Cervical red flags, pathology, & imaging

What is a common risk factor for neck pain that highly increases its likelihood?

Hx of neck pain

What are the red flag conditions for cervical spine pathology?

• vascular neck pathology

• fx

• upper cervical instability

• cervical myelopathy

• internal jugular vein thrombosis

• cardiac pathology

• lung pathology

What are the risk factors for vascular neck pathologies?

• head/neck trauma

• dissection: age <45

• atherosclerosis: age >50

• hx of clotting disorders

• smoking

• ligamentous laxity (instability, hypermobility syndrome, pregnancy, oral contraception, recent infection)

What are the Sx’s of vascular neck pathologies?

• unilateral headache/neck pain

• moderate to severe pain

• dizziness

• visual disturbance/diplopia

• facial/extremity paresthesias

• drop attacks/syncope

• dysphagia

• dysphonia/dysphasia

• nausea/vomiting

• tinnitus

• limb weakness

• unsteady gait

What are the exam findings for vascular neck pathologies?

• elevated BP

• provocation w/ contralateral cervical rotation (reduces blood flow in vertebral a.)

• (+) altered mental status, focal neuro signs, cranial nerve findings

• (+) upper cervical instability test

• ptosis

• carotid bruits

How do you find the internal carotid a. for bruit auscultation?

anterior to SCM

What test can you perform to rule in or out vascular neck pathologies?

What is a (+) test for this?

Cervical arterial testing

• reproduction of red flag Sx’s or nystagmus

What imagings should you recommend for pts w/ high suspicion of vascular neck pathologies?

CTA w/ contrast or MRA

What is upper cervical instability?

Alar or transverse ligament damage surrounding O-C1, C1-2

• no neurological dysfunction, major deformity, & incapacitating pain

What are the risk factors for upper cervical instability?

• RA

• SpA

• Down syndrome

• trauma

• other hypermobility syndromes

What are the Sx’s for upper cervical instability?

• minimal to severe neck pain/headache, worse w/ sagittal plane movement

• nausea/vomiting

• falling

• motor/sensory deficits in extremity or occipital area

• bowel/bladder or sexual dysfunction

• dysphonia

• dysphagia

• hand clumsiness

• lump in throat

• clanking

• crunching/clicking

What are the exam findings for upper cervical instability?

• Sx’s w/ cervical ROM, usually flex

• alleviated w/ stabilization or bracing

• if bone pressing on spinal cord:

  • unsteady gait

  • (+) Rhomberg

  • sensation loss in UE & LE

  • weak extremity

  • spasticity

• L-hermitte’s sign

• (+) UMN tests

What tests can you perform to rule in or out upper cervical instability?

What are the (+) tests for these?

Alar l. test

• C2 movement delay w/ SB or rotation

Sharp-Purser test (transverse l. test)

• O & C1 translates forward w/ flex —> aggravating

What imaging should you recommend for pts w/ high suspicion for upper cervical instability?

CT

How can you manage pts w/ upper cervical instability?

• if risk for serious complications (myelopathy, arterial compromise, cranial nerve involvement, or death) —> surgery

• if purely mechanical —> PT

  • pt education

  • avoid painful end range positions

  • joint mobility below C2

  • deep cervical flexors/extensors strengthening, endurance, motor control

What are the Canadian cervical spine rules?

Looks for cervical fx or instability

• neck pain from trauma, or

• no neck pain, but

  • visible injury above clavicles and

  • not ambulatory and

  • dangerous MOI

    • fall from 3ft/1m/5 stairs

    • axial load to head

    • MVC >100 km/hr, rollover, or ejection

    • motorized recreational vehicle incident

    • bike crash

• exclusion: age <16, injury sustained >48 hrs

According to the Canadian C spine rule, how do you determine if a pt should get a CT scan?

1. Does your pt have any of the following high risk factors: if yes to any, order CT

   • age ≥65

   • dangerous MOI

   • paresthesias

2. If no to 1, does your pt have any of the following low risk factors that allow for AROM testing: if no to all of these, order CT

   • simple rear end MVC

   • sitting in ED

   • ambulatory at any time

   • delayed onset neck pain

   • absence of midline C spine tenderness

3. If yes to 2, assess AROM

   • is cervical rotation 45° BIL: if yes, no imaging; if no, order CT

What is cervical myelopathy?

Narrowing of spinal canal in cervical spine region

What are the risk factors for cervical myelopathy?

