E1: cervical spine

brachial plexus roots

C5-T1

what are the branches of the brachial plexus?

musculocutaneous

axillary

radial

median

ulnar

(MARMU)

what is the C5 reflex?

biceps brachii

what is the C6 reflex?

brachioradialis

what is the C7 reflex?

triceps

what muscles does C5 control?

deltoid and biceps

what muscles does C6 control?

biceps and wrist extensors

what muscles does C7 control?

triceps, wrist flexors and finger extensors

what muscles does C8 control?

interossei muscles, finger flexors

what muscles does T1 control?

interossi (abduction & adduction)

PAD and DAB

what is the area of sensory for C2 & C3?

subocciput region of head

what is the area of sensory for C4?

trapezius

what is the area of sensory for C5?

lateral shoulder

lateral elbow crease

what is the area of sensory for C6?

lateral forearm

1-2 digits

what is the area of sensory for C7?

arm and 3rd digit

what is the area of sensory for C8?

4-5th digits

what is the area of sensory for T1?

medial elbow crease

which C-spine special test assesses for nerve root compression by seeing if there is radiating pain?

spurling

which C-spine special test:

relief of symptoms from an upward distracting force indicates foraminal compression of nerve root

distraction

which C-spine special test:

flexing hip/knee then extending knee that results in pain in or radiating to legs indicates meningeal irritation/infection

Kernig

which C-spine special test:

flexing the neck and hip that results in pain reduction indicates meningeal irritation

Brudzinski

which C-spine special test:

hyper flexion of the C-spine that results in a shocking sensation down the spinal cord indicates myelopathy or multiple sclerosis

Lhermitte's

which C-spine special test:

flicking the fingernail that results in index finger and thumb flexion indicates a long-tract spinal cord involvement in the neck

Hofffman

AABCDS mnemonic for reading C-spine radiology

Adequacy

Alignment

Bone

Cartilage

Disc

Soft tissue

what are the C-spine radiographic landmarks?

double cortical line

lateral mass

facet joint

lamina

pedicle

spinous process

C-spine lateral x-ray landmark lines

if one of the spinous processes is displaced to one side on an AP c-spine view, a ______ should be suspected

facet dislocation

What is a Fuch's view?

modified Water's view to demonstrate the odontoid tip

what is Swimmer's view?

lateral view of the c-spine that allows for assessment of vertebral alignment and apophyseal joints (cervicothoracic junction)

dull aching uni/bilateral neck pain (suboccipital) that is referred to the head that appears upon awakening and symptoms of dizziness, weakness, N/V, blurred vision and photophobia increase throughout the day

cervical headache (cephalgia)

what is seen on physical exam of a cervical headache?

↓ ROM and tenderness in suboccipital region

poor posture

weakness of scapulothoracic muscles and deep neck flexors

what is the treatment for cervical headaches?

- posture re-education training

- exercise (stretching suboccipitals) → McKenzie exercises > chin tucks

- analgesics

- behavioral changes → regular sleep/meals, stress reduction

neurogenic pain associated with a cervical nerve root or roots +/- associated numbness, weakness or loss of reflexes

cervical radiculopathy herniated cervical disk

what is the cause of cervical radiculopathy in young pts?

herniation of a cervical disk that entraps the root as it enters the foramen

what is the cause of cervical radiculopathy in older pts?

combo of foraminal narrowing d/t vertical settling of the disk space and arthritic involvement of the uncovertebral (facet) joint

what are risk factors for cervical radiculopathy from a herniated cervical disk?

cigarette smoking

frequent heavy lifting

diving

what are symptoms associated with a herniated cervical disk?

