Cervical Spine

T/F mobility > stability in the cervical spine

T

how many degrees of flexion is the OA joint responsible for?

15-20º

how many degrees of rotation does AA joint do?

50º, >50º may lead to kinking of contralateral vertebral a.

the orientation of facet joints facilitate what movement?

flexion/extension

face joints move by _____.

gliding

what innervates the facet joints?

dorsal ramus of exiting spinal nerve

greatest ROM occurs between what 2 vertebrae? degeneration is most likely between what vertebrae? what is resting position of cervical spine? closed pack position?

ROM greatest at C5-C6

degeneration most likely C4-C5-C6-C7

resting position: slight extension

CPP: complete extension

the IV discs make up __% of the height of the C-spine and give it its _____.

25, lordosis

what does the annulus do? is it innervated?

withstands tension in disc

nucleus has not innervation, outer annulus has some innervation

what is the uncinate process

vertical projection

T/F the facet joints bear a significant amount of weight

F, minimal; a small amount of weight bearing can lead to spondylotic changes

what protects the spinal cord? what are the attachment points for muscles? what is the first palpable spinous process?

vertebral arch

spinous processes and transverse processes

C2

what are common outcome surveys for C-spine?

pain

Neck Disability Index

Fear Avoidance Behavior Questionnaire

what is the MDC and MCID for numeric pain rating scale?

MDC - 2.1 is the amount of change needed to be considered to exceed measurement error

MCID - 1.3 is the smallest difference that patients perceive as beneficial

what is the most studied outcome measure for neck? what is included in it?

Neck Disability Index

10 items - 4 pain related, 4 ADLs, 2 personal care

what are the 5 D’s and 3 N’s?

signs of cervical ischemia

1. dizziness

2. drop attacks

3. dysarthria

4. dysphagia

5. diplopia

1. nausea

2. nystagmus

3. numbness

what are subjective considerations?

dizziness blackouts or drop attacks

any history of RA - can lead to ligament laxity and cervical instability problems

any neurological sx in LE’s

what are red flags?

cervical myelopathy

neoplastic conditions

upper cervical spine instability

vertebral artery insufficiency

inflammatory of systemic disease

what is the most common inflammatory disorder to affect the cervical spine?

RA, associated with upper c-spine instability and subluxation of the atlas on the axis

what are signs of cervical instability?

severe muscle spasm

reluctance to flex cervical spine

lip of facial paresthesia

dizziness-nausea-vomiting

nystagmus and pupil changes

lump in throat

what is the Sharp-Purser test?

tests the integrity of the transverse or cruciform ligament to determine subluxation of the atlas on the axis

pushing occiput, + if it releves pain

alar ligament test

tests stability of atlanto-occipital junction

should feel spinous process moving opposite direction of where you move head

what is vertebrobasilar vascular insufficiency (VBI)? most common sx? how to test for this?

restriction of blood flow through vertebral arteries, most common cause of sudden onset VBI is trauma (whiplash)

most common sx is pain in the head and neck often unilateral and suboccipital

passively hold rotation position of 10 sec, + if sx appear

subjective patient history

age (spondylosis or spondylotic disease risk)

severity - MOI/insidious (posture if insidious), constant/intermittent, improving/worsening, onset time?

occupation - standing, walking, bending etc., leisure/sports/hobbies

boundaries of pain - neck, arm, interscapular region, C4 and above no arm sx, cervical radiculopathy or myelopathy

radiation of pain - dermatome sensory testing, pain type, pain when coughing/sneezing, paresthesia (pins and needles)

headaches - location, frequency, intensity, duration, relief. often due to upper c-spine

gait deviations and balance - dizziness (semicircular canals or vertebral a.), SNS, CN

sx - aggs/eases, disturbed sleep, sleeping postures, pillows, improving/worsening?

previous history - year of first episode, past tx, mx hx, meds, surgery, accidents, imaging, red flag q’s

where is spondylosis seen in patients?

25 years and older

60% of people >45 years

85% of people >60 years

where does spondylotic disease most commonly occur?

lower cervical spine

cervical radiculopathy vs myelopathy

radiculopathy - injury to nerve roots muscle weakness (myotome), sensory alteration (dermatome), reflex hypoactivity

myelopathy - injury to spinal cord spastic weakness, paresthesias in LEs, proprioceptive and sphincter dysfunction

when to send someone in for imaging

objective

observation/posture

shoulder and thoracic clearing

ROM - active/passive/resistive

compression/distraction

neuro screen

accessory motion

what should you observe in objective exam inspection?

observation of general body posture and willingness to move

resting level of sx baseline

initial view is global then sx area

sitting - standing

do they shift head away from midline

what is tight/short and weak in cervical upper spine syndrome (Vladimir Janda)?

tight/short: pec major and minor, upper traps, levator scap, SCM

weak: lower and middle traps, serratus anterior, rhomboids, deep neck flexors

what to observe in posture posteriorly?