• increasing age

• family hx

• trauma (HNP, fx, spondylolisthesis)

• ossification of ligamentum flavum or PLL

• DDD/DJD

What are the Sx’s for cervical myelopathy?

• BIL UE paresthesias in hands in nondermatomal pattern

• gait instability/falling

• incontinence or constipation

• neck pain

• shock-like pain down spinal cord

• aggravated by C spine ext

• alleviated by C spine flex

• hand weakness, clumsiness, difficulty w/ fine motor tasks

• ED or inability to ejaculate

• reduced vaginal lubrication

What are the exam findings for cervical myelopathy?

• Sx’s w/ C spine ROM

• unsteady gait

• (+) Rhomberg

• sensation loss in UE & LE

• weak extremities

• atrophy of hand intrinsics

• spasticity

• (+) UE neurodynamics

• L’hermitte’s sign

What are the differential Dx for cervical myelopathy?

• ALS

• MS

• acute transverse myelitis

• GBS

• vitamin deficiency

• infection: HIV, encephalopathy

• PNI: cervical/lumbar radiculopathy, carpal tunnel syndrome

How can you manage pts w/ cervical myelopathy?

• if paresthesias are the only Sx’s —> PT, no MRI unless not improving in 4 weeks

  • T spine nonthrust/thrust mobs

  • UE nerve mobs

  • cervical strengthening

  • posture education

  • cervical traction

  • avoid mid nonthrust cervical PA (d/t ext moment)

• if bowel/bladder/sexual dysfunction, weakness, gait/balance Sx’s —> MRI, surgery

What is the typical surgical procedure for cervical myelopathy?

What are the common complications following surgery?

anterior cervical discectomy & fusion (ACDF)

• difficulty swallowing, speaking, hoarseness, throat lump sensation

What are the neck pain CPG categories?

• neck pain w/ mobility deficits

• neck pain w/ movement coordination deficits

• neck pain w/ headache

• neck pain w/ radiating pain

What are the MOI for facet arthropathy?

• prolonged positions (work station, sleep position)

• mild to moderate ext/flex trauma

What are the Sx’s for facet arthropathy?

• unilateral neck pain

• aggravated by prolonged position, MOI

• sharp (acutely), achy

What are the exam findings for facet arthropathy?

• limited cervical ROM in all directions, mainly ext, ipsi SB, rotation

• quadrant

• hypomobility d/t pain w/ UPA & CPA

What are the contributing impairments for facet arthropathy?

• poor posture

• joint hypomobility above/below

• chronic nociception —> hyperalgesia & trigger points in the cervicobrachial mms

• weak cervicoscapular mms

• poor motor control of UE/spine, maybe LE

• (+) craniocervical flexion test

• (+) joint position error

Is imaging recommended for facet arthropathy?

No; findings include disc height changes, osteophytic changes, & OA

How can you manage pts w/ facet arthropathy?

• remain active

• correct biomechanical faults

• cervical ROM exercises

• strengthen/stabilize paraspinals, abs, cervicoscapular/shoulder mms

• sleep education: pillow use, head/neck position

• posture education: taping reduces kyphosis when applied from AC joint to T6

• Cx/Tx nonthrust/thrust mobs

• traction

• STM, dry needling

• injections if not improving

What are the MOI for mm strain/trigger points?

• prolonged positions (work station, sleep position)

• mild to moderate trauma

• pillow use

What are the Sx’s for mm strain/trigger points

• neck pain/headache w/ or w/o radiating pain, often unilateral

• aggravated by MOI, awkward movements

• sharp (acutely), achy

What are the exam findings for mm strain/trigger points?

• painful Cx ROM

• painful Cx MLA

• active trigger points

What are the contributing impairments for mm strain/trigger points?

• poor posture

• joint hypo/hypermobility

• weak paraspinals, scapular mms, UE

How can you manage pts w/ mm strain/trigger points?

• STM, dry needling

• Cx/Tx nonthrust/thrust mobs

• Cx, shoulder, scapular strengthening & motor control

• posture & sleep education

What are the risk factor/MOI for cervical radiculopathy?

• middle aged adults w/ degenerative changes

• gradual

• trauma

What are the Sx’s for cervical radiculopathy?

• neck pain w/ UE radiating pain

• midscapular pain

• digits 1-2 paresthesias

• weakness

• radiating, burning in dermatome

What are the exam findings for cervical radiculopathy?

