E1 Ortho- Cervical

How many vertebrae are in the cervical spine?

7

How many pairs of nerves are in the cervical spine?

8

What is the name of C1?

Atlas

What is the name of C2?

Axis

C5 motor function

Deltoid & Biceps

C5 reflex

Biceps reflex

Review branches of the brachial plexus

:)

Review

dermatomes

C5 sensation

Lateral arm

C5 motor

deltoid, biceps

C5 reflex

biceps reflex

C6 motor

Biceps & Wrist extensors

C6 reflex

Brachioradialis reflex

C6 sensation

Lateral forearm and 1st digit (thumb)

C7 motor function

Triceps, Wrist flexors, Finger extensors

C7 reflex

Triceps reflex

C7 sensation

3rd digit (middle finger)

C8 motor function

Interossei mms, finger flexors

C8 sensation

Medial forearm & 5th digit (pinky)

C4 sensory

Trapezius

T1 motor

Interossei mm (abduction & adduction fingers)

T1 sensation

medial arm

special tests- cervical

slide 20; also videos you can watch

Spurling test (cervical)

axial load → lat. flex and rotate neck

• radiating pain indicates nerve root compression

Distraction test (cervical)

upward distracting force

• relief of sx indicates foraminal compression of nerve root

Kernig test (cervical)

supine: flex hip/knee then extend knee

• pain in/radiating to legs indicates meningeal irritation or infxn

Brudzinski test (cervical)

Supine: flex neck, hip flex

• pain reduction w/ knee knee flexion indicates meningeal irritation

Lhermitte’s test (cervical)

Supine: hyperflexion of C-spine

• shocking sensation down spinal cord = myelopathy or MS

How do you test for Hoffman reflex?

pt seated with their relaxed hand cradled in yours, flick the long fingernail

• index finger and thumb flexion is a sign of long-tract spinal cord involvement in the neck

review

life lines of C spine

What is the most important XR for C-spine trauma analysis?

Cross table lat view from C1-T1

What is a Fuchs view XR?

modified Water’s view to demonstrate the odontoid tip

What is a Swimmer’s view XR?

entire cervical spine is imaged, alignment of vertebrae and joints can be assessed and counted easily

What causes cervical headaches (cephalgia)?

neck pain that radiates to the head

What sx of a cervical headache?

usually unilateral, neck tenderness, HA is upon awaking and inc throughout the day, dizziness, weakness, migraine sx

What stretching exercise can be done to improve cervical headaches?

McKenzie exercise (chin tuck)

What RF inc the odds of a herniated cervical disk?

cigarette smoking, frequent heavy lifting, diving

What S/sx are associated w/ herniated cervical disk?

neck/shoulder pain, radiates, numbness, UE weakness/ paresthesia, muscle spasms, dec grip strength; worsens or lasts longer than a strain

What special test can be used to dx a herniated cervical disk?

(+) Spurling’s test

What is the confirmatory test for diagnosis of herniated cervical disk?

MRI or CT with contrast

*consider EMG if radiates

What test is helpful in differentiating radiculopathy from peripheral neuropathy and nerve compression syndromes?

EMG or NCV

What herniated cervical disk would result in pain at the base of neck, shoulder, and/or anterolateral arm?

C4-C5 (C5 root)

What herniated cervical disk would result in pain at the neck, shoulder, medial border of scapula, lateral aspect of arm, and/or radial aspect of forearm?

C5-C6 (C6 root)

What herniated cervical disk would result in pain at the neck, shoulder, medial border of scapula, lateral aspect of arm, and dorsum of forearm?

C6-C7 (C7 root)

What herniated cervical disk would result in numbness of deltoid region?

C4-C5 (C5 root)

What herniated cervical disk would result in numbness of dorsolateral aspect of thumb and index finger?

C5-C6 (C6 root)

What herniated cervical disk would result in numbness of index, long fingers, and/or dorsum of hand?

C6-C7 (C7 root)

What herniated cervical disk would result in motor weakness of deltoid and/or biceps?

C4-C5 (C5 root)

What herniated cervical disk would result in motor weakness of biceps and/or wrist extensors?

C5-C6 (C6 root)

What herniated cervical disk would result in motor weakness of triceps and/or finger extensors?

C6-C7 (C7 root)

What herniated cervical disk would result in a biceps reflex change?

C4-C5 (C5 root)

What herniated cervical disk would result in a biceps & brachioradialis reflex change?

C5-C6 (C6 root)

What herniated cervical disk would result in a triceps reflex change?

C6-C7 (C7 root)

What is the tx for a herniated cervical disk?

spontaneous resolution in 2-8 wks, anti-inflammatory meds, muscle relaxants

AVOID -narcotics, cervical manipulation

What are signs of cervical stenosis?

chronic neck pain, pain worsens w/ upright activity, dec ROM, HA, radicular pain in UE

Hoffman reflex, clonus, hyperreflexia, Babinski

Where do degenerative findings most commonly occur in the cervical spine?

