PHYT5215: Cervical Spine Considerations

What Framework should we use when dealing with the neck?

ICF Framework Classification and Impairments

What are the 3 classifications that we should use when treating the neck?

1. 3 broad categories

2. Pathoanatomical (consider what it could be)

3. ICF Framework (treat the right impairments)

4 ICF Framework categories

1. Neck pain with mobility deficit

2. Neck pain with movement coordination impairment (WAD)

3. Neck pain with headache (cerviogenic)

4. Neck pain with radiating pain (radicular)

Can MSK related symptoms also be red flags?

-Yes

-Headaches, dizziness, stiffness can also be related to red flags

When should the 5D's, 3N and ABH be asked?

If someone presents to the clinic with neck or spine related issues

-1st ask the 8 red flag questions + ROS

5D's

-Diplopia (any vision issues)

-Dysphagia (difficulties swallowing)

-Dysarthria (difficulties speaking)

-Dizziness (feeling like faint)

-Drop Attacks (Lose consciousness)

3N's

-Nystagmus (involuntary eye movement)

-Nausea

-Numbness ( if it is multiple nerve root or bilateral)

ABH

• Atxia (lack of coordination, dropping things, hand tremors)

• Balance (loss/decreased)

• Headache (hard ass heahache)

now name all of the red flags for cervical

• Diplopia – double vision (any vision issue)
  

• Dysphagia – difficulties swallowing
  

• Dysarthria – difficulties speaking
  

• Dizziness – lightheaded/spinning/etc.
  

• Drop Attacks – Unknown LOC
  

• Nystagmus – involuntary rapid eye movement
  

• Nausea – nauseated/vomiting
  

• Numbness – multiple nerve root or
  

• hemilateral or bilateral
  

• Ataxia – lack of co-ordination
  

• Balance – loss/decreased balance
  

• Headache – worsening, severe, thunderclap

  
  

Objective Tests for Cervical Spine Red Flags

-Observation

-Neuroconductivity Testing

-Upper motor neuron signs

-Cranial nerve testing & dizziness differential

-Lhermitte's Sign

Observation (Red Flag)

-Neck swelling, tone

*swelling = referral

*tone (meaning they are guarding it)

Neuroconductivity Testing

• Myotome

• Dermatome

• Reflexes

Patterns are red flags = the patient shows positive test for all of them in their right side

Upper Motor Neuron Testing

-Babinski

-Clonus

-Tromner

**tests to determine if the spinal cord or brain are involved

Lhermitte's Sign

• flex neck which creates sensation of pins and needles down the spine and near the end range of flexion

-Can also refer pain in extremities

Common Red Flag Questions

1. Any fatigue or malaise?

2. Any unexplained weight loss?

3. Any prolonged use of corticosteroids?

4. History of cancer?

5. Any fever?

6. Any night pain?

7. Is there any widespread changes in sensation? such as vision loss, balance?

4 red flag pathologies the neck?

1. Cervical Artery

2. Cervical myelopathy

3. Fractures

4. Cervical Instability

Cervical Artery

• they provide blood flow to the brain, so we check if is damaged by asking the red flag questions and cranial nerve signs

Spondylosis

• is a degenerative changes in the cervical spine

- multiple structures in the spine: discs, vertebrae, and facet joints

(includes DDD, facet arthrosis, and osteophyte formation)

Cervical Myelopathy

• compression of the spinal cord in the cervical region, can be due to spondylosis

• if +UMNs, nueroconductivity (multiple nerve root findings), possibly Lhermitte’s sign

Degenerative Disc Disease

-primarily involves degeneration of the intervertebral discs

-The discs lose hydration, become thinner

Facet Arthrosis

-Arthritis of the facet joints

What 3 pathologies are part or related to OA?

-Spondylosis

-Degenerative Disc Disease

-Facet Arthrosis

Cervical Artery Dysfunction

-Compromised carotid artery or vertebral artery

Vertebral Artery

-Refers artery that supplies the brainstem and spinal cord

What can cervical artery dysfunction lead too?

-Stroke

What does cervical artery dysfunction cause?

-compromised blood flow leading to neck pain

-Headache

-Cranial nerve signs (red flags) & UMN

What is a key characteristic in knowing that it is cervical artery dysfunction?

Multiple nerve roots are impacted, global weakness

Cervical Myelopathy

-Compression of spinal cord through central spinal stenosis

Spinal stenosis

-narrowing of the spinal canal

Cause of Cervical Myelopathy

-Spondolysis or space tumor

What neurological signs will be seen in cervical myelopathy?

+UMN

multiple levels of myotomal, dermatomal and reflex weakness

-Ataxia (lack of coordination) & balance

-LE and UE impacted

When should you do upper motor neuron testing?

-After doing neuroconductivity and noticing that there are multiple nerve roots or odd findings

3 Fractures categories

• C1 = Falls with compression
• C2 = Falls with hyper-flex, -ext, compression
• C3-7 = high impact (MVA)

C1 Fracture

-Occurs from falls with compression onto atlas

C2 Fractures

-Occurs with falls with hyper flexion, extension or compression

C3-C7 Fractures

-Occur due to high impact MVA

What is a major sign of fracture?

Lots of tone and guarding

significantly decreased ROM

What can we use to predict fracture?

Canadian C-Spine Rules

Canadian C-Spine Rules

High sensitivity

-helps inform assessment and decision making on fractures

3 questions from Canadian C-Spine Rules

1. Any high risk factor which mandates radiography? Yes = X ray

2. Any low risk factors which allows safe assessment of ROM? yes = no x ray

3. Able to actively rotate neck? no = x ray

Significant Cervical Instability def

-when there is so much loss of passive structure integrity that it compromises safety = red flag

Where can cervical instability occur?

Upper cervical spine C0, C1, C2

Mid/lower

how does severe significant instability lead to myelopathy/stenosis?

What is cervical instability caused by?

Severe degenerative cervical spondylosis

-trauma

What can cervical instability lead to?

-myelopathy/stenosis resulting in neurological signs and symptoms