Intro to clinic Week2 Stream B

Q: What are the common and important symptoms related to the cervical spine?

A:
• Pain
• Stiffness
• Weakness
• Instability
• Restricted ROM
• Altered coordination of movement

Q: What are the "red flags" for the Cx region?

A:
• History of major trauma
• Age >50 years
• Constant unrelenting pain
• Fever >38 degrees
• Anterior neck (throat) pain
• Unexplained weight loss
• Neurological deficit
• Radicular pain in arm
• History of RA
• Down syndrome

Q: What are the typical characteristics of acute torticollis (wry neck)?

A:
• Onset typically occurs upon waking or after a quick, uncontrolled movement. Commonly d/t performing unusual movements or holding strange positions (e.g. sleeping weird)
• Pain often transient, extreme pain. Nil neurological S/S
• Characteristic deformity is SCM spasticity w SB and slight flexion/rotation to one side

Q: Describe the distinct pain referral patterns for the different levels of the cervical zygapophysial joints.

A:
• Upper (C0-C3): Refer pain into head, jaw, and retro-orbital area.
• Mid-cervical: Refer pain toward the supraspinous fossa or shoulder. Often accompanied by ↓SB& Rot to that side + tenderness on lev scap
• Lower cervical: Refer pain to the inter-scapular region w cutaneous pain toward shoulder or LAT humeral condyle.

Q: What are the key features of cervicogenic headaches?

A:
• They arise from the upper three cervical segments (C0/1, C1/2, C2/3).
• The history usually involves upper neck pain with limited movement and a Hx of trauma (e.g. MVA)
• Pain is often daily or constant and can be unilateral or bilateral.
• Pain patterns can be occipital, occipito-temporo-maxillary, or supraorbital.

Q: What is cervical spondylosis and what are its typical pain characteristics?

A:
• It is the degeneration of cervical intervertebral joints, degeneration order: C5/6 and C6/7, C3-5 and C7/T1.
• Pain is typically dull, aching, and associated with stiffness and grating. It is not severe, but is worst in the morning and aggravated by sudden movement. May refer to shoulder, upper extremities, and vaguely to sub-occipital regions.

Q: why can there be Spinal Nerve compression In cervical spondylosis?

A:

• D/t the development of spinal canal stenosis, vascular compressions, cervical myelopathy.
• d/t formation of osteophytosis compressing the spinal structures.
• The most common N root lesions incl. C6, C7, C5.

Q: What can cause cervical canal stenosis?

A:

• Disc herniation, Spondylosis or other SOL’s.
• May be initially produced by ischemia d/t compression of the anterior spinal A.
• Cx Canal stenosis can produce Sx of Cx myelopathy (spinal cord compression)

Q: what is a Progressive cervical myelopathy?

A:

• Commonly between 30-70 y/o
• Present w SSx of mild cord compression affecting lower Cx spine
• Cord compression ruled out by MRI. Lesions are considered dynamic.
  o Cord stretching ANTly over degenerated disc osteophytes
  o Cord compression POSTly d/t hypertrophic ligamentum flavum

Q: List the five main inflammatory arthritides which can affect the Cx spine and cause spondyloarthropathies.

A:
• Rheumatoid Arthritis (RA) (sero-positive)
• Reiter’s syndrome (sero-negative)
• Psoriatic arthritis (sero-negative)
• Systemic lupus erythematosus (sero-negative)
• Ankylosing spondylitis (sero-negative)

Q: What makes cervical spondyloarthropathy a absolute contraindication to HVLA? Why?

A: The main concern is joint erosion and instability (particularly at atlanto-odontoid Jt).

Q: Which Cx disks are the most prone to herniation (common to less common)?

A: C5/6 > C6/7 > Remaining Cx vertebrae.

Q: What is the typical clinical presentation of a cervical disc herniation?

A:
• Severe pain in the neck, scapula, and arm. Any radicular pain follows the dermatome of the N root involved. Pain is exacerbated from activities which ↑ICP (coughing sneezing, or straining).
• Neck stiffness with ↓ROM & ↓Cx lordosis.
• Paraesthesia &/or neurological signs in the hand

Q: What are the three atypical presentations of a cervical disc herniation?

A:
• Upper extremity pain without neck or shoulder pain
• Neck pain only, w/o referred pain
• Signs of cord compression (cervical myelopathy)

Q: What is whiplash/ Whiplash Associated Disorders and what can they damage?

A:

• Whiplash is a rapid acceleration-deceleration injury to the neck
• Results in soft tissue damage to mm, N roots (d/t traction-type injury, inflam or direct pressure to IVD) , Z Jts, Synovial capsule, IVD
• Microfractures and long-term dysfunction

Q: What are the grades of Whiplash Associated Disorders (WAD)?

A: The WAD grades are:
• Grade 0: No pain or physical injury signs.
• Grade 1: Neck pain, stiffness, or tenderness, but no physical signs.
• Grade 2: Neck pain, stiffness, or tenderness plus physical signs (e.g. ↓ ROM).
• Grade 3: Neck pain, stiffness, or tenderness plus neurological signs.
• Grade 4: Neck pain, stiffness, or tenderness plus a fracture or dislocation.

Q: What ligaments must be considered for cervical instability following a whiplash injury?

