Cervical, Thoracic and Lumbar Conditions

Specific / Medical Causes of Neck Pain

Fractures

Infections

Inflammatory disorders

Malignancy

Vascular pathology

Neurological pathology

Mechanical (MSK related) Neck Pain Causes

Disc

Facet

Instability/Ligament

Muscle

Postural

Wry Neck (Adult) Presentation

Acute neck pain / stiffness / muscle spasm

Often awake from sleep with it

Sudden onset

Restricted ROM

Abnormal head posture: Usually head tilted to one side and chin turned to the other

May experience headaches, dizziness, nausea

Wry Neck (Adult) Causes

No clear cause

Could be muscle spasm, facet sprain, synovial fold etc.

Wry Neck (Adult) Treatment

Rest

Heat

Medications

Manual Therapy

NO HARM

Wry Neck (Children) Causes

Early weeks of life- often SCM tumor or fibrosis

Abnormal development of the cervical vertebrae

Cervical spine articular disruption

Intracranial pathology

Inflammation (juvenile idiopathic arthritis) or infection in the neck, head, spine, CNS, upper lobe chest

Trauma (fracture/dislocation, spinal haematoma)

Wry Neck (Children) Treatment

Heat pack, massage and basic analgesia should be appropriate

Cervical Instability Presentation

Neurovascular compromise including 5D’s and 3N’s

Headaches

Dizziness

Widespread neurological changes

Lump in throat

Fatigue with prolonged postures

Cervical Instability Causes

Lax/damage to the ligaments from:

Trauma

Congenital abnormalities

Inflammatory disease

Generalized hypermobility syndromes

Cervical Instability Treatment

Education

Manual therapy (lower cervical and thoracic)

Motor control and strength training

Whiplash Causes

Sudden acceleration and deceleration (forced forward and whipped backward)

• Car accidents

• Contact sports

• Falls

Whiplash Treatment

Accurate advice and education

Relative rest (not too much, not enough)

Simple medications

Exercise as appropriate to patient condition

Manual therapy

Specific dizziness assessment and management

Referral as required (imaging, medical, psychological)

Whiplash Presentation

Neck pain

Stiffness

Difficulty moving head, reduced ROM

Headaches

Muscle spasms

Case Study- C6 Radicular pain

Onset- gradual L lower neck pain - now with L arm, forearm, and thumb ache

Symptoms worsened with increased workload

Arm symptoms suggest C6 nerve root irritation, but no neurological deficits reported

Radiculopathy not confirmed due to absence of sensory / motor changes

C5-C6 segment- common site of degeneration and nerve root compression

C6 nerve root- refers pain to forearm and thumb

Hairdressing posture- repetitive arm elevation, neck flexion / rotation → ↑ cervical load

Possible foraminal narrowing- aggravated by extension and rotation

Muscle fatigue and joint stress- from sustained postures and repetitive use

Case Study- Cervicogenic Headache

Onset- prolonged neck extension and sustained computer posture

Pain- localized to upper cervical region, movement-provoked

No migrane history or red flags

Considerations: Joint Compression: C1–C3 under load in extension; C1–C2 rotation restricted Muscle Tone: ↑ Suboccipital tone; postural strain from upper traps, levator scap, SCM Posture: Forward Head Posture → ↓ Deep Neck Flexor activation, ↑ passive structure strain

Cervicogenic Headache Presentation

Unilateral pain in head (starting from one side of the posterior head and nek, migrating to the front)

Neck pain and stiffness

Pain aggravated by neck movements or sustained postures

Cervicogenic Headache Treatment

Manual therapy

Exercise

Education

Postural control

Pain relivers (NSAIDs)

Thoracic Outlet Syndrome Pathophysiology/Etiology

Nerve or blood vessels that gets compressed above or below the clavicle (infraclavicular fossa and supraclavicular fossa)

Can be just nerve or nerve and vein/artery

This condition comes on a lot when people are recovering from something traumatic like a first rib fracture or whiplash

Thoracic Outlet Syndrome Presentation (nTOS)

Neck, scap, trapezius, and/or arm pain potentially difficult to localize

Pins and needles, numbness

Thoracic Outlet Syndrome Presentation (vTOS)

