Cervical Spine Key Points + Safety + Blood Pressure

DAY 1

What does the cervical spine do?

• provide stability

• provide mobility

• protect spinal cord

the cervical spine represents one of the most remarkable engineering achievements in human anatomy

Development of Spinal Curvatures

The normal spinal shape has 4 curvatures:

• cervical lordosis

• thoracic kyphosis

• lumbar lordosis

• sacropelvic kyphosis

These normal curvatures develop shortly after birth:

• in utero and at birth - the whole spine is in mild kyphosis

• as head control is achieved in first few months post partum, the cervical lordosis forms

• as sitting and standing are achieved, the lumbar lordosis forms

WHY?

To allow bipedal movement and maintain a very centralized mass when upright

C1

Horizontal cupped facets cradle the occiput (atlas)

C2

Dens and facets favour rotation (axis)

Transverse ligament

Dens side is anterior

if this ligament doesn’t exist the weight of your head will pull C1 to C2

It is important so the spinal cord doesn’t get damaged

C3-7

45 DEGREES slope

How is cervical stability achieved?

bony architecture,

ligamentous stability, and

muscle activity

Cervical Spine bony stability

a. bony stability is sacrificed for more mobility

b. small vertebral bodies relative to thoracic and lumbar

c. unconvertable joints to prevent excessive lateral flexion

d. facet joints downsloping at 45 deg

Cervical Intervertebral Discs

Differ from lumbar discs

• crescent shaped annulus anteriorly with interwoven fibers

• posterior annulus is thinner and compromised of vertical fibers

Key Upper Cervical Ligaments

Stabilize C1 & C2 & Skull

• Transverse ligament

• Alar ligaments

• Tectorial membrane

Why are cervical ligaments important?

The most important ligament of the upper cervical spine is the transverse ligament of the atlas

The transverse ligament hold C1 firmly onto C2- stopping anterior translation of the skull and C1 on C2

Preventing compression of the brainstem with cervical flexion

Be aware that in certain conditions the upper cervical ligaments can be compromised:

• Most significant in RA

• Also linked to ankylosing spondylitis and psoriatic arthritis

• Downs syndrome, Ehlers-Danlos syndrome, post-partum

Risk of cervical myelopathy, cranial nerve neuropathy, brainstem compression or vertebral artery injury

Posterior Neck Extensors

Cervical Extensors are 2-3x stronger than flexors

Superficial muscles:

• semispinalis capitis

• splenius capitis

• lev scapulae

• trapezius

Deep muscles:

• splenius cervicis

• multifidus

4 suboccipital muscles

Muscles of the neck provide

• movement

• stability

• proprioception

What changes occur to cervical muscles in the presence of chronic dysfunction?

Presence of muscular fatty infiltration that affects the deep cervical musculature (multifidus, semispinalis cervicis)

Increased presence of fatty infiltrates at 3 months post injury predicted those that would go on to develop moderate to severe chronic symptoms

Sensorimotor control of cervical muscles

Cervical proprioception:

cervical facet joints and discs

• mechanoreceptors

• ruffini corpuscles

• pacinian corpuscles

• golgi tendon organs

suboccipital muscles

• rich in muscle spindles

• major role in proprioception and head / eye coordination

Sensory convergence- the trigeminocervical nucleus

pain from the muscles, ligaments and joints of the upper cervical spine can be felt in the neck, face and scalp

the mid- and lower-cervical spine refers locally and to the periscapular region

This is though to be due to sensory convergence through the trigeminocervical nucleus

Key Movements of the Cervical Spine

C0-1- ‘Atlantooccipital joint’

• ‘nod’ flexion/extension ~ 20 deg

C1-2- ‘Atlantoaxial joint’

• upper cervical rotation ~45 deg to either side

C3-7 Middle and Lower cervical spine

• combined multi-level movements to achieve:

  • remaining ~45 deg rotation (total ~90deg)

  • lateral flexion (almost all) (total ~45deg)

