MUSCULOSKELETAL EXAMINATION OF THE CERVICAL SPINE (P1; anatomy and subjective)

Heavily Magee Based,

True or False:
The cervical spine sacrifices stability for mobility

TRUE

Two areas of the spine:

Upper cervical spine is called (C0-C2) : _________________

Lower cervical spine is called (C3-7): _________________

Two areas of the spine:

Upper cervical spine is called (C0-C2) : cervicoencephalic / cervicocranial

Lower cervical spine is called (C3-7): cervicobrachial

Injuries in this region have the potential of involving the brain, brain stem, and spinal cord, what cervical region am I talking about?

cervicoencephalic / cervicocranial

Sx include:

• headache

• fatigue

• vertigo

• poor concentration

• hypertonia of the sympathetic nervous system

• irritability

• cognitive dysfunction

• cranial nerve dysfunction

Uppermost joint of the cervical region

atlanto-occipital joints

ellipsoid jt. ; works in unison with the atlanto-axial joint ; most complex articulations of the axial skeleton.

ROM of flexion and extension for the atlanto-occipital joints

15° to 20°

ROM of side flexion for the atlanto-occipital joints

10°

ROM of rotation for the atlanto-occipital joints

Negligible

Ligament supporting the anterior atlanto-occipital membrane of the atlanto-occipital jt.

anterior longitudinal ligament

Ligament between the atlas and occiput; replaces the ligamentum flavum.

Posterior atlanto-occipital membrane

A broad band covering the dens and its ligaments, is found within the vertebral canal.

Tectorial membrane

The tectorial membrane is a continuation of what ligament?

Posterior Longitudinal ligament

Two strong rounded cords found on each side of the upper dens passing upward and laterally to attach on the medial sides of the occipital condyles.

Alar ligaments

limit flexion and rotation and play a major role in stabilizing C1 and C2, especially in rotation

Joints that constitute the most mobile articulations of the spine

atlanto-axial joints

ROM of flexion and extension in atlanto-axial joints

10°

ROM of side flexion in atlanto-axial joints

5°

ROM of rotation in atlanto-axial joints

approx 50°

True or False:

With rotation, there is a decrease in height of the cervical spine at this level as the vertebrae approximate because of the shape of the facet joints

True

Middle Atlanto-Axial joint is a pivot (trochoidal) joint

Lateral Atlanto-Axial joints (facet joints) are plane joints.

Main supporting ligament of the atlanto-axial jt.

transverse ligament of the atlas

It is this ligament that weakens or ruptures in rheumatoid arthritis.

As the transverse ligament crosses the dens, there are two projections off the ligament, one going superiorly to the occiput and one inferiorly to the axis. The ligament and the projections form a cross, and the three parts, taken together are called the?

cruciform ligament of the atlas

The vertebral artery passes through the transverse processes of the cervical vertebrae through the transverse foramen, starts at the level of ________ but can enter as high as the level of __________.

The vertebral artery passes through the transverse processes of the cervical vertebrae through the transverse foramen, starts at the level of C6 but can enter as high as the level of C4.

Quick fax abt the vertebral artery:

• supplies 20% of the blood supply to the brain (primarily the hindbrain)

• lies close to the facet joints and vertebral body where it may be compressed by osteophyte formation or injury to the facet joint.

• vascular risk factors (e.g., hypertension, high fat or cholesterol levels, diabetes, smoking) may contribute to altered blood flow in the arteries.

vertebral and internal carotid arteries are stressed primarily by what cervical motions?

rotation, extension, and traction

True or False:

Rotation and extension of as little as 10° have been shown to significantly decrease vertebral artery blood flow.

FALSE:

Rotation and extension of as little as 20° have been shown to significantly decrease vertebral artery blood flow.

The greatest stresses are placed on the vertebral arteries in four places:

• where it enters the transverse process of C6

• within the bony canals of the vertebral transverse processes

• between C1 and C2 (greatest potential for problems)

• between C1 and the entry of the arteries into the skull (greatest potential for problems)

True or False:

The most common mechanism for nonpenetrating injury to the vertebral artery is neck flexion, with or without side flexion or rotation.