Arm pain

Swelling

Cyanosis

Thoracic Outlet Syndrome Presentation (aTOS)

Intermittent ischaemia

Pain

Pallor

Claudication

Paraesthesias

Coldness

Thoracic Outlet Syndrome Treatment (Conservative)

Education:

• Positions of ease and compression

• Avoid provoking postures

• Reduce training load overhead (if appropriate)

Muscle/Motor Retraining:

• Deep neck flexors

• Scapulothoracic strength / proprioception

Neural Glides:

• Gliding / flossing of ulna, radius, median nerves

Taping:

• Proprioception facilitation of scapular posture

Thoracic Outlet Syndrome Treatment (Surgical)

Main aim of surgery is to decompress the brachial plexus / subclavian artery or vein as it passes through the main site of compression.

Usually this would involve one or a combination of the following:

• Anterior scalene release

• Subclavius muscle release

• First rib resection

• Removal of cervical rib (if present)

Example TOS Treatment

Education- reducing compressive load via repeated activity

Posture- review sitting and standing / prolonged postures

Depending on site of compression -

• positions of ease + exercise

• taping (scapular proprioception using rocktape / kinesiotape)

• soft tissue modalities as indicated

• manual therapy over cervicothoracic junction if indicated

Exercise- 4pt kneel periscapular awareness/cervical extension training, serratus anterior wall push-ups, lat dorsi strengthening (and so on…)

Plan- consider imaging if not done already, refer onward if concerned regarding atrial compromise or possible DVT, review responsiveness to load management education and exercise program

What is Cervicogenic dizziness?

A condition that can be defined as a dysfunction/damage to the mechanoreceptors or sympathetic nerves in the upper cervical region causing symptoms that include dizziness, light-headedness, disorientation, postural imbalance, and/or headaches; all associated with neck movement

Cervicogenic Headaches- Aetiology

There is no clear aetiology that defines the onset of cervicogenic dizziness at present

Associated with many neck-related pathologies, such as:

• OA of the cervical facet joints

• WAD whiplash associated disorder

• Cervical artery insufficiency

Any pathology that can affect the typical function of cervical proprioception could be considered a cause for cervicogenic dizziness

Cervicogenic Headaches- Pathophysiology

Deep neck musculature has high muscle spindle density

Cervical joints also contribute to proprioceptive feedback

Dysfunction or damage to the cervical proprioceptors impairs the information provided to the occular motor, cervical motor, and lower limb motor systems

Pain may also contribute via maladaptive strategies, and recruitment patterns

Pain can also adversely modulate cervical afferent input

Cervicogenic Headaches Presentation

Dizziness

Imbalance

Light-headedness

Concurrent neck pain- aggravated by neck movement NOT head position

Symptoms present daily

Cervicogenic Headaches Assessment

To assess for cervicogenic dizziness, a musculoskeletal assessment of the cervical spine is performed:

• Active cervical ROM

• Palpation

• MLT, MMT

• PAVIMS, PPIVMS

• Joint position error testing

• Cervical Torsion test

• Head neck differentiation test

• Smooth pursuit torsion test

Idiopathic Thoracic Conditions

Scoliosis

Scheuermann disease

be aware of

• juvenile kyphosis, juvenile idiopathic arthritis

• hypermobility syndromes (Marfans, Loeys-Dietz, Elhers Danlos Syndrome)

• neuromuscular conditions: cerebral palsy, muscular dystrophy

Thoracic Conditions MSK

Intervertebral joint strain

Costovertebral strain

Rib fracture

Muscle or ligament sprain/strain

Nerve injury or irritation

be aware of

• SCJ injury

• DISH (Diffuse Idiopathic Skeletal Hyperostosis

Thoracic Conditions Non MSK

Osteoporotic vertebral fracture

Metastatic disease

Shingles (herpes zoster virus)

Structural Scoliosis Presentation

• Shoulders uneven

• Prominent shoulder blade

• Visible curve in erect standing

• Iliac crest heigh uneven

• “Rib Hump” in forward flexion

Functional Scoliosis

A functional scoliosis will appear curved in standing, however will have no curvature/ rib hump in forward flexion

