5. WAD & Pathoanatomical Dx of the C/S Flashcards
(65 cards)
1
Q
WAD stands for….
A
Whiplash Associated Disorders (WAD)
2
Q
Structures/tissues involved w/ WAD
*usually multiple tissues involved; diff to establish tissue source(s) of sx’s
A
- Mm’s
- ligs
- discs
- facets
- spinal nerves (CS)
- CNS
- esophagus
- trachea
- TMJ
3
Q
Whiplash Grades:
How many?
A
0-4
4
Q
Whiplash Grades:
all together
A
see pics
5
Q
Whiplash Grades:
Grade 0
A
No complaints about the neck.
No physical signs
6
Q
Whiplash Grades:
Grade 1
A
Neck complaint of pain, stiffness, tenderness only
NO physical signs
7
Q
Whiplash Grades:
Grade 2
A
Neck complaint AND MSK signs
MSK signs include: dec’d ROM and point of tenderness
8
Q
Whiplash Grades:
Grade 3
A
Neck complaint AND MSK signs AND Neurological signs
Neuro signs include: radicular sx’s, change in reflexes, radiating sx’s, +Spurlings, +ULTT
9
Q
Whiplash Grades:
Grade 4
A
Neck complaint AND Fx or Dislocation
10
Q
These patients are MORE vulnerable to WAD
A
pts w/ underlying DJD
11
Q
Remember to do this WITH WADs!!!
A
Check for neuro signs!!!!!
12
Q
With WADs… in addition to spinal nerves….what else may be involved?
A
Brachial Plexus
13
Q
WAD
Mechanism: Acceleration injury
HyperFLEX
what tissues likely to be injured
A
Post musculature
Discs
14
Q
WAD
Mechanism: Acceleration injury
HyperEXT
what tissues likely to be injured?
A
Facet jts
Discs
Anterior musculature
*NOTE: high # tissues involved w/ both→ hard to determine source
15
Q
General prognosis for WAD
A
½ recover w/in 3mos; half have chronic sx’s that last years
16
Q
WAD
Prognosis:
Greater risk of chronic sx’s if:
A
- rear-ended
- underlying DJD***
- Neuro deficits
- dermatomes
- myotomes
- DTRs
- etc…
17
Q
Add. prognostic factors for persisting CS sx’s @ 6mos:
*not predictive for everyone
A
- high baseline neck pain
- HA @ inception
- less educated
- no seatbelt***
- LBP @ inception
- NDI of >14.5/50
- preinjury h/o neck pain
- high catastrophizing
- female
- WAD grade II (neck complaints + MSK sx’s)
- WAD grade III (neck complaints + MSK + neuro signs)
18
Q
Systematic review of literature
Key Points w/ WADs
A
- serious phys injury is RARE
- reassurance about good prognosis → start EARLY
- Over-medicalization is detrimental
- Recovery is improved by early return to pre-accident act. lvls
- Self ex, manual tx, positive attitude and beliefs are important in regaining act. lvls
- Collars, rest, neg attitude and beleifs delay recovery and contribute to chronicity***
19
Q
Emergency and Acute Care Actions for WADs
Use of rigid back board w/ cervical collar IF WHAT:
A
- abnorm mental status
- spine tenderness
- neuro deficit
- Distraction MOI
- intoxication
*otherwise, just a c/s collar is adequate
20
Q
Other Emergency and Acute Care Actions
A
- neuro exam
- exam of spine to r/o fx or SCI
- if NOT classified as LOW RISK→ X-ray or CT
- use NEXUS criteria or Canadian C-spine Rule
- concussion eval→ overlaps w/ s/s whiplash injury
- NSAIDS, pain meds, mm relaxers
21
Q
Emergency and Acute Care Actions
talk about the first week and active interventions
A
Active interventions (in the first week from inj.) reduced costs and morbidity
*GET THEM MOVING!!!
22
Q
Does this pt need a CS X-ray to R/O Fx or Dislocation?
Canadian Cervical Spine Rule in Alert and Stable Trauma Pts
A
If pt sustained a trauma, X-ray needed if:
- >65yo
- dangerous MOI
- fall from >3’ elevation or 5 stairs
- axial load to head (ex. driving)
- MVA high speed (>100km/hr (65mph)) or rollover or ejection from vehicle
- MVA pushed into oncoming traffic
- MVA hit by bus or truck
- motorized recreational acts (motorcycles, etc.)