FLASE:

most common mechanism for nonpenetrating injury to the vertebral artery is neck extension, with or without side flexion or rotation.

Given the type of VA injury possible, symptoms may be delayed.

Symptoms related to the vertebral artery include:

• vertigo

• balance deficits

• arm paresthesia

• nausea

• tinnitus

• “drop attacks” (i.e., falling without fainting)

• visual disturbances

• in rare cases, stroke or death.

Pain in this cervical area is commonly referred into the upper extremity, what is the cervical area called?

cervicobrachial area (C3-7)

True or False:

Pathology in this region leads to both neck and arm pain, but never neck pain alone or arm pain alone.

False:

Pathology in this region leads to neck pain alone, arm pain alone, or both neck and arm pain.

Symptoms of cervicobrachial injury (skim thru):

• include neck and/or arm pain

• headaches

• restricted range of motion (ROM)

• paresthesia

• altered myotomes and dermatomes

• radicular signs

• Cognitive dysfunction (not common)

• cranial nerve dysfunction (not common)

• sympathetic dysfunction

• Injury to both areas (cervicobrachial and cervicoencephalic), if severe enough, may result in psychosocial issues.

How many facet (apophyseal) joints in the cervical spine (C1 to C7)?

14

True or False:

The upper four facet joints in the two upper thoracic vertebrae (T1 to T2) are often included in the examination of the cervical spine.

True

True or False:
Cervical rotation cannot happen without some forward flexion and vice versa, this is called coupled movement.

False:

Cervical rotation cannot happen without some side/lateral flexion and vice versa, this is called coupled movement.

Between which vertebra in the cervical region do coupled movement occur in the opposite direction?

i.e left rotation occurs with right lateral flexion and vice versa

C0-C2 & C7-T1

Between which vertebra in the cervical region do coupled movement occur in the same direction?

i.e left rotation occurs with left lateral flexion and vice versa

C2-C7

The greatest flexion-extension of the facet joints occurs between which vertebrae?

C5 and C6

Common levels of degeneration due to excess movement:

• C5 and C6

• C4 to C5

• C6 to C7

Cervical Spine

Resting position:

Close packed position:

Capsular pattern:

Cervical Spine

Resting position: Midway between flexion and extension

Close packed position: Full extension

Capsular pattern: Side flexion and rotation equally limited extension

The intervertebral discs make up approximately how many percent of the height of the cervical spine?

25%

True or False:

No disc is found between the atlas and the occiput (C0–C1) or between the atlas and the axis (C1–C2).

True

True or False:

It is the vertebrae that give the cervical spine its lordotic shape

False:

It is the discs rather than the vertebrae that give the cervical spine its lordotic shape

Which part of the IV disc acts as a buffer to axial compression in distributing compressive forces?

Nucleus Pulposus

Which part of the IV disc acts to withstand tension?

Annulus Fibrosus

The intervertebral disc has some innervation on the periphery of the annulus fibrosus.

a generalized disease of aging initiated by intervertebral disc degeneration.

Spondylosis

Spondylosis is often seen in what age?

25 y/o or older

Spondylosis is present in 60% of what age group?

Older than 45 years

Spondylosis is present in 85% of what age group?

Older than 65 years

Symptoms of osteoarthritis do not usually appear until a person is _____ years of age or older

60 years of age

Diff Dx for spondylosis:

S/Sx of cervical symptom pathology

Location of the symptoms may help determine what level of the cervical spine is involved (e.g., tingling in the middle finger may indicate a problem at C6 to C7)

Grading of Patients Suffering From Neck Pain:

Watkins severity scale for neurological deficit (Severity Score)

• mild episode =

• moderate episode =

• severe episode =

Watkins severity scale for neurological deficit (Severity Score)

• mild episode = 4

• moderate episode = 4 to 7

• severe episode = 8 to 10

Watkins severity scale for neurological deficit (Return to activity Score)

• minimum risk =

• moderate risk =

• severe risk =

Watkins severity scale for neurological deficit (Return to activity Score)

