Phys med: Conditions of cervical spine Flashcards
The clinical encounter: OHIPMNRS: what does this stand for?
Observe
History
-LO DR FICARA
Inspection
Palpation
Motion
Neurovascular
Referred Pain (screening adjacent areas)
Special tests
Observe:
Patient’s general appearance, posture & gait (how do they walk into the office?)
Emotional status (happy, sad): are they comfotable?
History (basic considerations):
Where is the problem? Point to it exactly. When did it start?
What makes it better or worse? Prior to treatment or injuries?
Quality of issue? (numbness, tingling, sharp, ache)
Severity (scale from 0-10)? Gradual or sudden onset?
LoDrFicara
Inspection(Visual):
Posture, gait, bony deformity, trouble with activities of daily living, (ADLs)
Obvious discomfort (painful expression, unable to sit comfortably, limp)
Bony & soft tissues (deformity, bruising, swelling, color, sweat/dry, scars, calluses, bunions, atrophy, ulcers)
Footwear (supportive, wear patterns on shoes, assisting devices such as orthotics or braces)
Palpation (360 degrees around joint/painful area):
Please Note: Temperature, texture, tone, tenderness (4 T’s)
360 degrees around the joint
A bit above and a bit below the site of injury/complaint
Apply enough pressure to feel deeper tissues and recreate pain.
Anatomy review (bone, tendons, ligaments, fascia, blood vessels, nerves, lymph, viscera)
Motion: AROM/PROM/RROM:
Order:
1) AROM (note any issues)
2) PROM Full ranges with over pressure for end feel
3) RROM Full strength but fully isometric (neutral/relaxed position)
Neurovascular screen:
-Dermatomes
-Myotomes
-Deep Tendon Reflexes
-Pulses, Capillary Refill, Temperature
Referred Pain (screen adjacent areas):
Is there pain in other areas?
Special tests (orthopedic tests):
Start with tests for the specific area of pain/concern
Keep in mind nerve referral pathways. So if appropriate, perform special tests above and below the site of pain/concern.
Cervical Spine Anatomy:
Joints of the cervical spine:
-Atlanto-occipital joints (C0-C1)
-Atlanto-axial joints (C1-C2)
-Facet joints (14 in total)
-Intervertebral discs
Atlanto-occipital joints (C0-C1):
Principal motion=flexion/extension (15-20 degrees)
Rotation is negligible
Stabilized by several ligaments
Atlanto-axial joints (C1-C2):
Most mobile articulation of the spine
Main supporting ligament is the transvers ligament holding the dens of the axis against the anterior arch of the atlas.
This ligament weakens or ruptures in rheumatoid arthritis.
Two projections of the ligament go superior to the occiput and inferior to the axis, together with the transverse is known as the cruciform ligament movements.
-Flexion
-Extension
-Lateral flexion
-Rotation
Facet joints (14 in total):
Facilitates flexion and extension.
Limited rotation or side flexion
Greatest flex/Ext occurs at C5-C6 and next between C4-C5 and C6-C7
Because of this mobility degeneration is more likely to be seen at these levels.
Intervertebral discs:
-Make up 25% of the height of the C/S
-No disc between C0-C1 and C1-C2
-Nucleus pulposus buffers axial compression
-Annulus fibrosis withstands tension within the disc
Although there are 7 cervical vertebrae there are 8 cervical nerve roots, each is named for the vertebrae ABOVE it:
C5 nerve root is between C4 and C5, rest of the spine the root is named for the vertebrae BELOW.