No bony changes on imaging

Scheuermann’s Disease

Etiology: Unsure

Vertebral end plate irregularities during growth affecting 4 or more vertebral bodies

Variance causes some of the vertebrae to become wedge-shaped

Results in hyper kyphosis of thoracic spine and a compensatory hyper lordosis of lumbar spine

Scheuermann’s Disease Presentation

1. Rigid hyperkyphotic curve, accentuated in flexion

2. Curve does not reduce in extension/supine/prone

3. Cervical lumbar hyper lordosis

4. “Barrel chest’ shape of thorax

Scheuermann’s Disease Treatment

Kyphosis relatively fixed in adulthood, aims during growth period for maintain thoracic ROM, increase hamstring length and abdominal strength, encourage general activity

Most Common Thoracic Injuries

Intervertebral facet joint sprain

Costovertebral/costotransverse sprain

Sternoclavicular joint sprain/dislocation

Rib fracture

Rib cartilage fracture

Intervertebral (facet joint / thoracic disc) Presentation

Pain with gross thoracic movement (flexion / extension / LF / rotation)

Pain with prolonged upright postures

Pain with unilateral / bilateral overhead arm movement

Moreso central / paraspinal thoracic pain

Pain with central PA of level above and below the irritated structure

Generally: pain with unilateral rotation and LF (facet), extension or flexion (facet/disc)

Bilateral or unilateral thoracic spine pain

Morning stiffness common (inflammatory)

Costovertebral Presentation

• Pain associated with breathing and increased exertion

• Pain with increased intra-abdominal pressure (cough/sneeze/laugh/abdominal contraction)

• Pain with deep inspiration or forced expiration

• Pinpoint pain over rib/transverse process

• Moreso unilateral thoracic pain

• Pain reproduced with deep inspiration with deep inspiration or expiration

• Thoracic flexion/extension OK, painful with rotation

• Pain reduced with rib support during inspiration/cough/sneeze

• Rib springs provocative on irritated rib

Osteoporotic Fracture Summary

Complaint:

• Mid-low central thoracic pain

Etiology:

• Often sudden onset of pain with minimal or no trauma (step off curb, fall onto buttocks)

Associated Symptoms:

• Previous fractures with minimal trauma

Pattern Recognition:

• Women > Men

• Post-menopause

• Family history of OP

• Corticosteroid use hx

• Excess alcohol or smoking

• Poor diet

Costal Cartilage Fractures Treatment

Supported cough/sneeze, symptomatic management

Protective padding recommended for RTS >3

Treatments for Mobility Deficits

PPVIMs

Unilateral PAVIMS

Central PAVIMS

MWM (transverse glide with rotation, ceph/caud glide with extension)

Always combined with exercise, which may target

• mobility (ie. thoracic ext with foam roller, exercise ball)

• endurance and strength

Treatments for Hypermobility

Exercise training working on motor control during functional movements

• endurance of paraspinal muscles (postural training)

• flexion/extension control in 4pt or 2pt kneel

• side flexion control over exercise ball (side lie)

• whole body coordination - lunge + upper thoracic rotation

Costovertebral Joint Summary

Complaint:

• Unilateral pain. Pain located over transverse process/rib articulation

Etiology:

• Generally related to clear MOI (hyper rotation, impact to chest wall)

Associated Symptoms:

• Pain with deep inspiration or forced expiration

Pattern Recognition:

• Pain reduced with support and provocation action (ie. cough, deep breath)

• Gross movements of trunk generally OK (can be painful in rotation)

Risk Factors for Spinal Osteoporotic Fractures

Age >64

Prolonged corticosteroid use

Trauma

Combination of: older age, female, trauma and steroid use hx

Subcutaneous emphysema

• Air escape from lung into subcutaneous tissue

• Feels like ‘bubble wrap’ under skin

Pneumothorax

• Air escape from lung into pleural cavity

• Area of lung collapse around it

• Increasing shortness of breath / work of breathing

Sternoclavicular Dislocations

Anterior (more obvious, most common and least dangerous)

Posterior (subtle, with mediastinal structures at risk)