C5-C6 & C6-C7 disk spaces

What testing is helpful to dx cervical spondylosis?

CT: evaluate canal narrowing

MRI: evaluate cord/root compression

What is Cervical spondylotic myelopathy (CSM)?

Narrowing of the spinal canal that leads to spinal cord compression in the cervical spine

What demographic is most affected by cervical spondylotic myelopathy?

males over 55 yo

What effect does Cervical spondylotic myelopathy (CSM) have on gait and reflexes?

Ataxia and hyperreflexia

What special tests help dx cervical spondylotic myelopathy?

(+) Hoffman and Babinski

(+) Lhermitte’s

R/O: vertebral artery test, spurling’s test

What tests help dx cervical spondylotic myelopathy?

XR - check alignment

MRI -look for compression

CT myelogram - better detail, show bone spurs, canal size

What is whiplash?

Cervical sprain caused by hyperextension of neck then flexion (MVA); ligamentous injury

What is a cervical strain?

self limiting muscle injury d/t strain from pillows or working at computers; muscle injury

MVA rear-end collision with general neck pain, XR neg, no motor deficits, most likely dx?

Cervical sprain (whiplash)

How does a cervical sprain/strain present?

noradiuclar, nonfocal neck pain, SCM or trapezius pain, worse w/ motion, HA, sleep disturbances; self-limiting, doesn’t radiate

What is a REQUIREMENT of cervical imaging?

All 7 cervical vertebrae must be seen

What is the tx for cervical fxs?

immediate IV steroids (Methylpred), brace c-spine and spine board, cervical collar

What is a Jefferson fracture?

Atlas (C1) burst fracture

What can cause a Jefferson (C1 burst) fracture?

Brick falling from building, football players, diving, compression injuries

What plain films are needed to evaluate a Jefferson fx?

AP, lat, open-mouth views

What causes an Odontoid (C2) fx?

forceful flexion, extension, or rotation; 25% cases assoicated w/ neuro deficit

What is a type 1 Odontoid fx?

rare, avulsion of the alar ligament w/ oblique fx at the tip of the dens

What is a type 2 Odontoid fx?

MC; at the base of the dens

What is a type 3 Odontoid fx?

extends from the dens all the way to the C2 body

What is an Odontoid Fx?

fracture of the dens on C2 (axis) caused by trauma

What is the Predental space?

distance from dens to C1 body; should not be more than 3mm in adults and 5 mm in children

What is the tx for type 1 Odontoid fx?

externally imobilized x 3 mo; repeat imaging

What is the tx for a Type 2 Odontoid fx?

reduction using traction and halo immobilization; elderly tx’d w/ C1-C2 arthrodesis

What is the tx for a Type 3 Odontoid fx?

traction reduction and halo immobilization x 3 months; elderly -C1-12 arthrodesis

What is a Flexion teardrop fx?

large wedge of the anterior aspect of vertebrae d/t forceful flexion

Where does a Clay-shoveler's fracture most commonly occur?

C7

What population is most likely to get a cervical spine dislocation?

M > F, 18-25 yo (inc likelihood of an accident)

What is the tx for a cervical spine dislocation?

emergency consult to ortho & neurosurgeon

cervical HALO

What are atraumatic causes of cervical spine dislocation?

RA, Down’s syndrome

What is a Facet dislocation?

Anterior subluxation of one vertebra on another

*< 50% of the width of a vertebral body = unifacet

*> 50% + widening of interspinous space = bilateral

What causes an Atlanto-occipital dislocation?

hyperextension, distraction, rotational injury w/ excessive force on the ligaments

Who is more likely to experience an Atlanto-occipital dislocation?

children 2x more than adults

What are the consequences of an Atlanto-occipital dislocation?

brainstem dysfunction, cranial nerve deficits, death

When assessing an Atlanto-occipital injury what should you NOT do?

manipulate the neck

What is a Type 1 Atlanto-occipital dislocation?

anterior dislocation and MC

What is a Type 2 Atlanto-occipital dislocation?

pure longitudinal dislocation

What is a Type 3 Atlanto-occipital dislocation?

posterior dislocation

What is a Hangman’s fracture?

spondylolisthesis of the axis d/t bilateral fx of pars; usually result of hyperextension

What is the most common cause of Hangman’s fracture?

MVA

C- spine trauma what do you do?

Backboard, collar, don't move patient

What is the tx for cervical osteoarthritis?

NSAIDS, PT -ROM exercises, ortho/neurosurgery consult

What are sx of Torticollis?

Tilting of the head with chin rotated to the opposite side; head tilts towards affected side

SCM contracture causing pain & dizziness

nystagmus or superior oblique palsy

What is another name for torticollis?

wry neck or “cock robin”

What is Torticollis?

skeletal dysplasia

-spasmodic = muscle or nerve involved