ex) L4 nerve root is between L4 & L5
Cervical spine assessment (Bony Palpation):
Anterior aspect:
-Thyroid cartilage (C4-C5)
-Cricoid Cartilage (C6)
Posterior aspect:
-Occiput
-Inion (EOP)
-Mastoid Process
-SP of the cervical vertebrae (C2-7)
-Facet Joints
Cervical spine assessment (Soft tissue palpation-Anterior Portion):
1) SCM:
-Involved in torticollis
-Note discrepancies in size, tone/damaged
-Hyperextension damages
-May cause torticollis
2) Lymph node chain:
-Along medial border of SCM
-Enlarged nodes in SCM region indicated URTI
3) Supraclavicular fossa:
-Palpate for unusual swellings or lumps
-Swelling in the fossa might be secondary to trauma
-Small lumps may be due to enlarged lymph node
Cervical spine assessment (Soft tissue palpation-Posterior Portion):
1) Trapezius muscle:
-Origin= Inion to T12
-Insertion = clavicle, acromion, spine of scapula
-Action = elevate retract, and depress shoulders
2) Lymph Nodes
-Anterolateral aspect of traps
-Enlarged with infection
3) Levator scapulae:
-Origin=Upper cervical TVP’s
Insertion = Superior angle of the scapulae
Action = shrug shoulders
4) Splenius and semispinalis capitus (Deep muscles)
5) Scalene (anterior, middle, posterior):
-Multiple attachments including ribs 1 and 2
ROM (cervical spine/muscles/joints):
If pain is acute, some movements will be left out to avoid exacerbation of symptoms
Flexion = 45-50 degrees
-Bring the chin to the chest
-Can divide the flexion into two parts C0-C2 gives nodding, C2-C7 gives flexion
-If problem with nodding is upper restriction
-For lower normal can be chin touching chest with mouth closed or up to 2 finger width space between chest and chin
Extension = 70 degrees
-Bend the head backwards, lift the chin up without moving the neck
-Normally the nose and forehead can go nearly horizontal
-Tingling, loss of balance etc. Suggests serious complication of cord compression
Rotation= 70-90 degrees
-Look over your left and right shoulders
-Usually the chin does not quite reach the plane of the shoulder
Lateral flexion =20-45 degrees
-Bring each ear to the shoulder
-Be sure ear is moving to shoulder and not the reverse
Neurological testing:
Dermatomes
Myotomes
DTR’s
Dermatomes:
Myotomes (upper limbs):
Best held for 5 seconds:
Myotomes (lower limbs):
Must be held for 5 seconds:
DTR’s:
Cervical Degenerative Joint disease (DJD):
Cervical facet (zygapophyseal joint) irritation or damage that may cause cranial, cervical or upper shoulder & back pain referral; often difficult to differentiate from other neck issues.
DJD Differential diagnosis:
Differential diagnosis:
-Discogenic pain syndrome or sprain/strain
-Cervical radiculopathy
-fibromyalgia, myofascial pain syndrome
-Infection, neoplasm, aneurysm
DJD history:
-Dull, achy localized pain, although may be sharp during acute episodes, headaches and limited ROM: patient will often have pinpoint pain, neck muscle spasm/ torticollis
-Sometimes radiates to the shoudler or midback regions, although does not often radiate beyond the elbow or upper thoracic spine
Patient may report a history of whiplash injury
Pain is reduced when supine
DJD physical:
-Increased pain on extension & rotation (due to facet approximation)
-Antalgia is typically away from the facet in acute patients resulting in slight flexion and lateral flexion position (torticollis like position)
-Possible muscle splinting and guarding ROM
-No neurological deficit (DTRs, motor, sensation)
DJD special tests:
Cervical compression test:
(+) local pain with compression
Cervical Distraction test
(+) DECREASED pain with distraction.
