Week 2 Cervicothoracic spine Flashcards
function of spine - regional (cervical, thoracic, lumbar spine)
cervical - conduit of vertebral artery
thoracic - supports thoracic cage, resolves forces from the humerus/ clavicle/ scapular
lumbar - supports muscles from hip and pelvis
‘stiffness’ lay term vs physio term
lay term: lack of comfort during movement
physio term: loss of end range movement in joints
Erect standing: sagittal plane - cervical and thoracic spine
LoG
cervical spine:
LoG passes posteriorly creating an extension moment
thoracic spine:
LoG passes anteriorly, creating a flexion moment
Forward deviations of the head and neck result in
increased demand on the levator scapula and upper trapezius
Ruptured transverse ligament
橫韌帶斷裂
C1 can slide forward on C2, risking compression of the brainstem- Common causes of rupture:
Trauma,Rheumatoid arthritis,Down syndrome - Halo-Thoracic brace
transverse ligament maintains the relationship between C1 and C2
RA: immune system attack joint
symptoms: flu-like symtoms (fatigue, fever), often bilateral, morning stiffness more than 30 mins
Costovertebral movements
- The ribs move in a ‘bucket handle’ motion during respiration
- Flexion, extension and coupled rotation/ lateral flexion
Neutral zone
- translational (accessory) movement is greatest
- relatively less tension in spinal ligaments
flexion - limit to movement (O/C1, C1/C2, C2-C7)
O/C1:
ligamentum nuchae
posterior atlantoaxial ligament
C1/C2:
ligamentum nuchae
ligamentum flavumfacet joint capsules
C2-C7:
ligamentum nuchae
ligamentum flavum PLL
flexion - limit to movement (thoracic and lumbar spine)
thoracic spine:
ligamentum flavum
PLL
facet joint capsules
rib cage
lumbar spine:
ligamentum flavum facet joint capsules
posterior annulus
extension - limit to movement (O/C1, C1/C2, C2-C7)
O/C1, C1/C2:
passive tension in the anterior atlantoaxial ligament
C2-C7:
contact of spinous process
ALL
anterior neck muscles
extension - limit to movement (thoracic and lumbar spine)
thoracic spine:
contact of spinous process
ALL
anterior trunk muscles
lumbar spine:
contact of spinous process
ALL
anterior trunk muscles
anterior annulus
rotation & lateral flexion - limit to movement (O/C1, C1/2, C2-C7)
O/C1:
alar ligaments
C1/C2:
alar ligaments
C2-C7:
annulus fibrosis
rotation & lateral flexion - limit to movement (thoracic and lumbar spine)
thoracic spine:
annulus fibrosis
facet joint capsules
intertransverse ligaments
lumbar spine:
annulus fibrosis
facet joint capsules
intertransverse ligaments
iliolumbar ligaments
coupled movements
the facet joints and biomechanics of the soft tissues result in a coupled movement of rotation and lateral flexion occurring simultaneously
muscle action
info
Using the cervicothoracic spine as a stable base, the musculature of this region supports and moves the upper quadrant and thoracic cage
Muscle attachments from the upper limb extend the length of the cervical and thoracic spines to allow a broad dispersal of forces, e.g. trapezius, latissimus dorsi
what is vertebral arteries
- branches of the subclavian arteries
- enter deep to the transverse process of C6
- pass upwards through the transverse process of each cervical vertebra until C1 and enter the skull via the foramen magnum
- the vertebral artery is vulnerable to stretch and trauma
- as it passes through the
transverse foramenand passesposteriorly around the lateral mass of C1 - result in damage to the lining of the artery 動脈內壁損傷 =
brainstem stroke
risk factors for neck pain (high evidence)
female
previous episode of neck pain
risk factors for prognosis:
- pain intensity
- level of self rated disability
- pain catastrophizing –> wont feel better anymore
- post traumatic stress symptoms
- cold hyperalgesia (increase pain associated with cold)
characteristics of inflammatory BP vs mechanical BP - age at symptom onset, onset, activity, morning stiffness, inflammatory markers
info