  • remaining flexion / extension (total 50-60deg)

Upslope/ Downslope

Ipsilateral LF and rotation = downslope

Contralateral LF and rotation = upslope

Flexion = downslope

Extension = upslope

Coupled Movement

Cervical spine: rotation and side bend to the SAME SIDE

IF one movement direction is restricted, the coupled movement will also be restricted

IE. Impaired cervical LF will also reduce ipsilateral rotation (to the same side)

Forward Head Posture

• Increased FHP in adults with neck pain

• Not associated with neck pain in children

• More FHP with age

3 Quick Tests

0 / C1 (AO Joint)

• horizontal “cradle”

• favors F/E Approx. 20 deg

C1 / C2

• favors rotation (approx. 45 deg)

C2 / C7

• slope down backwards

• upslope & downslope

• collectively approx. 45 deg rot.

Upper Cervical Spine Summary

Often refers pain into face and scalp

Responsible for ‘nod’ (C0-1) and half of all rotation (C12)

Mid Cervical Spine Summary

Mostly flexion and extension

Coupled movement of LF and rotation

Lower cervical spine - summary

significant load bearing

contributes to F/E, LF, Rotation

also has couples movement of LF and rotation

Cervical spine summary

highly tuned sensory integration into eye, vestibular and joint proprioception

cervical stability is largely provided by ligament and muscle activity - much less bony stability than the much larger lumbar vertebrae

Facet joint orientation largely dictates what movement is available at a particular joint level - pay attention to this for all spinal regions

Pain is caused by

MSK structures, but not always

• vascular pathology

• neurological pathology

• fractures

• infections

• inflammatory disease

• tumors

• many other medical conditions

Shoulder Pian presentation

Emergency: Heart attack

Medical: Inflammatory conditions (ie. polymyalgia)

MSK: Subacromial impingement

Child with knee pain presentation

Emergency: Infection (septic arthritis)

Medical: Osteochondritis dissecans

MSK: Patellofemoral pain

Neck pain and headache presentation

Emergency: Subarachnoid haemorrhage CAD

Medical: Brain tumor, temporal arthritis

MSK: Cervicogneic headaches

Low back pain presentation

Emergency: Abdominal aortic aneurysm, cauda equina syndrome

Medical: Kidney infection, ankylosing spondylitis

MSK: None-specific

Calf pain presentation

Emergency: DVT (deep vein thrombosis)

Medical: Achilles tendon rupture

MSK: Gastrocnemius strain

What could possibly go wrong?

1. Wrong patient

• The patient should be with a different professional

• Failure to recognize or act on non-msk pathology

• Appropriate care is delayed

Physio may worsen the underlying condition

2. Wrong care (or poorly delivered care)

The patient needs physio but the treatment causes harm

• Treatment applied in an unsafe way

• Non-response is ignored, delaying appropriate care

• Treatment causes direct harm to the patient

RED FALGS- am I the right person for this patient?

Subjective findings

Objective findings

They are NOT tests

Help identify serious spinal pathology

Raise suspicion of non-msk pathology

International Framework for Red Flags for Potential Serious Spinal Pathologies (IFOMPT)

What contributes to clinical level of coner:

Evidence:

• Prevalence of pathology

• Red flags (supported by high-quality evidence)

VS

• Red flags (Supported by consensus only)

• Red flags in combination

Clinical Profile

• Symptom progression

• Response to care

• Urgency (consequence of delay)

• Comorbidities

• Repeat visit?

