Chapters 11- 14

Cervical/ Upper Thoracic Spine

What is the anatomy of the cervical vertebrae

houses spinal cord

intervertebral foramen

Intervertebral foramen

opening for paired spinal nerves

What are the landmarkings

\*add image

1. superior articular process
2. transverse process
3. facet
4. spinosus processes
5. lamina
6. vertebral foramen
7. pedicle
8. body
9. superior vertebral notch

What is included in intervertebral discs

annlulus fibrosus- outer fibrous rings

nucleus pulposus- soft inner mucoid material

What is the normal curvature of the of the vertebral column

cervical (7)- anterior convex

thoracic (12)- posterior concave

lumbar (5)- anterior convex

sacrum (5)

coccyx (4)- posterior concave

What are the movements of the cervical spine?

flexion

extension

lateral flexion and extension

rotation

Where does rotation occur in the cervical spine?

atlantooccipital joint (between skull and c1) primarily permits flexion and extension

atlantoaxial joint (between c1 and c2) primairly permits rotation

Neurological anatomy of the spine (plexus)

cervical plexus (c1-c4)

brachial plexus (c5-t1)

What does c2-c4 do?

provide sensation and motor control to the neck

Phrenic nerve controls what?

diaphragm

location: cervical plexus

Where do you palpate the cervical spine?

posterior structures

lateral structures

anterior structures

Palpation of posterior cervical structures?

Bony

* spinosus processes of c2-t1
* base of the occiput

Soft tissue

* upper trapezius
* levator scapulae
* spleni group
* paraspinal muscles

Palpation of lateral cervical structures

lateral fibers of upper trapezius and sternocleidomastoid

c1 transverse process palpable behind ear

Palpation of anterior cervical structures

bony

* hyoid bone
* thyroid cartilage
* first cricoid ring
* the first rib

soft tissue

* distal attachment of the sternocleidomastoid
* scalene muscles
* anterior lymph nodes
* carotid arteries bilaterally

Active range of motion exam (cervical)

flexion- chin to chest

extension- eyes point straight to ceiling

lateral flexion- approximately 45 degree angle between vertical line and line through nose and chin

rotation- chin should almost line up with tip of shoulder

Passive ROM exam (cervical)

each painless active motion is followed by a gentle passive movement

determine pain and end feel of the motion

Instrumented cervical examination

objective measurement using a goniometer, inclinometer, or tape measure

What is this

tape measurement exam: forward flexion

Cervical spine strength testing

resistance provided at the head

isometric

* flexion
* extension
* lateral flexion
* rotation

What is this?

manual strength tests for cervical spine: flexion

What is this?

manual strength tests for cervical spine: extension

What is this?

manual strength tests for cervical spine: lateral flexion

What is this?

manual strength tests for cervical spine: lateral rotation

Neurological examination- cervical

used to determine neurovascular compromise secondary to nerve compression, brachial plexus pathology, disc pathology, and thoracic outlet syndrome

* dermatomes
* myotomes
* reflexes

C1 dermatome and myotome

d- top of head

m- forward neck flexion

C2 dermatome and myotome

d- temporal and occipital regions

m- forward neck flexion

C3 dermatome and myotome

d- posterior cheek and neck

m- lateral neck flexion

C4 dermatome and myotome

d- superior shoulder, clavicle

m- shoulder shrug

C5 dermatome and myotome

d- deltoid, lateral upper arm

m- shoulder abduction

r- biceps

C6 dermatome and myotome

d- lateral forearm, radial side of hand

m- elbow flexors, wrist extensors

r- brachioradialis

C7 dermatome and myotome

d- posterior lateral arm and forearm, middle finger

m- elbow extensors, wrist flexors

r- triceps

C8 dermatome and myotome

d- medial forearm, ulnar border of hand, ring, and little finder

m- thumb extensors, wrist ulnar deviatorss

T1 dermatomes and myotomes

m- finger abductors

Acute soft tissue injuries

contusions

sprains

strains

Contusions (cervical)

relatively uncommon to cervical area

signs and symptoms

* pain
* muscle spasm
* decreased ROM
* potential trauma to the brachial plexus resulting in numbness and weakness in the upper extremity