inflammatory:
age at symptom onset - <40 yo
onset - persists for >3 months, insidious
activity - improves with exercise
morning stiffness - moderate, persists for >45 minutes
inflammatory markers - elevated in 50-70%
mechanical:
age at symptom onset - any age
onset - variable
activity - improves with rest
morning stiffness - mild, short-lived
inflammatory markers - normal
red flags questions need to ask in an interview
- UWL
- medications are using
- any x-rays
- any difficulty using bladder
- any pins and needles/ numbness in both legs and arms
- any fever or night sweats
red flag pathologies of the cervical and thoracic spine (8)
- inflammatory/ systemic conditions
- cervical myleopathy/ cauda equina
- vertebral artery
- spinal infection
- spinal malignancy 脊椎惡性腫瘤
- spinal fractures/ upper ligamentous instability
- cervical fractures
- thoracic compression fracture
symptoms/ signs of inflammatory/ systemic conditions
- temp > 37 degrees
- BP > 160/95mmHg
- resting pulse > 100bpm
- resting resp rate > 25pm
- fatigue
- morning stiffness - persists > 45 mins, better with movement
- insidious onset 起病隱匿, persists > 3 months
symptoms/ signs of cervical myelopathy/ cauda equina
central myelopathy (central stenosis)
- sensory disturbance of hands
- wasting of hands intrinsic muscles
- Hoffman’s sign
- unsteady gait/ heaviness in legs/ loss of balance
- bladder disturbances
- neurological signs: decreased sensation/ motor weakness
- radicular pain
if pt say yes, maybe there is some specific neuropathology
Hoffman’s sign - involuntary flexion movement of the thumb and or 2nd finger when the examiner flicks 3rd finger
頸椎頸脊髓病變(Cervical Myelopathy) 脊髓病變是臨床上常見疾病，極容易被病人所忽視疾病。 頸椎神經根病變會帶給病人疼痛感覺，脊髓病變症狀進展情況緩慢，不會有很特殊的症狀。 初期雙手麻而已，慢慢地出現上身有緊縛感、下肢無力等。 當意識到情況不對時，往往 在臨床上已經相當嚴重了。
common cause of cervical myleopathy/ cauda equina
- central disc herniation
- spinal canal stenosis
- post spinal surgery
- high risk: < 50 yo and obese –> requires a surgical opinion
symptoms/ signs of vertebral artery
- dizziness
- difficulty talking (dysarthria)
- difficulty swallowing (dysohagia)
- double vision
- drop attacks (fainting 昏厥)
- nausea 噁心
- vomiting, sweating
- also be wary of presence of gait disturbances, balance problems
risk factors of spinal infection
- recent pre-existing infection
- imminosupression 免疫抑制
- IV drug use
- surgery
- social/ environmental factors (homelessness, prisoner)
symptoms and signs of cervical infection
symptoms:
- local progressive pain
- neuro symptoms
- fatigue
- fever
- UWL
signs:
- TOP (tenderness of palpation)
- radiculopathy
- neuro signs
- blood tests
- MRI
symptoms and signs spinal malignancy 脊椎惡性腫瘤
- constant pain/ severe progressive
- night pain
- UWL
- PHx of cancer
- neuro signs (bilateral, gait disturbance, bowel/ baldder dysfunction)
- fatigue, nausea, fever
risk factors, symptoms and signs of spinal fractures/ upper ligamentous instability
risk factors:
- history of osteoporosis 骨質疏鬆
- corticosteroid use history
- PHx of cancer
- Hx of falls
- female
- older age (>65 yo female, >75 yo male)
- severe taruma
- previous spinal fracture
symptoms:
- pain
- severe pain
- neurological symptoms
- instability
signs:
- TOP
- neuro signs
- spinal deformity
- contusion or abrasion 挫傷或擦傷
cervical fractures
- history of trauma
- high risk activities (diving, horse riding, football, skiing, gymnastics and hand gliding)
thoracic compression fracture
- occur people with reduce bone density or trauma (such as falls)
- effect on cervical posture
whiplash injury
- acceleration-deceleration injury
- may result from motor vehicle accidents, but can also occur during falls, diving
symptoms of whiplash injury
- activity limitation
- cervicothoracic pain
- dizziness
- muscle spasm 肌肉痙攣
- tenderness
- pain or numbness in the arm and/or hand
- poor concentration
- stiffness reduced ROM
- +/- arm pain
WAD need imaging? (high risk factors)
any high risk factors?