• minimum risk = 6

• moderate risk = 6 to 10

• severe risk = 10 to 15

True or False:

Acute post-whiplash syndrome can lead to anxiety, pain catastrophizing (negative or heightened orientation toward pain), and other adverse psychosocial factors over time, and it can play a major role in the symptoms felt by the patient

FALSE

Chronic post-whiplash syndrome can lead to anxiety, pain catastrophizing (negative or heightened orientation toward pain), and other adverse psychosocial factors over time, and it can play a major role in the symptoms felt by the patient

Yellow Flags

Red Flags

trauma may cause a whiplash-type (acceleration) injury or what type of disorder?

whiplash-associated disorder (WAD)

The Quebec Severity Classification of Whiplash-Associated Disorders:

Trauma, compression, or stretch of the brachial plexus:

Burners or Stingers

typically occur from a blow to part of the brachial plexus or from stretching or compression of the brachial plexus

overuse or sustained postures may result in what type of symptoms?

Thoracic outlet symptoms

This type of palsy has symptoms, commonly bilateral, that are related to the brachial plexus (i.e., paresis, numbness, paresthesia, and painless motor weakness in the shoulder girdle and elbow flexor muscles).

Associated with carrying a heavy backpack

Backpack palsy (BPP)

In chronic cases of pain or headache, what can be useful to help determine pain patterns or factors that trigger the pain or headaches?

Pain Diary

Factors That Increase Chances of Recovery From an Episode of Neck Pain:

True or false:

Upper cervical symptoms may result from excessive nodding

True

True or False:

Cervicobrachial joint problems are often painful when activities that require push and-pull motion (such as lawn mowing, sawing, and cleaning windows) are performed.

FALSE

Cervicothoracic joint problems are often painful when activities that require pushand-pull motion (such as lawn mowing, sawing, and cleaning windows) are performed

True or false

Bone pain usually occurs immediately, but muscle or ligamentous pain only occurs several hours or days later

FALSE:

Bone pain usually occurs immediately, but muscle or ligamentous pain can either come on immediately (e.g., a tear) or occur several hours or days later

how many percent of whiplash patients reported immediate symptom occurrence?

70%

Myofascial pain syndromes demonstrate generalized _______ and at least ______ trigger points, which have lasted for at least ____ months with no history of trauma

Myofascial pain syndromes demonstrate generalized aching and at least three trigger points, which have lasted for at least 3 months with no history of trauma

True or False:

For a C4 nerve root injuries and above, symptoms do not go down the arm.

True

C2 and C3 nerve roots go to the lateral neck while C4 and C5 nerve roots go to the lateral neck and shoulders.

Injury to the nerve roots in the cervical spine

Cervical radiculopathy

True or False:

Cervical radiculopathy presents primarily with bilateral motor and sensory problems, myotome affectation and dermatome affectation and reflex hypoactivity

False:

Cervical radiculopathy presents primarily with unilateral motor and sensory problems, myotome affectation and dermatome affectation and reflex hypoactivity

Acute radioculopathies commonly associated with =

Chronic radiculopathies commonly associated with =

Disc Herniation

Spondylosis

True or false:

Disc herniations in the cervical spine increase in pain on coughing, sneezing, jarring or straining

TRUE

Disc injury in the cervical spine can refer pain to the thoracic spine:

• Which disc refers pain to the cervicothoracic junction and ipsilateral upper trapezius?

• Which disc refers pain to the superomedial border of the scapula?

• Which disc refers pain to the midscapular area?

• Which disc refers pain to the lower scapular area and along the medial scapular border?

• C3-4

• C4-5

• C5-6

• C6-7

An injury to the spinal cord itself:

Cervical Myelopathy

Sx of cervical myelopathy:

Hand symptoms found early in cervical myelopathy:

Myelopathic hand

• weakness then loss of adduction and extension of the ulnar two or three fingers (Wartenberg sign)

• inability to grip and release these fingers rapidly

  • grip and release test = grip and release for 10 seconds.