Sprains (cervical)

also know as cervical whiplash

results from mechanisms of forceful hyperflexion, hyperextension, and rotation

Signs and symptoms of cervical sprains

neck or interscapular pain

restricted and painful ROM, especially with movement into extension

muscle weakness secondary to pain

neurological symptoms uncommon

Strain (cervical)

common to the levator scapula, trapezius, rhomboid, sternocleidomastoid, scalene, and the extensor muscle group

caused by mechanical overload or violent stretching into flexion, extension, or rotation

overuse and poor posture can be predisoposing factors

Signs and symptoms of cervical strains

muscular pain

point tenderness

spasm

decreased ROM

pain with contraction or stretching

compensatory stiffening of splinting

Chronic soft tissue injuries

often caused by muscular dysfunction resulting from poor posture or recurrent injuries

* fibromyalgia
* degenerative disc disease
* facet syndrome
* chronic cervical joint instabilities

Fibromyalgia

chronic myofascial disorder

etiology and cure unknown

Fibromyalgia signs and symptoms

chronic musculoskeletal pain

fatigue

localized tenderness

Degenerative disc disease

results from recurrent sprains and chronic joint dysfunction

possible weakening of annlulus fibrosis due to repetitive injury or stress

loss of disc height and shock absorbing injury

Facet syndrome

results from extension overload, repetitive strain, and inpingement secondary to disc degeneration

Facet syndrome signs and symptoms

pain

decreassed ROm at the facet joints

increase in pain with extension and rotation to the involved side

Chronic cervical joint instabilities

hypermobility can put neurological structures at risk

usually not apparent through an assessment

typically require radiographs

Fractures and dislocations of the cervical spine

have potential for serious, life threatening spinal cord injury

head-first contact is a primary mechanism

compression and buckling of the cervical spine are associated with direction of the impact (vertebrae in a line)

Signs and symptoms for cervical fracture/ dislocation

central spine pain

tenderness upon palpation of spinosus processes

muscle spasm

deformity

unwillingness to move the neck

Signs and symptoms associated with cord injury

bilateral sensory deficits

motor weakness

paralysis of upper and lower extremities

Cervical spine injury via compression

spine a straight, segmented column with flexed to 30 degrees

axial loading

burst, wedge, and compression can occur to any cervical vertebra

Dislocation via compression (cervical)

can occur with or without fracture

superior vertebra tends to dislocate anteriorly

neurological involvement is likely, involving both the nerve root and spinal cord

Hyperflexion mechanism

anterior body compressed

posterior ligaments torn

Hyperextension mechanism

facet-first mechanism

patients with spinal stenosis or osteophytes at increased risk of neurological compression

Secondary defects and abnormalities (cervical)

osteophytes (bone spurs)

spinal stenosis

Transient neuropraxis

occurs in secondary to posterior disc herniation, spinal stenosis, congenital fusion, or instability of cervical spine

symptoms usually subside in a few minutes or may persist from 1 to 2 days

Intervertebral disc herniations

cervical herniation is uncommon in athletics

gradual weakening of annulus fibrosis over time due to repetitive mechanical stress

* poor posture
* limited segmental movement
* degenerative changes

Label the picture of posterolateral disc herniation compressing the exiting nerve root

1 bulge

2 exiting nerve root

3 nucleus

4 annulus

5 spinal cord

Signs and symptoms of disc herniation

typically unilateral

pain that improves with cervical distraction

worsens with extension or rotation toward the involved side

potential for atrophy in chronic cases

decreased ROM

muscular splinting

pain along distribution of the nerve root

neurological deficits

Special tests for nerve root compression

valsalva maneuver

spurlings test (compression test)