age > 65
dangerous mechanism
numbness in extremities 四肢麻木
–> if yes, radiography
WAD need imaging? (low risk factors)
low risk factors:
- not immediate onset of neck pain
- ambulatory at any time (can walk anytime)
- sitting position in ED (able to sit in ED)
- absence of midline C-spine tenderness
—-> if the patient do not have any low risk factors, must go to radiography
if there is one of the above:
then, is the patient able to rotate neck (45 degrees left and right) actively?
—-> No, go to radiography
if yes, no radiography
WAD grading systems
grade 0 - no complaints or physical signs (no pain)
grade 1 - neck complaints but no physical signs (pain/ stiffness/ instability; normal AROM, strength, length testing)
grade 2 - neck complaints and musculoskeletal signs (decrease ROM/ coordination strength/ endurance)
grade 3 - neck complaints and neurological signs (decrease/ absent tendon reflexes in UL and LL)
grade 4 - fracture/ dislocation
psychosocial and pain factors associated with chronicity/ disability (yellow flags) for WAD
- anxiety
- high pain intensity
- high NDI (neck disability index) score
- post traumatic stress symptoms
- poor expectations of recovery
not a predictor for WAD
- accident features
- imaging findings
- motor dysfunction 運動功能障礙
prognosis of WAD
- high levels of reported pain: Visual analogue scale (VAS) > 5.5/10
- higher levels of disability: Neck disability index (NDI) >29
- 50% will continue to report pain and disability 1 year after injury
- take place within the first 2-3 months after recovery occurs 發生在恢復後的前 2-3 個月內
management of WAD
- education:
return to normal activity ASAP
avoid use of cervical collar - exercises:
ROM, strengthening, postural, functional retraining - pain education and management
cervicogenic headache
- pain in head but referred from a primary source in the cervical spine
-
pain may arise from any structure (eg:
muscles, joints, ligaments discof the cervical spine) - innervated by C1-C3 nerves
presentations of cervicogenic headache
- slow onset, intermittent
- unilateral headache, generally starting in the neck and ‘spreading’ forwards
- muscle tightness
- decreased strength endurance
- reduced neck flexion/ extension ROM
management of cervicogenic headache
- exercise (stretching, shoulder girdle)
- cervical mobilisation
- exercise + manual therapy
- dry needling + exercise
cervical spondylosis
affects the lower cervical spine, C5/6 is the most mobile region of the neck
symptoms/ signs of neck pain with radiating arm pain - radiculopathy
- can occur due to spondylosis resulting in a narrowing of the intervertebral foreman (lateral stenosis)
- result from a disc protrusion 椎間盤突出
symptoms/ signs:
- neck pain with radiating UL pain
- increased pain with Cx ROM
- neuro signs (nerve root distribution)
management of neck pain with radiating arm pain
- strengthening/ posture exercise
- pain management education
what is wry neck (torticollis)?
presentation of wry neck?
prognosis of wry neck?
idiopathic/ nerve or muscle damage
presentation:
- reduce neck ROM, difficulty to look to one side
- pain
- palpable facet joint tenderness/ stiffness
prognosis: resolve within 3-10 days but may be recurrent
在自然情況下，當一個人的臉部總是轉向固定的一側，而頭頸部傾向另一側，這種情形即稱為斜頸症
management of non specific neck pain
- Acute/ Sub acute:
– Exercise: Cx/ Thoracic ROM, scapulothoracic strengthening, endurance
– Cervical mobilisation - Chronic:
– As above
– Pain education
– Postural, coordination, proprioception, kinaesthetic
and cognitive awareness retraining, aerobic exercise
– Dry needling, traction (grade B)
