C Spine

Excludes Pathologies and Clinical Practice Guidelines

Occipital Atlanto

_____ is responsible for 15-20 deg of flexion/extension

Atlanto Axial, Rotation

_______ is responsible for 50 deg of ______ but more than 50 deg might lead of kinking of contralateral vertebral artery

80-90

Normal amount of Rotation is _____ degrees

14, flexion, extension

There are _____ facet joints in the C spine that facilitate ____ and ____ via gliding of facets

C5 + C6

Greatest ROM occurs between ________

Degeneration

______ is most likely between C4-C7 and bone spurs can form

extension, closed packed position

C spine Resting position is slight _____ while _______ of facets is complete extension

Flexion, Rotation

______ and ______ are vulnerable positions for the spine

25%

IV discs make up ____ of the height of the C spine

compressive

Nucleus functions to reduce ________ force

tension

Annulus functions to withstand ______ in the disc

innervation, some

Nucleus has no _____ while the outer annulus has _____

uncinate process

the _____ is the vertical projection on the vertebral body

minimal, spondylitic

The facets bear ______weight as it could lead to ______ changes

Right, Left

R SCM does _____ side bend and ____ rotation

Neck Disability Index (NDI)

Most studied Outcome measure for C Spine is ______

• 10 items (6 are scored 0-5)

• 4 = pain related

• 4 ADLs

• 2 personal care

• MDC and MCID are 7 for C. radiculopathy

dizziness, drop attacks, dysarthria, dysphagia, diplopia

5 D’s are ________

nausea, nystagmus, numbness

3 N’s are _______

dizziness/blackouts, neurologic

Subjective Considerations include _____/______, drop attacks, hx of RA, any ______ sx in LE’s

myelopathy, instability, inflammatory

Red Flags include cervical _______, neoplastic conditions, upper cervical spine _______, vertebral artery insufficiency, and _______ or systemic disease

RA, upper, subluxation

_____ is the most common inflammatory disorder to affect the c spine → associated with _____ c spine instability or ______ of the atlas on the axis

instability

Signs of Cervical _______ include:

• severe muscle spasm

• reluctance to flex cervical spine

• lip or fascial paresthesia

• dizziness-nausea-vomiting

• nystagmus and pupil changes

• lump in throat

Sharp-Purser Test, transverse, cruciform

______ tests the integrity of the _______ or _______ ligament to determine subluxation of the Atlas on the Axis

Alar Ligament Test

_____ tests the stability of atlanto-occipital junction

Vertebrobasilar Vascular Insufficiency (VBI)

_______ is a disorder characterized by restriction of blood flow through the vertebral arteries caused by trauma/whiplash

vertigo, dizziness, tinnitus, visual-perception disturbances, fainting

VBI patients might experience _____, _____, _____, ________, and ______

pain, unilateral, suboccipital

Most common symptom of VBI is ______ in the head and neck often _____ and _____

spondylitic

Age can increase risk of ______ changes in the c spine

• 25+ yo. → spondylosis can start

lower

Spondylitic disease most commonly occurs in _____ c spine

Cervical Radiculopathy, lower

_______ is an unilateral injury to the nerve roots and causes muscle weakness (myotomes) and sensory alteration (dermatomes) and reflex hypoactivity

• _____ motor neuron issue

Cervical Myelopathy, upper

______ is a bilateral injury to the spinal cord that causes spastic weakness, paresthesia in LE’s, and proprioceptive and sphincter dysfunction

• ____ motor neuron issue

deep, superficial, burning, shooting

Radiating pain could be described as ____, _____, _____ or _____

dermatome

Radiating pain indicates ______ sensory testing during exam

increases

Coughing or sneezing _____ intrathoracic or intra abdominal pressure which makes the pain increase

pins, needles

paresthesia pain is often described as ____ and ____

headaches, upper

_____ are dependent on location, frequency, intensity, precipitating factors, and duration → _____ c spine is often the source of mechanical headaches

myelopathy, dizziness

With gait deviations, look for _____, _____, or sympathetic nervous system issue → assess these patients with SLS or in Tandem

High Risk

Canadian C Spine Rules: _____ factors include:

• Age >55

• Dangerous MOI (fall from >3 ft, axial load to head, MVC, collision)

• paresthesia in extremities

Low Risk

Canadian C Spine Rules: _____ factors include:

• simple rear end MVC

• delayed onset of neck pain

• sitting position in ED

• ambulatory at any time

• absence of midline C spine tenderness

Inspection

______ includes observing general body posture and willingness to move, baseline of symptoms, symptomatic area, and how the patient sits and stands

pecs, upper traps, levator scap, SCM

lower and middle traps, SA, rhomboids, deep neck flexors

Upper Crossed Syndrome involves tight and short ____, ______, _____, and ______ while also having weak _______, ______, ______, and _______

lateral shift, tilt, scoliosis, atrophy/hypertrophy

In the posterior view, look for _______, _____, acromial and scapula heights, ______, muscular size, and _____/_____

shift, list, torticollis

In the Anterior view, look for _____, _____, muscular size, atrophy/hypertrophy, and _____

dowager’s hump, kyphosis

In the lateral view, look for sagittal plane position of head, ________, and thoracic ____

Postural Deformities

_______ like protective, non protective/structural scoliosis, or non protective behavioral personality, can direct the hypothesis and its cause

willingness

quality

reproduction

AROM assessment is used to determine the amount of ROM and ______ to move:

• look at _____ of motion

• movement and pain relationship

• ______ of sx

supine, end range

If full AROM is pain free, then do PROM in ______ and apply overpressure at ______ to establish end feel