- neck pain w/ radicular pain, numbness and paresthesia in UE distribution

- HA

- muscle spasms

- weakness, lack of coordination, changes in handwriting & grip strength

- trunk/leg dysfunction, bowel/bladder changes

what is seen on physical exam of a herniated cervical disk?

reduced cervical lordosis

↓ AROM

pain in the shoulder/arm with extension/rotation

+ Spurling's test

possible + Babinski's reflex

what are diagnostic tests for herniated cervical disks?

radiographs → areas of spondylosis/degenerative involvement of disk or facet joint

MRI/CT w/ contrast → confirms dx

EMG/NCV → differentiates radiculopathy from peripheral neuropathy

what is the treatment for a herniated cervical disk?

spontaneous resolution in 2-8 wks

anti-inflammatory meds

PT

muscle relaxants

cervical ESI

what should be avoided with a herniated cervical disk?

narcotics and cervical manipulation

degenerative disk disease in the cervical spine produced by bony spur growth, buckling or protrusion of the ligamentum flavum causing narrowing of the neural foramen and stenosis of the spinal canal

cervical spondylosis (cervical stenosis)

which condition has symptoms of chronic pain that worsen w/ upright activity, ↓ AROM of the cervical spine, HA that originate in the neck, irritability, fatigue, sleep problems and radicular pain in the UEs?

cervical spondylosis (stenosis)

what is seen on physical exam of cervical spondylosis?

tenderness along lateral neck or spinous processes

limited/painful ROM

myelopathy → flexion produces shock that travels down spine

Hoffman & Babinski reflex

clonus

hyperrflexia

what is seen on a lateral x-ray of cervical spondylosis?

bony reactive changes w/ osteophytes anteriorly, posteriorly or at facet joints

what is seen on AP view of cervical spondylosis?

anterior subluxation of one vertebra onto the vertebra below

where are degenerative findings of cervical spondylosis most common?

C5-6 and C6-7 disk spaces

what is the treatment for cervical spondylosis?

NSAIDs

doxepin/amitryptiline → for sleep

rehab

steroid injection

surgery → decompression, laminectomy, discectomy

AVOID narcotics

narrowing of the spinal canal due to wear and tear (disc degeneration/inflammation) that leads to spinal cord compression causing sympotms of limited ROM of spine, morning stiffness of neck, neck pain/tenderness, tingling/numbness, difficulty walking, wide-based gait and coordination problems

cervical spondylotic myelopathy (CSM)

what are physical exam findings of cervical spondylotic myelopathy?

tenderness along lateral neck/spinous processes

↓ ROM w/ shock-like symptoms

ataxia

hyperrflexia

+ Hoffman & Babinski

+ Lhermitte's sign

what is the treatment for cervical spondylotic myelopathy?

electrotherapeutic modality → control pain

immobilization

ROM exercises

isometric & cervical stabilization exercises

surgical decompression/fusion → intractable pain + neuro findings

cervical sprain (ligamentous injury) from hyperextension of the neck then flexion (commonly MVA rear-end collision)

whiplash

muscle strain of the neck that is caused by > pillows and working at computers

cervical strain

what are the symptoms associated with cervical sprain/strain?

most common → nonradicular, nonsocial neck pain anywhere on the base of the skull

SCM/trap pain that is worse w motion

occipital HA

irritability, fatigue, sleep disturbances, diff concentrating

what is seen on physical exam of a cervical sprain/strain?

paraspinal tenderness

limited AROM

pain at extremes of motion

normal neuro exam

what is the treatment for cervical sprain/strain?

soft collar immobilization

NSAIDs

muscle relaxants → Robin, Flexeril, Skelaxin

PT

ice & heat

what should you suspect for ALL patients who complain of neck pain?

cervical fx

when do cervical fxs occur?

high-energy trauma (MVA, falling, diving)

when are cervical fxs missed?

pts who have closed head injury (CHI), unconscious or intoxicated

- most commonly upper & lower c-spine areas

what condition has symptoms of severe neck pain, paraspinous muscle spasms, point manual tenderness, pain w/ radiculopathy and global sensory/motor deficits?

cervical fracture

what is the most important x-ray view for a multiply injured patient?

cross-table lateral view of the c-spine (include C1-T1)

what is the treatment for cervical fractures?

immobilize!

immediate IV steroids → methylprednisone

fracture of C1 from axial compression w hyperextension, hyperflexion or forced lateral flexion commonly seen in football players/contact sports and divers

Jefferson/atlas burst fracture

what x-ray views should you get to evaluate a Jefferson fx?