- bicycle collision
- parasthesias in extremities***
23
Q
If NONE of the Canadian C/S Rule factors are present….
what should you do?
A
Assess CS rotation AROM if all risk factors are LOW
24
Q
If NONE of the Canadian C/S Rule factors are present….
assess CS rotation ROM if all risk factors listed below are LOW
Low-risk factors included:
A
-
simple rear-end MVA (low speed)
- IF high speed, rollover, ejection, get x-ray and do NOT assess ROM
-
pt able to sit in ER waiting room
- IF pt unable to sit, get x-ray and DO NOT assess ROM
-
Pt able to ambulate after accident
- IF unable to ambulate, get x-ray and DO NOT assess ROM
-
delayed onset of neck pain
- IF immediate, get X-ray and DO NOT assess ROM
-
absence of midline CS tenderness
- IF midline tenderness, get x-ray and DO NOT assess ROM
*IF all above low-risk factors present→ assess pts ability to do CS AROM for rotation (L&R)
*IF <45deg to L and R→ get x-ray
*IF >45deg rot to L and R→ NO X-ray
25
Pts w/ persistent WAD demo. **fibrosis of facet-jt meniscoids and fatty infiltration of the DCEMs and deep cervical multifidi and deep cervical flexor mm's**
see pics
**T1 axial MRI @ C2-3 lvl demo'ing _fatty infiltration (atrophy)_ in the longus capitis/colli mm's in _Fig A_ on the L vs _healthy control Fig B_**
26
Clinical implication
## Footnote
**These interventions are important to _prevent occurence of chronic WAD w/ potential permanent fatty atrophy_**
* EARLY activation of the **cervical extensors** and **deep cervical flexors**
27
Which subgroup is BEST for pts w/ **WAD?**
* IF **recent (\<30d)** and **relatively HIGH initial pain ratings/disability→ _PAIN CONTROL_**
* move into any other subgroups after short pd of pain control\*\*\*\*
* IF **recent (\>30d), BUT relatively LOW pain/disability→** ANY **other** sugroup(s)
28
Gen Guidelines for Pts w/ WAD
## Footnote
**What are the 3 stages and timelines?**
1. **Acute Stage →** approx. 2 wks
2. **Subacute→** 2-10wks
3. **Chronic→** \>10wks
29
Gen Guidelines for pts w/ WAD
## Footnote
**Acute Stage (approx 2 wks)**
* **Exam findings:**
* swelling, spasm, soreness, stiff
* Spasm of SCM can cause FHP and flattening of CS lordosis
* **Goals:**
* protect against further injury, reduce/control pain
* **Interventions:**
* gentle mobs
* STM
* modals
* UE mvmt (scap)
* walking
30
Gen Guidelines pts w/ WAD
## Footnote
**Subacute (2-10wks)**
* Wean off/min. use of acute stage intervents (get away from modals)
* progress gradually into **chronic stage intervents**
* DCFMs early on→ think back to early intervention of multifidi in L/S
31
Gen Guidelines pts w/ WAD
## Footnote
**Chronic Stage (\>10wks)**
* **Goals:**
* restoration of C/S lordosis and normal posture
* restore CS ROM and strength
* restore function
* control/elim. pain
* Pathoanatomics of injury (if known) and repro. of pain upon exam are **key guides to tx**
* **Interventions:**
* strength/cond.
* functional retraining
* aerobic
32
**Tissue Sources** of **Cervical Pain**
see pics
33
REVIEW MEDICAL RED FLAGS FOR SERIOUS SPINAL PATHO!!
## Footnote
**MAGEE TABLE 9-6**
IN THE L/S UNIT AS WELL!!!
34
S/S assoc'd w/ **C/S Dysfunction**
* cervical pain
* HAs
* T/S and scapular pain
* TMJ/craniofacial pain
* UE pain
* UE neuro signs
* P&N, numbness, reflex changes, motor weakness)
* balance, auditory, visual disturbs
* cervical myelopathy
* vertebral aa s/s
35
Cervical Myelopathy
## Footnote
**Defined:**
**Functional** or **pathologic** changes in the SC
36
Cervical Myelopathy is a consequence of WHAT?
