PT4 - Cspine Flashcards
When is it ok to treat non-specific csp pain (NSCSP)?
- unilateral presentation
- no red flags e.g. neuro - HAs, dizziness, changes in special senses
- possible radiations
- mechanically aggravated
What happens in the upper CSP regarding movement?
- OA/AA supports head
- OA minimal movement => results in quick translation to CSP
- C1-C2 => mostly rotation (around Odontoid peg), NO discs, 50% rotation, has a lot of ligaments (cruciate, transverse, alar), very bursa rich to lubricate, common site of RA
- C3-C5 => mainly flexion + extension + SB
- C6-C7 => transition to thorax => reduced movement
What will movement feel like in the neck if you suspect RA/instability?
- lag between head coming off pillow and csp coming off pillow => CAUTION => ligaments have lost resiliance + stretching (hence lag) suspect instability in OA/AA => inspect hands + wrists for sign of RA
- can also feel similar in Spondylosis
What are common presentations of NSCSP?
- HAs
- Radiations to side/shoulder
- Be moderately careful on first TTT
- Common to twist further than available in cape e.g. reaching backwards in car => acute MM response => facet “lock” as joint capsule stretched => intense hypertonicity (segmentation overstrain) => MM spasm prevents movement (tends to happen in mid-csp) => PT wakes with pain
- Whiplash is a type of NSCSP => common in RTA from behind. First => flexion => seat hits thorax => extension through C3-C5, ligamentus strain => recoil => adrenaline rush => MM tearing posteriorly => mild enough not to be felt at the time => present with NSCSP the following day with symptoms. Good care position => head in contact with headrest => fully depresses levers, diminishes impact => modern car that crumples (don’t want to be turning a corner). Seatbelts => rotational injuries (driver seat => worse on left hand side). If hit from front => MM tearing as preparing for impact (can see it coming)
- Sporting injuries e.g. rugby/boxing => usually minor, no symptoms at the time => MM tearing + PPW pain the following day => ligament (facet compression) => very straight csp + facet joints compressed
What are the 3 divisions of the neck (for healthy function)?
- upper csp: orientation sense organs + cranial base => stable base for head + face function
- mid csp: rotation
- lower csp: dissipation of forces into thorax
What are the mid-csp specialisations?
- bony shape
- myofascial balance
- neurovascular health
- adaptation
- all can be come dysfunctional
What functions happen at the lower csp?
- CTJ provides:
—> dissipation of forces
—> protection of viscera and neurovascular structures
—> lower csp movement on first rib
—> aids movement of shoulder girdle
What is the function of the clavipectoral fascia?
- anterior fascia
- scalenes are part of force dissipation
- cervical fascia blends with deep fascia sandwiched between pectoralis major + minor => large clavipectoral band => can be tightened => fibrotic impacting thoracic outlet
-
List key anomalies of a cervical rib
- failure of normal ossification
- 1% incidence
- 2:1 F:M
- transverse apophysomegaly more common @ 3% (transverse process grows longer to join with a rib from cervical spine)
What are the symptoms of thoracic outlet syndrome?
- pain and fatigue
- numbness and tingling
- weakness and wasting
- pallor/cynosis
- swelling
- loss of pulse
Where and what is carpel tunnel syndrome?
- median nerve impacted (major nerve between hand + brain)
- flexor tendons => fibrous tissues connecting muscle to bone => slide back and forth as fingers move
- transverse carpal ligament => tough ligament (scaphoid + trapezium => pisiform + hamate) => roof of carpal tunnel
- tendon sheath => protective outer covering => lets tendon move easily
- carpal bones => u shaped group of bones => hard floor + sides of carpal tunnel
What are the 3 types of TOS?
- costoclavicular (Edens) syndrome
- Scalenes-anticus syndrome
- Hyperabduction syndrome
What happens in costoclavicular (Edens) syndrome?
- clavicle compresses vessels and nerves from neck (between clavicle + 1st rib)
What happens in scalènes anticus syndrome?
- scalenes compressing artery and nerves from the neck (between anterior + middle scalene)
What happens in hyperabduction syndrome?
- pectoralis minor compressing vessels and nerves from neck (pec minor + 2nd rib)
What are the diagnostic types of TOS?
- vascular TOS => arterial + venous
- neurological TOS => true neurological TOS + Symptomatic TOS
What are the main causes of compression in TOS?
- anatomical defects
- poor posture, overuse of the scaleni
- trauma
- repetitive activity and sports
- traction trauma
Where are the 3 potential areas of entrapment of TOS?
- interscalene (anterior + middle)
- costoclavicular lesion (clavicle + 1st rib + subclavius)
- infraclavicular lesion (hyperabdcution syndrome) (pec minor + 2nd rib)
What happens in TOS?
- compression of major blood vessels + nerves/plexus
- vaso-nervorum compressed
- dynamic or static
Match the names of TOS for the 3 different locations where this can occur
- costoclavicular space = costoclavicular syndrome (clavicle + first rib + subclavian MM)
- inter scalene triangle = scalene anticus syndrome (anterior + middle scalenes + 1st rib)
- hyperabduction syndrome = intrapectoral space (pec minor + 2nd rib)
What are the diagnostic tests for TOS?
- Adson’s => intermittent claudication test
- Roo’s => pain, swelling, cyanosis, paraesthesia
What are the cervical ligaments and MMs concerned with structure and function of csp?
