Cervical Spine (Neck)

what are high-risk factors that mandates radiography in the canadian C-spine rules?

• age > or = 65 years old

• dangerous mechanism

• paresthesias in extremities

if patient doesn’t present with any high-risk factors, what should you do?

assess low-risk factors

what are the low-risk factors which allows safe assessment of ROM in canadian c-spine rule?

• simple rearend MVA

• sitting position in emergency department

• ambulatory at any time

• delayed onset of neck pain

• absence of midline c-spine tenderness

If there are also no low-risk factors present, what is the next step?

radiography

If there are low-risk factors present, what is the next step?

check if the patient is able to rotate their neck 45 degrees left and right

If they are unable to rotate neck 45 degrees left and right, what’s next step?

radiography

if they are able to rotate neck 45 degrees left and right, what’s next?

no radiography

the canadian c-spine rule is not applicable if…

• non-trauma cases

• GCS < 15

• unstable vital signs

• age < 16 years

• acute paralysis

• known vertebral disease

• previous c-spine surgery

what are the dangerous mechanisms of canadian c-spine rule?

• fall from elevation > 3 feet / 5 stairs

• axial load to head (like diving)

• high speed MVA (>100 mph)

• motorized recreational vehicles

• bicycle struck or collision

a simple rearend MVA excludes…

• pushed into oncoming traffic

• hit by bus/large truck

• rollover

• hit by high speed vehicle

prevalence of neck pain…

increases with age and is most common in women around the fifth decade of life

Presentation of upper cervical instability (RED FLAG)

• loses balance with head movements

• facial lip paresthesia that is reproduced via active or passive neck movements

  • could be CN involvement

• bilateral or quadrilateral limb paresthesias

  • SC issue

  • this symptom is either constant or come on with neck movements

• Nystagmus with active or passive neck movements

Additional warning signs of upper cervical instability

• neck pain

• limited ROM

• torticollis

• headache

• dizziness

• tinnitus

• dysphagia

• hyper-reflexia

• spasticity

• gait disturbances

Most common adverse affects due to manipulations include…

• local discomfort

• local headache

• fatigue

• radiating discomfort

  • occurs as mild to moderate severity resolving within 24 hours

Ngan et al. 2005 showed…

• the average peak velocity was 127 degrees per second

• mean thrust velocity was 72 degrees per second

• peak acceleration of the thrust phase was 2183 degrees per second squared

Contraindications to do manips/mobs in C/S include…

• Bony Issues

  • tumor, infection, metabolic, congenital dysplasia, long term corticosteroid use, severe RA, fracture

• Neurologic Conditions

  • cervical myelopathy, cord compression, cauda equina, nerve root compression w/ increasing neurological deficits

• Vascular Compromise

  • diagnosis involving VBI, aortic aneurysm, bleeding diatheses, severe hemophilia

• Excessive or extreme pain

• Lack of clinical diagnosis

• Lack of patient consent

Precautions to do manips/mobs in C/S include…

• had an adverse reaction to previous manual therapy

• disc herniation or prolapse

• pregnancy (especially at 12-14 weeks)

• spondylosis or spondylolisthesis

• physiological dependence on manipulative techniques

• ligmanteous laxity