvement
imaging not always warranted except to determine cause

Question 25

cervical radiculopathy tx

Answer 25

Tylenol, NSAIDs
neuropathic drugs (AEDs, antidepressants)
cervical traction (if not contraindicated) and stretching
heat and ice for spasm
epidural corticosteroids
if severe, consider surgery for underlying cause

Question 26

sudden onset neck pain ddx

Answer 26

most common: muscle strain

common in hx of ddd: disk herniation

not uncommon in hx of recent trauma: dens fracture

can’t miss in high-risk pts: atlantoaxial instability with acute displacement

Question 27

gradual onset neck pain without paresthesias ddx

Answer 27

most common:
muscle strain (d/t chronic factors e.g. ergonomics, stress)
ddd

possible: scoliosis

can’t miss in high-risk pts: atlantoaxial instability without acute displacement

Question 28

gradual onset neck pain with paresthesias ddx

Answer 28

most likely:
ddd with radiculopathy
chronic muscle strain with paraspinal spasm around spinal nerve