A:

• Alar & Apical Lig
• Tectorial membrane (PLL)
• Ligamentum flavum.
• POST Atlanto-occipital lig.
• ANT longitudinal lig
• ANT Atlanto-occipital lig.
• Cruciate ligament (transverse lig and longitudinal lig)
• Anterior longitudinal ligament

Q: What is the most common type of cervical spine fracture?

A: A flexion/distraction injury.

Q: What is the typical cause of cervical fractures?

A:

• Flexion/distraction injury, causing flexion strain of POST ligs, leading to MID column failure, followed by ANT column failure, then compression of superior end=plate of sub-adjacent vertebrae

Q: What is a hangmans fracture?

A: Fracture of bilateral Pars Interarticularis on the axis d/t hyperextension.

Q: What is a Jefferson fracture?

A: fracture of the anterior and posterior arch of the atlas.

Q: Name and describe the three types of brachial plexus injuries (BPI).

A:
• Avulsions: Nerve root torn off spinal cord. Un-repairable.
• Rupture: Forceful stretch of N, causing partial or full tears. Sometimes repairable w surgery.
• Neuropraxia (Stretch): Nerve is mildly stretched, may heal itself, may need non-surgical treatment.

Q: Aetiology of BPI?

A:

1. MVA (two wheelers) account for >90% cases
2. Industrial trauma: weight falling on shoulder or arm being dragged into machine.
3. Heavy fall with stretched neck
4. Iatrogenic injury: deliberate within cases of tumour surgery involving N roots. Otherwise, is accidental when performing surgery on POST neck triangle.

Q: What are the three primary ways to classify a Brachial Plexus Injury (BPI)?

A:

• By site (Root, Cord, Trunk, or Nerve level injury)

• Or By root ( Upper plexus i.e. C5C6+/-C7, or Lower plexus C8/T1, Global i.e whole plexus)

• Or relation to clavicle (Supra clavicular, Retro clavicular, Infra clavicular)

Q: What is the presentation of a "burner" or "stinger" and what is the cause?

A:

• It presents as sudden onset of burning pain, numbness down the lateral arm with weakness. Usually follows an acute SB injury to the neck. Common S/S incl weakness of shoulder in ABD, ER, GH flexion. Symptoms only last few mins
• Caused by BPI to upper trunk, often d/t a distraction injury. May be caused by a compression injury to N roots.

Q: What causes Erb-Duchenne palsy and what are its characteristic motor & sensory deficits?

A:

• Avulsion injury to of C5 and/or C6 N root. Onset follows forceful separation of neck from shoulders.
• Motor: shoulder Abd, ER/IR, elbow flex, pronation, supination. Results in arm hanging limp by side.
• sensory: LAT arm & forearm, as well as LAT hand and its LAT 2 digits

Q: What are the four categories of Thoracic Outlet Syndrome (TOS)?

A:
• Costoclavicular
• Cervical rib
• Scalenes anterior
• Traumatic (e.g., Rib or Clavicle fracture)

Q: What is the Aetiologic of TOS?

A:

• F>M, often 20-50 y/o
• 95% cases affect Brachial Plexus, remainder effect vascular structures in area (subclavian A/V)

Q: What are the 3 factors that cause TOS

A: Mechanical (e.g. fractures), congenital (e.g. Cx rib), Acquired ()

Q: Describe the general presentation of TOS

A:

• Vague, diffuse aches in upper limb w or w/o neuro or vasc Sx

Q: What are the general neurological Sx associated with TOS?

A:

• Often relate to lower trunk lesions of brachial plexus
• Paraesthesia / numbness in MED forearm w Motor weakness of hand and fingers.
• Potential wasting of thenar, hypothenar, or interosseous muscles.

Q: What are the general vascular Sx associated with TOS?

A:

• Ischaemic pain

• Peripheral cyanosis

• ↓ pulses

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• Trophic changes in the skin

• Gangrene of fingers.

Q: What are the typical characteristics of Arterial TOS?

A:

• Usually seen in young adults with vigorous arm activity.
• Pt presents hand pain, claudication, pallor, cold intolerance, paraesthesia’s.
• symptoms usually appear suddenly.

Q: What are the typical characteristics of Venous TOS?

A:

• Usually seen in young men with vigorous arm activity.
• Pt presents with cyanosis, feeling of heaviness, paraesthesia in fingers and hand (due to oedema), as well as oedema of the arm.

Q: What are the typical characteristics of True TOS?

A:

• Hx of neck trauma
• Pt presents with pain, paraesthesia, numbness, and/or weakness, occipital H/A, loss of fine motor skills, cold intolerance (Raynaud's phenomenon?), objective weakness
• Symptoms present day and/or night.

Q: What injury mechanism causes Central Cord Syndrome and what is its classic presentation?

A:

• Occurs following hyperextension injury in a degenerated spine. Osteophytes compress the spinal cord AP and PA simultaneously.
• Maximal damage to central cord results in sensory/motor change in upper limb, however no change to lower limbs d/t arrangement of spinal tracts.

Q: What injury mechanism causes Anterior Cord Syndrome and what are the SSx?

A:

• Occurs following hyperflexion injury which produces a tear drop fracture of vertebral bodies or extrusion of the discs.
• Can also be caused by comminuted fracture of vertebral body.
• There is complete loss of motor function and pain/temperature sensation below the injury level. However, Deep touch, joint position, and vibration sense remain intact.