- ligamentus attachments of viscera:
—> from cranial base to mandible
—> support and control hyoid
—> run to shoulder + thorax
- MM of anterior csp:
—> longus colli
—> longus capitis
—> scalenes
What are pain sensitive structures of the csp?
- apophyseal joints = zygapophyseal = facet joint
- nerve root sheaths = vaso-nervorum + nervi-nervorum
- meninges = dura, pia mater, arachnoid mater
- outer fibres of IVD
- uncovertebral joints (joints of van luschia) = uncinate joints (lost in side bend first)
- myotendons structures
What happens to longus colli + capitis in neck pain?
- ischaemia
- metabolites
- trigger points
- sensitisation
When longus colli + capitis are in pain, what does this lead to?
- contracture
- fibrosis
- wasting
- poor head control
How do you perform the craniocervical flexion test?
- PT supine
- biofeedback unit inflated to 20mmHg under PT cspine
- Stage1: PT performs headnod until increase of 2mmHg for 2-3 secs (performed on exhalation if epical breathing pattern)
- observe:
—> analyse motion of headnod (should see increase in flexion from OA)
—> PPT scalene + SCM muscles (should only see these work in the last stages of the test)
- stage2:
—> performed if PT can achieve stage 1
—> isometric endurance of deep cervical flexors
—> 3 x 10 sec hold @ 22mmHg
Observe:
—> jerkiness of hold or reduced pressure
What is Suprling’s test for?
- cervical nerve root compression
How is Spurling’s test performed?
Spurlings A test:
- PT sitting + OP behind
- Lateral flexion of PT cspine + 8kg force down by hand + OP opposite hand on torso to stabilise
- +ve test is reproduction of symptoms
Spurlings B test:
- same PT + Op position as above
- Lateral flexion + contralateral rotation away of PT cspine + OP opposite hand on torso to stabilise
- +ve test is reproduction of symptoms
Has been performed @ C1-C2 to C6-C7
What is whiplash?
- compression/decompression (sigmoid deformation)
- NOT flexion/extension injury
- Rear, front or side on TA OR diving and sports
- Distraction at anterior disc, where annulus fibres coverage, possibly leading to tearing of disc
- compaction at posterior aspect particularly compounding facet joints and synovial folds
Which vertebrae is normally impacted by whiplash injuries?
- C5 compresses onto C6 in extension
What are the biomechanics of whiplash?
- usually rear impact TRA (PT unaware = relaxed)
- MM off guard => ligaments increase in direct stress
- primary injury => cspine extension affecting OA
- apex C4/C5
- as CSP flexes => posterior protection => tearing of MM + ligaments
- mid CSP key centre of flexion severely affected
- increase damage to transverse cruciate ligament + tectorial membrane (spinal cord)
- Affected areas: OA, mid CSP, C1-C2 if rotation involved
What is the Whiplash grading (Whiplash Associated Disorders)?
- Grade 0 = no complaints/physical signs
- Grade 1 = CSP complaints (pain, tenderness, stiffness) + no physical signs
- Grade 2 = CSP complaints + MSK signs (decreased ROM + MM weakness)
- Grade 3/4 = CSP complaints + neuro signs (sensory deficit) e.g. fracture/dislocation
What are the guidelines for WAD?
- Case Hx
- Grades 1 => 5 => X ray
- If +ve for fracture => immediate referral for A&E/specialist surgeon
- If -ve for fracture => reassure, encourage activity, manage pain
What are the stages for a non-fracture WAD recovery?
- 7 days => if not resolving, reassess + consider manual/physical therapies
- 3 weeks => if not resolving seek specialist advice
- 6 weeks => if not resolving => multidisciplinary pain team/rehab provider evaluation
What is the Canadian CSP rule? (CCR)
- are the following NOT true:
—> +65, mechanism of onset dangerous, numbness or tingling in extremities
- are the following present:
—> simple rear-end motor vehicle collision
—> PT ambulatory at any time since injury
—> delayed onset of CSP pain
—> PT in sitting position in emergency department
—> absence of midline cervical spine tenderness
- is PT able to actively rotate CSP 45 degrees L + R
What is Whiplash Associated Disorder (WAD)?
- whiplash injury with no demonstrable changes on imaging => pain without tissue damage
What symptoms are associated with WAD?
- dizziness
- HAs
- TMJ
- Tinnitus
- May run in a 1-2 year period of recovery
- Also called Late Whiplash Syndrome (LWS)
In a rear end RTA collision, what are the primary injuries?
- CSP extension
- OA joint primarily affected due to momentum of head
- mid apex = C4/C5
What initiatives should be undertaken to prevent and rehabilitate PT with WAD?
- educate car user
- seat + head restraints
- education of PT
- pro-active funded TTT
- protocols for management
- quick compensation/lower costs
What movement happens in neural tissue in WAD?
- rotation + side bending results in stenosis of intervertebral foramen (IVF)
What is the biggest predictor of non-recovery in WAD?
- insurance claims => yellow flag for recovery
Provide a way of testing craniocervical flexion test?
- anatomical markers position on Tagus of ear + medial protuberance of mandible + lateral aspect of CSP
- digital image taken + software used to calculate craniocervical flexion ROM
What other test are available to assess CSP?
- lift head off table and perform nodding movement
- can PT flex upper and lower CSP?
- if PT can’t get head off plinth => positive craniocervical test