lateral shift, tilt, acromial and scapula heights, scoliosis, muscular size and atrophy/hypertrophy

what to observe in posture anteriorly?

shift, list, muscular size, atrophy/hypertrophy, torticollis

what to observe in posture laterally?

sagittal plane position of head, dowager’s hump (excessive kyphosis), thoracic kyphosis

what are some causes of postural deformities? why is it important to know this?

protective - voluntary/involuntary

non-protective - structural

non-protective - behavioral

identification of postural deformity directs clinician to hypothesize cause and assess adaptive/assistive deviceswhat

what should you observe in skin?

trauma and wound healing

incisions - scars

skin color - inflammation, cyanosis, redness

red streaks - infection

tropic changes - PVD

what to observe in active motion testing?

resting level of pain

baseline, sx, quality

ROM

guarding, deviation, crepitus

pain during and after

repeated motions

what to do if full AROM is pain free?

PROM overpressure at end range to establish end feel and stress tissues sufficiently to rule out c-spine

what is flex ROM? how much larger do the IV foramen expand?

80-90º; up to 2 fingers width

20-30% larger with flexion

what is extension ROM? what could be possible problems if there is no anatomical block? what should you be aware of?

normal is 70º, nose and forehead are nearly horizontal

if there is no anatomical block, reasons for problems could be whiplash or cervical strain

be aware of VBI sx

what is normal side flexion ROM? where does it most occur at (vertebrae)? what to be aware of?

20-45º

most occurs at occiput and C1 and C1-C2

be wary of altered motion like couples rotation or flexion

rotation normal ROM? what to be aware of?

70-90º

SB and rotation are coupled movements and cannot occur alone, rotation and SB occur same side

note extension and and VBI sx in SB

what is the capsular pattern of the cervical spine? what are causes of noncapsular patterns?

lateral flexion and rotation equally limited, flexion is full range and painful, extension is limited

ligamentous adhesions, internal derangements and extra-articular lesions

what are resisted isometric movements? how do you measure it?

same movements that were tested actively, many therapists do not check RROM

measured as strong/weak, painful/painless

what are the cervical myotomes of RROM?

neck flexion: C1-C2

neck side flexion: C3

shoulder elevation: C4

shoulder abduction: C5

elbow flex and wrist ext: C6

elbow ext and wrist flex: C7

thumb ext and uln dev: C8

abd and add hand intrinsics: T1

what is the valsalva test? + test?

moderately reliable and specific for patients with cervical radiculopathy

hold breath and bear down

+ is reproduced sx

what is the shoulder abduction test?

moderately specific, not good screening; unlikely to identify level of cervical radiculopathy

assess sx in sitting

pt actively places hand on top of head

+ is reduction of pain

what is the shoulder depression test?

brachial plexus test

apply compressive force with hand above clavicle on sx side

+ reproduction of radicular sx, unlikely that this test could discriminate b/w radiculopathy and TOS

compression test

narrowing of neural foramen, pressure on facet joint or muscle spasms can cause increased pain on compression, may reproduce radicular pain from cervical spine

sitting apply compression upon the top of the head

if pain note exact distribution of neck or UE

Jackson and Spurling’s tests

Jackson test: apply compression with head rotated to the side of sx, + if produces radicular pain in UE

Spurling’s test: position narrows the IV forman, pt’s head is placed in lateral flex prior to axial compression

Spurling’s has moderate to high specificity for identifying pts with IVF stenosis with referred sx

T/F PROM is greater than AROM in supine

T

what is supine lateral flexion PROM?

75-80º due to relaxation of muscles holding up head

why do muscle length testing? how do you do it?

muscles attaching to the cervical spine and associated structures may cause limitation in ROM and pain

assessing muscle length may help plan tx program

all muscle length tests are done bilaterally for comparison

cranial cervical flexion test

for forward head posture - overuse of platysma, hyoid muscles and SCM

decreased activation and endurance of deep cervical flex m, rectus capitis, ant and lateralis, longus colli and longus capitis

the pressure that pt can hold steady with minimal substitution of superficial muscles is the one that you measure endurance

what is passive intervertebral motion assessment (PIVM)?

provides extent of available PROM, irritability of tissue

accessory motion tests

anterior-posterior glide

specific mobs

anterior glide - PA central vertebral pressure

above mob segment if extension, below is flexion

posterior anterior unilateral pressure

produces minimal rotation of cervical spine, assess response of sx

distraction test

traction force is applied when pt is in sitting or supine, + test is reduction of sx

has good specificity

ULTT

+ ULTT is most likely with nerve root compromise from lateral foraminal stenosis

test good side first, position first shoulder, forearm, wrist, fingers, then elbow last; each phase added until sx are produced

maintain constant depression force on shoulder!

what is a contraindication for ULTT?

cauda equina or SC lesion

the median nerve tension test has a strong association with?

cervical radiculopathy

what is equivalent to the SLR in lumbar spine for the UE?