Outpatient Assessment- Process

Subjective Assessment (history)

• screen out non-msk, hypothesis development, SSSSNIPRD Tool

Objective Assessment (physical)

• Test and re-assess, hypothesis testing

Analysis

• Develop treatment plan to address hypothesis

• Diagnosis/hypothesis

Treat (and re-assess*)

• Reflect and confirm

• Change in condition, confirm or refute diagnosis

Plan

• What to assess and treat next session (what markers you will use)

How to deliver safe care

Communication

• with the patient

• with the wider healthcare team

Treatment selection

• always consider irritability

• understand contraindications and precautions

Documentation

• soap notes

• legal requirements

Vascular pathologies

(can present with neck pain or headache)

• dissection

• haemorrhage

• aneurysm

• atherosclerosis

• stenosis

• thrombosis

• embolism

• malformation

• inflammatory

Vascular dissection

Abrupt tear in the vessel wall

More often in young - middle aged

Potential consequence is a stroke

Purpose of the IFOMPT Document

1. Some patients may present to a physio with symptoms from a neurovascular (not msk) pathology. Symptoms including neck pain / headache

2. The potential link between neurovascular incidents and manual therapy of the cervical spine

The IFOMPT Document

• Provides an international consensus statement on best practice

• Aims to increase understanding of risk and pathology, thereby promoting patient safety

• Helps identify patients at risk, NOT appropriate for treatment and need onward referral

• Helps identify those patients APPROPRIATE for manual therapy

Risk of Cervical Manipulation

• Potential risk of artery dissection with/after manipulation is between 1/1.3 million sessions and 1/400,000 manipulations

Patient History Considerations

is there presence of frank vascular pathologies of neck?

subtle signs and symptoms of the suspected pathologies should be recognized

is there predisposition to vascular pathologies of the neck?

risk factors indicating the potential for neuro-vascular pathology should be recognized

WHY- head and/or neck pain may be a symptoms of underlying vascular pathology or dysfunction

Dissecting Stroke

Recent trauma may represent an important significant risk factor for dissection

Risk factors-

• recent trauma

• vascular anomaly

• current or past smoker

Symptoms-

• headache

• neck pain

• visual disturbance

• paresthesia (upper limb, face, lower limb)

• dizziness

Signs-

• unsteadiness

• ptosis

• weakness (upper limb, lower limb)

• facial palsy

• speech difficulties

• swallowing difficulties

• nausea/vomiting

• dizziness

• drowsiness

• loss of consciousness

• confusion

Non-Dissecting Stroke

Risk Factors:

• current or past smoker

• hypertension

• high cholesterol

Symptoms:

• headache

• paresthesia (upper limb, lower limb, face)

• visual disturbance

• neck pain

• dizziness

Signs:

• weakness (upper limb, lower limb)

• speech difficulties

• ptosis

• facial palsy

• unsteadiness

• confusion

• vomiting

• swallowing difficulties

• loss of consciousness

• drowsiness

Dizziness

One of the most common presenting symptoms of vascular involvement

Causes of dizziness

• vestibular system

• BP related (hypotension)

• vertebrobasilar artery insufficiency

• upper cervical ligament instability

• cervicogenic

5 D’s

Diplopia (seeing double)

Dysarthria (difficulty forming words)

Dysphagia (difficulty swallowing)

Dizziness

Drop attacks

3 N’s

Nausea

Numbness (facial, lips, tongue)

Nystagmus

Dizziness Table

Dizziness

• VBI- rarely constant

• Vestibular- usually constant

Dizziness with ‘head movement’

• VBI- provoked by neck movements

• Vestibular- provoked by head movements, may have associated nystagmus

Supine vs sitting

• VBI- symptoms same in either position

• Vestibular- symptoms may be different in supine rather than sitting

• Orthostatic hypotension- provoked by change from low to high, or supine to sitting

Nystagmus

• VBI- not fatigueable

• Vestibular- latent fatigueable and habituates

Other cautions (in addition to the 5D’s and 3N’s)

Miscellaneous:

• Cervical fracture or severe whiplash history or recent concussion

• Vertebrobasilar insufficiency

• Severe OA and RA

• Cranio-cervical abnormalities (Downs syndrome, marfams)

Ligament Instability

• history of trauma

• congenital collagenous compromise (downs syndrome)

• inflammatory arthritis (rheumatoid)

• immediately post-partum

recent neck/head/dental surgery

recent infection

long term steroids

Vascular Risk Factors

Trauma to cervical spine (large or small) —- most common mechanism for VA injury is neck hyperextension with or without rotation or side bending

tinnitus

history of migraine type headache

“the worst headache of my life)

hypertension

hypercholesterolemia

cardiac disease

history of CVA or TIA

diabetes

anticoagulant therapy

history of smoking

Physical Examination

No single test alone will provide decision-making information, positional testing is unlikely to influence decision making

Clinical suspicion of vascular cause is supported by reasoned historical and or clinical examination findings

Are there any precautions or contraindications to physical examination?