• diminished DTR

• dermatomal sensory loss

• myotomal weakness

• limited Cx ROM, usually ext, ipsi rotation, SB

• limited CPA & UPA at level

• ABD relief sign

• (+) UE neurodynamic testing

What are the contributing impairments for cervical radiculopathy?

• joint hypomobility above/below

• poor posture

What is the 4-item cluster for cervical radiculopathy?

• (+) median n. neurodynamic test

• alleviated by neck distraction

• (+) Spurling’s test

• Cx rotation AROM <60° either way

What are the differential Dx for cervical radiculopathy?

• Pancoast tumor (lung cancer pressing on brachial plexus)

• peripheral nerve entrapments (CTS)

• brachial plexus injury

• MS

• MI

• complex regional pain syndrome (CRPS)

• TOS

• abscess

What criteria should be met to be considered a true radiculopathy?

• hard neuro signs

• (+) imaging

• (+) NCV or EMG testing

How can you manage pts w/ cervical radiculopathy?

• cervical collar for 1-2 weeks

• remain active

• posture training

• ROM & strengthening exercises for paraspinals, scapular, shoulder mms

• manual therapy for Cx/Tx spine

• intermittent traction

• neuromobilization (Cx lateral glide)

• MRI w/o contrast if not improving

What are some of the medical management options for a true radiculopathy?

• NSAIDs

• epidural steroid injections

• surgery if progressive motor weakness or if not improving

  • myotomal weakness alone not enough; has to be worsening or not improving over 4 weeks

  • discectomy, laminectomy, ACDF

What is the prognosis for cervical radiculopathy w/ conservative treatment?

6 weeks

What is cervicobrachial pain?

Neck pain that refers to arm w/ or w/o paresthesias (pseudo-radicular, nociplastic)

How can you manage pts w/ cervicobrachial pain?

• same as radicular pain, but need more pain education, CBT

• will respond to pain medication targeting CNS

• will not respond to NSAIDs/steroid injections

What are whiplash-associated disorders? What structure is often affected?

Umbrella term for neck-related pain d/t an acceleration/deceleration MOI

• 30-60% caused by facet

What are the grading classification for whiplash-associated disorders?

• grade 0: none

• grade 1: neck pain, stiffness, or TTP only; no physical signs

• grade 2: neck complaint + MSK signs (reduced ROM, TTP)

• grade 3: neck complaint + neuro signs (reduced or absent DTR, weakness, sensory deficits)

• grade 4: neck complaint + fx or dislocation

What are the risk factor/MOI for whiplash-associated disorders?

• high levels of psychosocial stress or psychosis

• trauma

What are the Sx’s for whiplash-associated disorders?

• neck pain w/ or w/o radiating pain or headache

• fatigue

• dizziness or “floating”

• nausea/vomiting

• difficulty concentrating

• memory deficits

• confusion

• post-trauma stress

• depression

• TMD

What are the exam findings for whiplash-associated disorders?

• painful Cx ROM

• painful Cx MLA

• active trigger points

• (+) joint mobility tests

• (+) neurodynamic tests

What are the contributing impairments for whiplash-associated disorders?

• (+) cranial Cx flexion test

• (+) deep Cx flexor endurance test

• deep lower Cx extensor strength/endurance

• (+) joint position error

What is the prognosis for whiplash-associated disorders?

• recovery occurs most rapidly in first 12 weeks post-injury

• NDI ≥40%, age ≥35, post-traumatic stress predict ongoing moderate to severe disability

• those w/ dizziness & memory issues less likely to have satisfactory outcome treated by PCP alone

What are the risk factors for poor prognosis for pts w/ whiplash-associated disorders?

• NDI ≥40%

• age ≥35

• post-traumatic stress

How can the Pain Catastrophizing Scale be used?

What is the relationship b/w the score and prognosis?

As a screening tool to develop prognosis

• higher score —> worse prognosis

What are some medical management options for whiplash-associated disorders?

Tylenol, NSAIDs, injections

What PT management is recommended for pts w/ whiplash-associated disorders?

Initial

• reassure it will improve in 3 months, remain active

• ROM, isometrics, endurance exercises

• manual therapy

• for pts w/ poor prognosis:

  • exercise

  • stress inoculation

Later

• Cx/Tx nonthrust/thrust mobs if not improving

• vestibular rehab if appropriate

• sensorimotor training

• TENS