Dislocations generally reduced under general anesthesia ± thoracic surgery

Post reduction will be managed in sling, AROM will start around 3 weeks post reduction

Costal Cartilage Fractures- Conservative Management

Supported cough/sneeze, symptomatic management

Protective padding recommended for RTS >3

Costal Cartilage Fracture- Prognosis

Pain settled relatively quick and good RTS rates

Clicking can persist well beyond acute healing times

General Rib Injury Treatments

aims of txt

• analgesia

• restore normal breathing mechanics (pump handle/bucket handle)

• teach supported cough/sneeze

• maintain cervical, shoulder and thoracic

can consider:

• taping (dynamic generally preferable)

• compression

• positions of comfort

Intervertebral discs are made of:

1. Nucleus

2. Annulus

3. Cartilaginous endplate

4. Anterior longitudinal ligament

5. Posterior longitudinal ligament

Typical Aging Disc

• dehydration

• reduced height

• NP and anulus less distinct

• calcification of endplate

• genetic and loading causes

Typical Young Disc

• more fluid nucleus

• more mobile nucleus

• acute injury and rapid recovery

• disc compression of nerve root

• classic derangement syndrome

Stages of Disc Herniation

bulging - disc protrudes outward but remains intact

protrusion - nucleus pushes against outer layer but is still contained

extrusion - nucleus tears through the outer ring and extends beyond the discs boundary

sequestration - a fragment of the disc breaks off and separates from the disc

Discogenic Pain Presentation (Typical)

often caused by flexion activities

can be sudden onset or gradual onset

central back pain BUT can radiate

nerve root (radicular / radiculopathy) can happen

pain with increased intra-abdominal pressure

often displays direction preference

Dysfunction Syndrome

Pain directly related to mechanical loading

• Presence of load = pain

• Absence of load = no pain

Pain is intermittent depending on load

• Pain often at end- ROM due to stretching or compression

Conceptual model in the spine is articular dysfunction

Classified in respect to movement loss

• ie. extension dysfunction = loss extension

Derangement Syndrome

Conceptual model for derangement related to an internal derangement of the IVD

Mechanical presentation

• direction preference

• repeated movements and sustained postures can aggravate or or alleviate symptoms

• centralization or peripheralization

May have postural abnormality

• flexion and/or side shift

Facet Joint Pain Presentation

innervation = medial branches dorsal of the same level

richly innervated with nociceptors

often caused by repetitive loading in extension or rotation

increased risk with increased lordotic posture

often unilateral

tender on palpation

local muscle tension / spasm

age-related change like any synovial joint

Spondylolisthesis Stages

Grade 1- <25% slip

Grade 2- <50% slip

Grade 3- <75% slip

Grade 4- >75% slip

Grade 5- completely off (paralysis)

Pars Stress Fracture

Can be congenital or traumatic

• Sports with repeated extension (ie. dance, gymnastics)

Disc Pain Presentation

Central or unilateral back pain

Radicular pain common

Often flexion related coughing/sneeze

Disc Pain Treatment

Repeated movements (derangement)

Facet Joint Pain Presentation

• Unilateral

• Normally extension related

Facet Joint Pain Treatment

(normally) mobilization

Instability Presentation

Central pain

Normally extension related

Instability Treatment

Stabilization exercises

SIJ Presentation

Unilateral buttock pain

SIJ loading, SL weight bearing aggravating

SIJ Treatment

Mobilize or Stabilize

Inflammatory Back Pain

Night Pain

Morning Stiffness

Autoimmune disease

Systemic

3 Causes of Discogenic Change

Trauma

Degenerative change

Prolonged postures

Posterior Chest Wall Injury

Posterior chest wall injury

Subclavian artery/vein

Trachea

What is Spondylolysis

A stress fracture or defect in the pars interarticularis

Commonly affects children and teens involved in sports like gymnastics, weight-lifting and football- repetitive trauma is a significant cause

Spondylolisthesis

A condition where a vertebra in the spine slips forward out of its normal position

Symptoms may include LBP, pain down glutes or thigh, and hamstring tightness

Causes can be degenerative, isthmic or due to birth defects or trauma

Spondylosis

Age related wear-and-tear of the spinal discs