Pathoanatomical Diagnoses of C-Spine Flashcards
What are the 4 clinical practice guidlines available for neck pain?
- neck pain with mobility deficit
- neck pain with headache
- neck pain with movement
- neck pain with radiating pain
What are some signs of cervical radiculopathy?
- neck and radiating pain to arm
- numbness, sensory deficits
- myotome distribution in neck and arm
When does cervical radiculopathy occur?
- compression
- irritation
- traction
- herniated disc
- foraminal narrowing
- degenerative spondylitic change
What are the 4 criteria considered predictive of the presence of cervical radiculopathy?
- (+) ULTT:
- IL neck SB decreases sx, CL neck lateral flex increases sx
- >10 deg elbow ext difference - involved side cervical rotation ROM
What are the 4 types of cervical disc diseases?
- protrusion & bulging
- Prolapse
- Disc extrusion
- Sequestration
Describe what occurs with disc protrusion and bulging
no AF rupture, NP bulges
Describe what occurs with disc prolapse
outermost fibers of AF contain the nucleus
Describe what occurs with disc extrusion
- AF is perforated
- discal material moves to epidural space
Describe what occurs with disc sequestration
-discal fragments from AF & outside the disc proper
describe the symptoms that occur with central posterior herniations
pain radiates into limbs BL and myelopathic sx
describe the symptoms that occur with posterior/posteriolateral herniations
- pain/aching
- decreased c-spine ROM
- UL UE radicular pain
define directional preference
- specific direction of trunk movement or posture that alleviates or decreases the pain
- with or without the pain changing location and/or improving a limitation of movement
Define cervical spine instability
- increase in the neutral zone of 1 or more cervical spine segments
- lack of control of neutral zone WITHOUT compromise of the vascular or neural structures
- poor motor control of ROM
What are the primary causes of instability?
- degeneration & mechanical injury of the cervical stabilization components
- trauma, surgery, systemic disease or tumors
What are signs of instability
- aberrant motion
2. poor motor control of deep core muscles
What is the proposed intervention for c-spine instabilty
cervo-thoracic stabilization exercises
What is the definition of spinal stenosis?
narrowing of the spinal canal (usually degeneratively), IV foramina or radicular canals due to bony or soft tissue encroachment space b/t SP cord & vertebral elements is compromised
What is the normal A-P cervical SP Canal diameter?
17-18 mm
What is a A-P cervical canal diameter of
congenital stenosis
What is a ratio of A-P transverse diameter
substantial SP cord flattening
What is the most frequently used form of imaging for spinal stenosis?
MRI
What two forms of electrodiagnosis distinguish cervical radiculopathy from other UE problems?
- EMG
2. Nerve Conduction
What does somatic sensory evoke potentials look for?
cervical myelopathy
What parts of the SC are affected with a transverse lesion?
corticospinal, spinothalamic & posterior cord tracts
What parts of the SC are affected with a motor system lesion?
corticospinal tracts and anterior horn cells
What parts of the SC are affected with central cord syndrome?
more pronounced UE deficits > LE
What parts of the SC are affected with Brown-Sequard Syndrome?
motor deficits on IL side, CL sensory deficits
What parts of the SC are affected with brachialgia & cord
radicular UE pain occurs with motor and/or sensory long-tract signs
what are the signs and symptoms of spinal stenosis when it’s primarily the nerve root that’s involved?
pain, sensory, reflex & motor distribution of involved nerves (will lok like neuropathy)
what are the signs and symptoms of spinal stenosis when it’s primarily the SC that’s involved?
- clinical presentation will depend on area that’s compressed
- insidious onset
- difficulty with use of hands
- possible balance difficulties
- awkward gait
Interventions for spinal stenosis include:
Goal= improve function & pain
- stretching
- cardiovascular exercise
- specific strengthening
- postural re-ed
- scapular stabilization
- joint manipulation/mobilization
- training in ADL’s
List of primary headaches
- migraine
- tension type-headache (muscular origin)
- cluster headache & other trigeminal autonomic cephalalgias
List of secondary headaches
- cervicogenic
- head/neck trauma
- cranial/cervical vascular disorder
- substance/withdrawal
- infection
- homeostasis disorder
- HA or facial pain
Migraine w/o auro has at least 5 attacks of the following:
- attacks lasting 4-72 hours
- has ≥2 characteristics of:
- UL location
- pulsating
- mod-severe pain
- avoidance of routine Physical activity - During headache, ≥ 1 of:
- nausea/vomitting
- photophobia or phonophobia
What happens with a migraine w/ aura
recurrent attacks
- lasting minutes
- UL fully reversible visual, sensory, or other CNS sx that usually develop gradually
- followed by HA & associated migraine sx
When does aura occur?
before the migraine (like a signal)
what is scotoma?
area of diminished vision moving across visual field
What are the 4 stages of a migraine?
- Prodrome= sx of light and sound sensitivity, depression, irritability, and lack of appetite
- Aura: occur up to 1 hr prior to headache
- Headache: pain can be mod-severe, lasting up to 3 days
- Postdrome: “migraine hangover”
What are some ways to manage migraines?