shoulder abduction test

cervical distraction relief test

Brachial plexus injury

aka stinger or burner

traction or compresssion mechanism

Signs and symptoms of brachial plexus injury

sharp, burning pain radiating down one arm

temporary weakness

inability to move the arm

lateral flexion reproduces symptoms

Special tests for brachial plexus injury

brachial plexus neuropathy test

shoulder depression test

tinel’s sign

passive upper limb tension test

active upper limb tension test

Thoracic outlet syndrome

compression of neurovascular structures as they exit through the thoracic outlet

prevalent in patients with postural imbalances

Sites of compression in thoracic outlet syndrome

interscalene triangle

costoclavicular space

insertion of the pectoralis minor

Signs and symptoms of thoracic outlet syndrome

pain and altered or absent sensations

weakness, fatigue, or heavy feeling in arm

fatigue

swelling

discoloration

pain with abduction, external rotation, and overhead activites

Special tests for thoracic outlet syndrome

adson’s test

allen test

military brace position

Adsons test

Allen test

Vertebral artery compromise

disruption of inner lining of artery

whiplash mechanism, blunt trauma, or sudden neck movements

Signs and symptoms of vertebral artery compromise

headache

dizziness

nystagmus

light-headedness

syncope

difficulty speaking or swallowing

Vertebral artery test

implicates compression of the vertebral artery

passive flexion, lateral flexion, and rotation to the neck to cause dizziness

Torticollis

lateral or rotational deviation of cervical spine

often referred to as wryneck or stiff neck

congenital or acquired deformity affecting the sternocleidomastoid muscle

Kyphosis

an excessive posterior curvature of the upper and midthoracic spines

curve accentuation secondary to congenital factors, muscular imbalance, joint disease, compression fractures, osteoporosis, and scheuermann’s disease

Scheuermann’s disease

growth disorder characterized by inflammation and osteochondritis of the thoracic vertebrae

What is the shoulder

highly mobile

relatively unstable

must maintain a delicate balance between mobility and stability

Label the anterior aspect of the shoulder

Label the posterior aspect of the shoulder

What are the movements of the shoulder

flexion

extension

hyperextension

adduction

abduction

medial and lateral rotation

horizontal adduction and abduction

What is the shoulder girdle

acts as a stabilizing platform for glenohumeral motion

strong scapular muscles are imperative for efficient joint mechanics and function

What are the movements of the shoulder girdle

elevation

depression

protraction

retractioon

upward and downward rotation

forward and backward tilt\`

What is the neural innervation of the shoulder muscles

brachial plexus C5-T1

PALPATIONS???

What do you test first in upper extremity

active ROM

* glenohumeral motion
* scapular motion
* combined movements (Apley’s scratch test)

What do you test second in upper extremity

passive ROM when active ROM is less than normal

* glenohumeral joint (spine)
* scapula (side-lying)

Glenohumeral joint mobility

loose packed position- 55 degrees of flexion and 20-30 degrees of horizontal abduction

What should you assess for in glenohumeral joint mobility

distraction

caudal

posterior

anterior

What should you assess for in scapulothoracic l joint mobility

inferior

superior

lateral

medial

Strength examination for upper extremity

MMT (against gravity when appropriate)

* all glenohumeral motions
* all scapular motions

What machine is effective for testing upper extremity

isokinetic

What is the neurovascular examination for upper extremity

performed if fracture or dislocation is suspected

* dermatomes
* myotomes
* reflexes

Bone contusions upper extremity

acromion

clavicle

blocker’s exostosis

Muscle contusions upper extremity

can lead to hematoma or myositis ossifications

Glenohumeral joint sprains

first and second degree sprains are uncommon

often cause subluxation or dislocation

tensioning and potential for injury at the extreme ranges of motion

What happens after first time shoulder dislocation and subluxation

they can become recurrent and chronic

How can shoulder dislocations and subluxations occur?

anterior

posterior

inferior

Anterior dislocation- shoulder

arm abducted and externally rotated

stresses anterior and inferior ligaments

What is the most common dislocation direction - upper extremity

anterior

Signs and symptoms of anterior dislocation

patients arm slightly abducted and supported

acromion process more prominent

flattened deltoid

pain

unwillingness to move

impaired sensation and motor function if axillary nerve is involved

What is this

glenohumeral dislocation, anterior

Posterior dislocation- upper extremity

occurs with arm flexed forward with a posteriorly directed force

often spontaneously reduces