Conduct appropriate elements of the physical examination:

• neuro exam (cranial and peripheral)

• co-ordination and gait consideration

• BP

• Ausculation

Vascular and Cranial Nerve Screening

Blood Pressure and Measurement

• HT is a risk factor for carotid and vertebral artery disease

• Acute elevation in BP can result from acute arterial trauma, and can be an early symptom of TIA or CVA

Vertebral artery sufficiency screening

• sustained 10 sec hold in rotation

Neurological testing

• cranial nerve testing

Clinical Reasoning and Shared Decision Making

Clinical reasoning

• history

• exam

• knowledge of risks

Practitioner

• evaluation

• risks and benefits

• alternatives

• uncertainty

Patient

• narrative and expectations

• what matters (values)

• context

Consensual decision making

• consent

• treatment planning

• referral

Cranial Nerves

CN I - Olfactory

CN II - Optic

CN III - Oculomotor

CN IV - Trochlear

CN V - Trigeminal

CN VI - Abducens

CN VII - Facial

CN VIII - Vestibulocochlear

CN IX - Glossopharyngeal

CN X - Vagus

CN XI - Accessory

CN XII - Hypoglossal

Blood Pressure

Cornerstone of clinical assessment

• CV health, fluid balance, and circulatory status

Systolic and diastolic pressures

• Cardiac contraction and relaxation

BP Step 1- Equipment Prep

Blood Pressure Cuff

• brachial artery - reflects intravascular pressure

Stethoscope

• auscultating Korotkoff sounds - changes in blood flow

Sphygmomanometer

• pressure gauge quantifies the pressure required to occlude / release arterial blood flow

BP Step 2- Patient Prep

Position: minimize hydrostatic effects

• patient should be calm / rest to prevent stress-induced elevations (white coat syndrome or hypertension)

avoid stimulants (ie. caffeine) decrease transient pressor effects- vasoconstriction on blood vessels

BP Step 3- Cuff placement / inflation

Cuff Placement- placement above the brachial artery ensures accurate measurement of central arterial pressure

Inflation- occluding blood flow, the cuff increases pressure within the arterial segment beneath the cuff, abolishing blood flow

BP Step 4- Korotkoff sounds

Phases of Sound: Cuff deflation permits blood flow in the artery. Turbulent blood flow generates Korotkoff sounds

• Phase I- 1st audible sound correlate with the onset of blood flow through partially occluded artery (systolic pressure)

• Phase V- Cuff pressure drops, sounds disappear when arterial flow fully re-establishes (diastolic pressure)

sounds between Phase I and Phase V are often muffled - not used to determine BP values (Korotkoff phases II, III, IV)

BP Step 5- Deflation

Deflation- Allows reperfusion, enabling recognition of initiation and cessation sounds

Recording-

• Systolic - phase i - first sound heart

• Diastolic - phase v = cessation of sound

Remeasure

• wait 2 minutes for reperfusion = avg readings

• normal variability between left and right arm

Further BP investigations if ?

if there is a systolic BP difference > 10mmHg further investigation by Primary Healthcare Provider

BP normative values

BP values can vary - age, sex, and overall health

Normal - systolic <120mmHg & diastolic < 80mmHg

Elevated- systolic 120-129mmHg & diastolic <80mmHg

Hypertension stage 1- systolic 120-139mmHg or diastolic 80-89mmHg

Hypertension stage 2- systolic > 140mmHg or diastolic > 90mmHg