- modification of risk factors
- treatment of associated co-morbidities
- check for medication overuse
- treatment of acute migraine attacks
- preventative therapy (strengthening/education)
- no evidence of benefit of manual therapy
What are some modifiable risk factors for migraine?
- medication overuse
- obesity
- depression
- stressful life events
- snoring
What are cervicogenic headaches?
HA assoicated with neck pain and stiffness
- can be UL or BL
- frequent TMJ relation
- may occur with trigger point palpation
- aggravated by sustained neck positions
- normal imaging
What is the proposed pathophysiology of CGH?
convergence of sensory input from the upper c-spine into the trigeminal spinal nucleus, including input from:
- upper cervical facets and muscles
- C2-C3 intervertebral disc
- vertebral & internal carotid arteries
- dura mater of the upper SC
- posterior cranial fossa
if a patient with a headaches comes into clinic, what might you find in their postural assessment?
- upper crossed syndrome
- forward head
- weakness and decreased endurance of deep neck flexors
if a patient with cervicogenic headaches comes into clinic, what might you find in their manual assessment?
- impaired C1/C2 rotation
2. AA rotation to side of HA is half of CL side
What is a whiplash-associated disorder?
- term used to describe the mechanism of injury
- effects of sudden acceleration-deceleration forces on the neck and upper trunk as a result of external forces exerting a “lash-like” effect
Describe Grade 0 for modified quebec task force
no complaints about neck pain, no physical signs
Describe Grade I for modified quebec task force
no c/o of pain or physical signs, stiffness or tenderness only
Describe Grade IIA for modified quebec task force
- neck complaint
- motor impairment= decreased ROM; altered muscle recruitment patterns
- sensory impairment= local cervical mechanical hyperalgesia
Describe Grade IIB for modified quebec task force
everything in IIA + psychological impairment
Describe Grade III for modified quebec task force
Grade IIB+ now some SNS disturbances, sensory hypersensitivity, neurologic signs of conduction loss, psycholgoical impairment
Describe Grade IV for modified quebec task force
fracture or dislocation
At 12 months, what percent of WAD patients continue to have pain/disability
12-84%
What are risk factors for poor outcomes for patients with WAD (strong evidence)
- high baseline neck pain intensity
- presence of headache on intake
- no post secondary education
- WAD grade 2 or 3
What are risk factors for poor outcomes for patients with WAD (moderate evidence)
- catastrophizing= over exaggeration
- no seat belt in use at time of accident
- history of neck pain prior to accident
- female
if the MOI is osteoligamentous in a WAD, what happens during the early phase?
- cervical spine flexes
- torso motion occurs, lower–> upper vertebrae
- C & T spinal straightening
if the MOI is osteoligamentous in a WAD, what happens during the second phase?
- cervical spine extends
- C6 moves first (before upper vertebrae)
if the MOI is osteoligamentous in a WAD, what happens during the middle phase?
- Axis of Rotation is moved from C6 to C5
- open book motion= vertebrae separate anteriorly & zygapophyseal impact occurs posteriorly
- impingement of inflamed synovial folds in zygapophysial joints
If a rear-end impact occurs, what muscles are affected?
- SCM activated more and most
- SCM injured before other injuries
If lateral impact occurs, what muscles are affected?
opposite splenius capitis is contracted significantly
Does awareness of the impact increase or decrease the muscle response?
decreases muscle response
describe the hierarchical model of what is affected with a WAD
muscles–> ligaments–> facet joints–> brain
What are the most common sx with a WAD?
- sub-occipital heachace
- neck pain that is constant or motion induced
- up to 48 hr delay of sx onset from initial injury
What percent of WAD recover within 6 months?
85%
what joint is the most common source of pain in chronic WAD?
Zygapophyseal joint
What are the indications for gentle approach in patients with WAD?
- recent trauma ≤ 6 weeks
- acute capsular pattern
- severe movement loss
- paresthesia
- segmental or multisegmental hypo or areflexia
- constant pain
- mod- severe radiating pain and/or headaches
- dizziness
What does a high initial pain intensity on VAS indicate?
extended recovery for WAD patients
What do high NDI scores initially predict?
high NDI scores @ 2-3 years post injury & mod-severe pain/sx
What are some forms of passive treatment for WAD patients
- cervical collar
- physical modalities
- rest
- inactivity
What are some forms of active treatment for WAD patients?
- exercise
- normal activities
- mobilization/manipulation
What is the most effective for improved pain and ROM in WAD patients?
mobilization
What is the goal for Phase 1 of WAD intervention?
- decrease pain
- provide info
- explain consequences of WAD
What are the interventions for Phase 1 of WAD?
- pt education
- active CROM
- NSAIDS (consult MD)
What is the goal for Phase 2 of WAD intervention?
- provide info
- improve function
- return patient to normal activities
What are the interventions for Phase 2 of WAD?
- education
- exercise therapy
- functional activities
What is the goal for Phase 3 of WAD intervention?
- provide info
- explain consequences of whiplash
- improve function
- increase activities
What are the interventions for Phase 3 of WAD?
- education
- exercise therapy
- functional activities