AP

lateral → eval for atlantal ligament disruption & occipitoatlantal dislocation

open-mouth

what is the treatment for a Jefferson fx?

stable → hard collar immobilization

unstable → rigid halo immobilization & C1-2 arthrodesis

what does an odontoid (C2) fracture result from?

forceful flexion, extension and/or rotational injury

what are the 3 types of an odontoid fracture?

type 1 = rare, avulsion injury of alar ligament w oblique fx at tip of dens

type 2 = MC, base of dens

type 3 = fx of dens to body of C2

the distance from the dens to the C1 body

predental space

what is the normal predental space in adults and children?

adults = < 3 mm

children = < 5 mm

what is indicated if the predental space is increased?

fx of odontoid process or disruption of transverse ligament

what is the treatment for an odontoid fx?

type 1 = externally immobilized

type 2 = reduction using traction & halo immobilization

type 3 = traction reduction & halo immobilization

what fracture results from forceful flexion?

flexion teardrop fx

what are the radiographic findings of a flexion teardrop fracture?

large wedge oof the anterior aspect of affected vertebra

fracture of C7 caused by flexion

Clay-Shoveler's fx

what are the radiographic findings of a Clay-Shoveler's fx?

avulsion of posterior aspect of spinous process

- usually incidental finding

what are traumatic causes of cervical spine dislocation?

MVA

diving

blunt trauma

what are atraumatic causes of cervical spine dislocation?

RA

down's syndrome

what are symptoms associated with cervical spine dislocation?

neck pain after trauma

muscle weakness or paresthesia

what is seen on physical exam of cervical spine dislocation?

spinous process "step off"

check C4-T1 motor

check reflexes & sensory

what are the best radiographic views for eval of cervical spine dislocation?

AP & lateral

what is the treatment for cervical spine dislocation?

cervical HALO

emergent ortho/neurosurgeon consult

< 50% anterior subluxation of one vertebra on another

unilateral facet dislocation

> 50% anterior subluxation of one vertebra on another accompanied by widening of the interspinous & interlaminar spaces

bilateral facet dislocation

what does an atlanto-occipital dislocation result from?

hyperextension, distraction &/or rotational injury w excessive force on the ligaments most commonly from a MVA

what are consequences of an atlanto-occipital dislocation?

brainstem dysfunction

cranial nerve deficits

death

the distance for the occiput to the atlas should not exceed ___

5 mm

what are the 3 types of atlanto-occipital dislocation?

type 1 = anterior dislocation (MC)

type 2 = pure longitudinal dislocation

type 3 = posterior dislocation

what is the treatment for atlanto-occipital dislocation?

tx of choice = halo immobilization w posterior occipital-cervical fusion

type 2&3 = gentle reduction w/ 2-5 lbs weights

traction is CI in type 1

what is the cause for a Hangman's fx (C2)?

spondylolisthesis of the axis d/t bilateral fx of pars interarticularis C2

what fx results from hyperextension with secondary flexion (tears PLL & disc) most commonly from a MVA

Hangman's fx (C2)

what is seen on radiographs of a Hangman's fx?

subluxation

what is the study of choice for a Hangman's fx?

CT → delineates fx pattern

what is the treatment for a Hangman's fx?

C2-3 fusion w open reduction of facet dislocation

- anterior C2-3 interbody fusion

- posterior C1-3 fusion

what are causes for atlanto-axial subluxation?

RA

Down's syndrome

what are x-ray findings of atlanto-axial subluxation?

asymmetric lateral aspects on odontoid view

↑ predental space

cervical spine trauma may be cleared clinically if which preconditions are met?

- fully alert & oriented

- no drugs or alcohol

- no neck pain

- no abnormal neurology

- no significant other distracting injury

can the cereal spine be cleared if there is no bruising or deformity, no tenderness and a pain free range of active movements?

yes

which condition has symptoms of neck discomfort w motion, stiffness, loss of function, ↓ ROM, joint effusion & deformity?

cervical osteoarthritis

what is the treatment for cervical osteoarthritis?

NSAIDs

ROM exercises

ortho/neurosurgeon consult

a condition where the neck muscle contract involuntarily, causing the head to twist/turn to one side?

torticollis (aka skeletal wry neck or "cock robin")