Spurling’s or Maximal compression test:
(+) Local pain with compression
Cervical radiculopathy:
Neurocompressive disorder of the cervical nerve roots resulting in various neurological findings (7 vertebrae & 8 nerve root)
Pathogenesis occurs from the inflammatory process initiated by nerve root compression
Cervical radiculopathy differential diagnosis:
-Peripheral Neuropathy
-Facet syndrome, meniscoid, instability
-Myofascial pain syndrome, trigger point referral
-Cervical myelopathy, CNS lesions
-Infection, neoplasm, fracture, rotator cuff injury
Cervical radiculopathy history:
-Patient describes deep aching burning neck pain & radicular arm pain (“numbness, tingling, sharp, shooting, electrical”) that may follow a neck injury or be of insidious onset
-May be a history of multiple episodes of previous neck pain. Possible muscle weakness in the arm/hands or sensory changes along the involved nerve
-Patient may state symptom relief when shoulder is abducted with hand held behind head (shoulder abduction test)
Observation: Head tilt & neck posture; head tilt away from the side of injury & holds neck stiffly
Cervical radiculopathy physical:
AROM: Limitations: extension, rotation & lateral bending either away or towards the affected nerve root (increased pain, numbness, tingling or electrical pain)
-Pain away from the affected side = disc herniation
-Pain towards affected side = impingement of nerve root at site of IVF
Palpation:
-Tenderness along cervical paraspinalis
-Muscle tenderness along muscles where symptoms are referred (medial scapula, proximal arm, lateral elbow) and associated hypertonicity/spasm
Motor weakness:
-Grip and pinch weakness
Sensory changes:
-Decreased sensation to pain and light touch (dermatomal distribution)
-Burners or stingers
DTRs:
-Hyporeflexia indicates peripheral neuropathy, hyperreflexia indicates CNS lesion
Cervical radiculopathy special tests:
Valsalva test:
(+) Reproduction of neck or radicular pain in case of disc herniation or SOL
Cervical Compression Test:
(+) Reproduction of neck or radicular pain due to nerve root compression
Cervical distraction:
(+) DECREASED radicular symptoms
Brachial Stretch Test:
(+) Reproduction of dermatomal pain referral
TMJ syndrome:
Pain & tenderness due to a dysfunction of the TMJ or surrounding musculature & soft tissue.
3 subtypes:
1) Myofascial pain dysfunction
2) Internal derangement
3) Degenerative joint disease
TMJ differential diagnosis:
-Headache (cluster, migraine, tension)
-Temporal/Giant cell arteritis, trigeminal neuralgia
-Dental infections, parotiditis
TMJ history:
-Jaw or facial pain (80%), pain with mastication (chewing)
-Locking or clicking or catching with motion, limited ROM, grinding & popping
-Headache, earache (30%) & neck pain
-History of neck or facial trauma (whiplash)
TMJ physical
Observation: asymmetry, muscle hypertrophy, abnormal dental wear
Palpation: tender (80%) over the muscles of mastication, can feel crepitus in the joint in late stages
ROM: decreased jaw opening
normal= 40mm or at least 3 knuckles inserted between upper and lower incisors
Clicking or popping of TMJ, crepitus over joint (may indicate disc damage)
Abnormal mandibular tracking (gait): lateral deviation of mandible, non-uniform pattern
TMJ special tests:
Rule out DDXs:
-Often special tests are done to rule out other conditions you are considering to make TMJ syndrome your most likely working diagnosis.
Benign paroxysmal positional vertigo (BPPV):
A disorder arising from a problem in the inner ear where the underlying mechanism typically involves small calcified otolith moving around loose in the inner ear.
Type of balance disorder
BPPV differential diagnosis:
-Labyrinthitis
-Meniere’s disease
BPPV history:
-Any nausea
-Any head injury
What is the patient’s age?
What are the symptoms:
-Spinning sensation (vertigo)
-Nausea/Vomiting
-Symptoms worsen with movement of head
-Is it paroxysmal (suddenly and short duration)
-Per-syncope or syncope
BPPV special tests:
Rule out DDXs:
-Dix-Hallpike test
-Is nystagmus observed
BPPV treatment:
-Usually involves simple movements such as the Epley maneuver or other maneuvers based on direction of nystagmus
-Prescription drugs to help with nausea
Whiplash:
Injury to the neck due to sudden acceleration or deceleration
Results in a flexion or extension deformation of the spine
2 common scenarios for whiplash
A body as rest suddenly put in motion (ex: quarterback being hit from behind)
A moving body suddenly stopped (ex: hockey player absorbing a hit in open hit)
Types of whiplash:
-Posteroanterior (back to front)
-Anteroposterior (front to back)
-Lateral (right to left)
-Lateral (left to right)
Symptoms of whiplash:
-Neck pain
-Onset can be immediate or hours later
-Soreness, stiffness, fatigue
-Nausea
Symptoms if structural damage is found:
-Sharper pain
-Quicker onset
-Pain may radiate anywhere
-ROM can be severely limited