Flexion

Max ROM of _____ is 80-90 deg with chin to chest (mouth closed)

• IV foramen gets 20-30% larger with this motion

Extension

Normal ROM of _____ is 70 deg with nose and forehead horizontal/parallel to ceiling

• be aware of VBI sx

• no anatomical block but whiplash and strains might cause problems

extension, flexion

Protraction involves upper cervical ______ and lower cervical _____

flexion, extension

Retraction is upper cervical ______ and lower cervical ______

Side Flexion

Normal ROM of ______ is 20-45 deg and mostly occurs at occiput and C1 and C1 and C2

• make sure ear moves to shoulder

• be aware of altered motion → rotation or flexion to get more range

Rotation

Normal ROM of ______ is 80-90 deg and occurs with side bending occuring on the same side

• look for extension

• be aware of VBI sx

• more than ½ of motion comes from Upper C Spine

lateral flexion, rotation, flexion, extension

Capsular Pattern for C Spine is ________ and _____are qually limited, _____ is full range and painful, _____ is limited

ligamentous adhesions, internal derangements, extra-articular lesions

Non capsular patterns are from _________, _________, and________

strong, weak, painful, painless

Resisted Isometric movements are measured as ______, ______ or ______, _____

Valsalva Test

_____ is a moderately reliable and specific test for cervical radiculopathy

• sit and hold breath and bear down

• (+) is reproducing sxs and pain

Shoulder ABD Test

______ is moderately specific for cervical radiculopathy but cannot determine level of injury

• patient puts hand on top of head and holds

• (+) is reduction of pain

Shoulder Depression Test

_______ is a brachial plexus test where compressive force is applied above the clavicle on symptomatic side

• force is lateral to scalenes to apply traction to nerve bundle

• test can’t discriminate between radiculopathy and TOS

• (+) is reproduction of radicular sxs

Compression Test

______ is when compression is applied on top of head while patient is sitting

• narrowing of neural foramen, pressure on facets, muscle spasms can cause increased pain on compression

• (+) is possible reproduction of radicular pain and increase of sxs in arm

Jackson Test

_____ is when compression is applied to the head while its rotated to the side of sxs

• (+) if radicular pain is produced in UEs

Spurling’s Test

_____ is when the patient’s head is placed in lateral flexion with slight extension + rotation then axially compressed which narrows the intervertebral foramen

• similar to quadrant position

• moderate to high specificity for identifying IVF stenosis with referred sxs

Lateral Flexion

In supine, _____ PROM is increased to 75-80 deg due to the relaxation of muscles holding up the head

side flexion, rotation, extension

Capsular Pattern for C Spine is ______ and _______ equally limited, _____ less limited

Muscle length Testing

_______ can help to plan the treatment program

• done bilaterally for comparison

• muscle tension can cause limited ROM and pain

Cranial Cervical Flexion Test

_________ involves the patient pushing back into a BP cuff bladder @ 20mm Hg to test deep neck flexors without major compensation of accessory muscles

• hold chin tuck against bladder for 10s and get up to 30 mm Hg in 2 mmHg increments

PROM, irritability

Passive Intervertebral Motions (PIVM) can help assess available _____ (level by level) and ______ of tissue and degree of inflammation

General Mobs

______ involve an ANT/POST glide with one hand on the occiput and one hand on the chin (forehead in lab) → can also do distraction force here to put traction on C Spine

Specific Mobs

______ involve ant/post glide on one spinous process to create motion at one primary segment

• can be done in supine or prone

PA Central Vertebral Pressure (PACVP)

_________ can be done in prone or supine and involve a gentle downward force on the spinous process with thumbs

• mob at C5 will create extension at C4 and above + flexion at C6 and below

• most useful when assessing pain

PA Unilateral Pressure (PAUVP)

______ involves thumb placement over lamina or posterior aspect of facet column and produces minimal rotation of c spine when in prone

• assess responses of sxs

traction, chin cradle

Distraction Test is done in sitting or supine and looks at assessing symptoms when _____ force is applied using a ______ grip

• (+) is reduction of sxs

• good specificity

Upper Limb Tension Tests (ULTT)

Positive _____ are most likely with nerve root compromise from lateral foraminal stenosis and are equivalent to the SLR test for the Lumbar spine

• test the good side first

• add a phase/component until sx are produced

cauda equina, spinal cord lesion

DO NOT do a ULTT if there is ______ or _________ present

side flexion

During ULTTs, _______ of the neck may be added to sensitize the test

depression force

It is crucial to maintain constant ________on the shoulder during ULTT

Median/anterior interosseous

ULTT 1 tests the _______/_________ nerve (C5-C7). Patient position:

• supine w/ legs straight

• scapula depression

• shoulder ABD 90-110 and ER

• elbow flexion

• forearm supination

• wrist and finger extension

• elbow extension

cubital fossa, forearm, radial, anterior

With a normal/negative ULTT, expect:

• deep ache/stretch in _________ or anterior aspect of _____ and _____ aspect of hand

• tingling to finger along specific nerve bias distribution

• stretch to _____ shoulder

reproduction, ipsilateral, difference

With a positive ULTT, expect:

• _______ of sx

• sensitizing test in ______ UE changes the sx

• _______ in sx b/w sides

hyoid bone

C3 is the same level as the _____

thyroid cartilage

C4-C5 is the same level as _________

C6

the first cricoid ring is at level _____

1 in, facet column

Facet joints are about _____lateral from the spinous process in the C spine, also called the _______

stability, mobility

In the C spine _____ is sacrificed for ______

SCM, anterior, posterior

the _____ divides the neck into _____ and _____ triangles

Articular pillar, pedicle

_______ are located where lamina meets the ________