    • Normal range = 20+ reps

True or False:

when an athlete experiences a “burner,” the sensation is a lightning-like, boring pain into the shoulder and arm, followed by a period of heaviness or loss of function in the arm.

False:

when an athlete experiences a “burner,” the sensation is a lightning-like, burning pain into the shoulder and arm, followed by a period of heaviness or loss of function in the arm.

If the pain is affected by laughing, coughing, sneezing, or straining, an increase what type of pressure affects the condition?

Intrathoracic, Intraabdominal

These headaches occur as a symptom of musculoskeletal dysfunction in the cervical spine, especially C1, C2, and C3

Cervicogenic headaches

Clinical Criteria for the Diagnosis of Cervicogenic Headache:

Craniovertebral joint dysfunction commonly is accompanied by headaches:

• headaches occur at the base and top of the head =

• headaches are referred to the temporal area =

Craniovertebral joint dysfunction commonly is accompanied by headaches:

• headaches occur at the base and top of the head = C1

• headaches are referred to the temporal area = C2

Basically dermatome distribution (doesn’t count as a headache if the dermatome isn’t on the head)

True or False

Cervical arterial dissection, which is common, may result in neck pain and a migraine-like headache.

False

Cervical arterial dissection, although rare , may result in neck pain and a migraine-like headache.

If the headache is a major complaint especially following trauma, then the examiner should take a blood pressure measurement, assess the mental state of the patient as is done with a concussion, and assess the cranial nerves

Dissection of a cervical artery usually results in “unusual” acute moderate to severe neck pain that is different from anything previously experienced. This may be followed by what?

Transient ischemic attack (TIA) or stroke

Differentiation Between Features of Cervical Artery Dissection and Vertebrobasilar Insufficiency (important)

True or False

Many patients of cranial artery dissection have transient neurological signs and symptoms days or weeks prior to dissection.

True

Internal carotid artery dissection sx:

• unilateral frontal pain

• retro-orbital pain

• constriction of the pupil

• facial palsy

Sign when pain and referred symptoms are decreased or relieved by placing the hand or arm of the affected side on top of the head.

indicative of problems in the C4 or C5 area.

Bakody Sign

True or False:

Unilateral symptoms usually indicate either systemic disorders

False

Bilateral symptoms usually indicate either systemic disorders

You have a patient with a blood pressure of 130/90, is the patient susceptible to carotid and vertebral artery diseases?

Yes

hypertension can be a risk factor for carotid and vertebral artery disease

True or False:

Instability due to problems with the craniovertebral ligaments could compromise neurological and muscular tissues in the upper cervical spine.

False:

Instability due to problems with the craniovertebral ligaments could compromise neurological and vascular tissues in the upper cervical spine.

Risk factors related to vertebrobasilar insufficiency :

• cardiovascular disease

• TIA

• blood clotting disorders

• anticoagulant therapy

• oral contraceptives, smoking

• long-term use of steroids

• and past history of trauma to the neck.

This finding may indicate a severe problem affecting the spinal cord in cervical conditions.

lower-limb symptoms (lahat basta lower limb myelopathy)

indicative of myelopathy

__________ canal problems or ___________ problems can lead to dizziness

Semicircular canal problems or vertebral artery problems can lead to dizziness

True or False:

Dizziness from a semicircular canal problem is commonly associated with other symptoms.

FALSE:

Dizziness from a vertebral artery problem is commonly associated with other symptoms.

Falling with no provocation while remaining conscious is sometimes called a _______________.

Drop Attack

S/Sx of VBI (skim)

5 D’s Of VBI

• Dizziness 

• Diplopia (double vision)

• Drop attack 

• Dysarthria (diff in speaking) 

• Dysphagia (diff in swallowing) 

Sympathetic symptoms may be indicative of injuries to what structures / system?

Cranial Nerves / Sympathetic Nervous System

True or False:

Severe injuries (e.g., acceleration/whiplash type) can lead to hypotonia of the sympathetic nervous system.

False:

Severe injuries (e.g., acceleration/whiplash type) can lead to hypertonia of the sympathetic nervous system.