ULTT

positioning for ULTT of median nerve, anterior interosseous nerve C5, 6, 7?

supine legs straight

scap depression, shoulder abd 90-110 with elbow flexed, forearm sup, wrist/finger ext, shoulder lat rot, elbow exxt, contralateral cervical side flex

sensitivity: 22%, specificity: 97%

where are articular pillars located?

where lamina meets pedicle

what muscle divides the neck into anterior and posterior triangles?

SCM

is radiculopathy UMN or LMN? sx?

LMN - hyporeflexia or absent DTR’s

decreased sensation dermatomal pattern, muscle weakness following myotomal pattern, biceps reflex diminished increases the changes of cervical radiculopathy from 23% to 59%

what is affected in radiculopathy? what is the most common MOI? common complaints?

nerve root

could be compressive or non-compressive etiology, commonly compressive from spondylosis and disk herniation

reports of numbness, tingling, weakness

myotomes

C5 - lateral forearm

C6 - distal thumb

C7 - distal middle finger

C8 - distal 5th

T1 - medial forearm

what is cervical spondylosis? what could it lead to? what causes it?

general term for nonspecific degenerative changes of the spine

may be the cause of cervical canal stenosis

aging

degenerative changes of discs, facets, vertebral bodies, uncovertebral joints resulting in loss of curve

what is DJD? common sx? what is DDD?

primary findings are bone subchondral sclerosis, joint space narrowing, lipping or spurring

common characteristic is morning sx that lessen throughout the day

DDD: degenerative disc disease, can occur without DJD, and vice versa

what does cervical disc disease entail?

dehydration, fibrosis, mechanical incompetence of the disc

disc height diminishes increasing load on bones and joints

nucleus functions to reduce compression force and annulus functions to withstand tension in the disc

how many facets in c-spine? what are they innervated by? what is facet syndrome?

14 facet joints in c-spine, orientation facilitates flexion and extension, move by gliding and greatest ROM occurs between C5 and 6

innervation: dorsal ramus of exiting spinal nerve

evidence supports these joint capsules can be the source of local and referred pain

what is myelopathy? what increases risk? how does onset present?

compression, most likely to occur at C5-6 level, can lead to spinal cord disease

congenital narrow canal increases risk, usually narrowing of the spinal canal is the end point of degenerative changes

onset is usually gradual and sx may be present in multiple extremities

sx of myelopathy?

LE sx with no history of lumbar dysfunction

loss of muscle tone and decreased girth measurements

ataxia and loss of dexterity with fine motor skills

muscle weakness, hyperactive reflexes, decreased sensation

reports of multiple dermatomal or myotomal weakness

common signs of UMN pathology (myelopathy)?

hyperreflexia UE or LE

sensory changes that are nondermatomal

clonus ankle, Hoffman, Babinski reflex

clumsiness in gait, generalized weakness

cervical spine strain and sprain? MOI?

for conditions that do not fit a particular diagnosis, should refer to a condition where a ligament has been sprained or a muscle strained

may arise from poor posture, may follow performing hard task, sleeping in awkward position, poor ergonomic environment at home or work; whiplash

after trauma, a decreased willingness to move the head could be red flag for?

upper cervical spine instability

neck pain CPG

1. neck pain with radiating pain

2. mobility deficits

3. movement coordination impairments

4. HA’s

neck pain with radiating pain sx

radiating pain into UE

dermatomal/myotomal deficits

neck pain with radiating pain exam findings

cluster findings: ULTT median nerve, distraction test, Spurling’s test, <60º cervical rotation to involved side

all 4 + is 99% specificity

any 3 + is 94% specificity

helps with clinical dx of cervical radiculopathy

neck pain with mobility deficits sx

central and/or unilateral neck pain

decreased cervical ROm and reproduces pt sx

may have referred pain to shoulder girdle

neck pain with mobility deficits exam findings

decreased C/T mobility, accessory motion

pain reproduced with provocation testing (PA mobs)

may see scap mm strength/motor control deficits

neck pain with movement coordination impairments (WAD) sx

MOI of trauma or whiplash

may have referred pain to shoulder girdle or UE

may have concussion sx

dizziness/nausea

HA, concentration or memory difficulties, hypersensitivity to light, sound, temperature, heightened affective stress

neck pain with movement coordination impairments (WAD) exam findings

+ CCF test

+ neck flexor mm endurance test

+ pressure algometry

neck pain in mid-range that can worse at end-range

myofacial trigger points

altered movement patterns, balance, posture

pain with provocation testing

neck pain with headache sx

noncontinuous unilateral neck pain and associated HA

HA aggravated by neck movements or sustained postures/positions

neck pain with HA exam findings

+ CCF test

HA reproduced with provocation testing of upper C-spine

limited cervical ROM

restricted upper cervical mobility with mobs

strength, endurance and coordination deficits of neck mms