Consequence of **CS DJD, spondylosis, and/or central stenosis**
37
Cervical Myelopathy may also be **secondary to** \_\_\_\_\_\_\_\_\_
**Secondary to** congenital or dev. cond's or diseases
Ex's: CP, tumor, infections, UMN dis., HIV, syph.
38
Cervical Myelopathy
## Footnote
**Dx?**
MRI
Correlation w/ clinical exam
39
S/S **Cervical Myelopathy**
see pics
40
Course of Pathology for **Cervical Myelopathy**
* Prolonged, long pds of **non-progressive disability COMMON**
* phase of disability for awhile then more progressive loss
* RARE instances of progressive deterioration
41
Course of Patho for **Cervical Myelopathy**
## Footnote
**Interventions??**
* Conservative Tx (meds, PT)
* **interventions depend on sx response**
* **Sx**
**\*\*AVOID EXTENSION!!!**
42
What interventions should be **AVOIDED** w/ **Cervical Myelopathy**
EXTENSION!!!
43
DJD (OA) in **C/S**
## Footnote
**Will affect what?**
Atlanto-occipital jt
Facet jts @ C2-3 **and lvls below**
44
Assoc'd w/ DJD (OA)
## Footnote
**Spondylosis (OA of spine):**
term typ NOT used specifically for facet jts, but more for **global degen changes b/w vertebrae and IVF**
45
2 other characteristics of DJD (OA) in C/S
\*NOTE: both will **limit ROM**
\*widening of vertebral end plates
\*osteophytes may be present
46
AKA **painful facet joints**
Facet syndrome
47
2 types of **Stenosis:**
1. Central (think **Cord)**
2. Lateral (think **nerves)**
48
Central **stenosis**
* watch for s/s of **myelopathy**
* **think _cord_**
49
Lateral **stenosis**
* watch for s/s of **radiculopathy**
* **think _nerves_**
50
3 things assoc'd w/ **Disc Patho:**
1. DDD (think disc hts)
2. Bulging\*
3. Herniations\*
NOTE: \*→ by age 40, the nucleus's **fluid content** has diminished greatly and the nucleus now mostly a “**ligamentous/fibrocartilaginous dry core”**
51
Nerve root impingement aka
radiculopathy
“pinched nerve”
52
Nerve root impingement
## Footnote
**Can occur due to…..**
* disc bulge
* disc herniation
* DDD
* spondylosis
* lateral stenosis
53
Terms/jargon assoc'd w/ **disc patho:**
**Protrusion/degen**
**THINK “BULGING”**
post or post/lat **bulge** w/out any sig. tearing of annulus
54
Terms/jargon assoc'd w/ **disc patho:**
## Footnote
**Herniations: 3 phases**
1. **Prolapse→** outermost rings of annulus still intact
2. **Extrusion→** just moving→ annulus completely perforated; disc mat. moves into epidural space
3. **Sequestration→** disc fragments “escape” and may migrate into epidural space; may put pressure on:
1. SC
2. nerve roots
55
Terms/jargon assoc'd w/ **disc patho:**
see pics
56
C/S disc disease (**DDD, herniation)**
## Footnote
**May req. sx intervention IF:**
* progressive myelopathy
* worsening of hard neuro s/s over time, OR impairments related to SC involvement
* CS radic. that is recalcitrant (not resp.) to conservative Tx for **@ least 6-8wks**
* Recurrent radic.
* **Progressive neuro deficits (**gradual worsening of DTRs, myotomes, derms, and/or peripheralization of sx's)
* Severe incapacitating neck pain recalcitrant to conservative tx that **correlates w/ clinical exam and dx studies**
57
Dx tests used to **confirm patho detected upon clinical exam:**
* EMG/NCV
* distinguishes bw **nerve root compression vs. peripheral neuropathy**
* radiographs
* MRI (**most Sn img to detect SC patho.)**
* Cervical myelogram/CT scan
* **good for foraminal stenosis and cortical bony margins**
* Provocative discography
* **confirms that pain is of _discogenic origin_ and/or determine _which disc lvls involved_**
58
Most common procedure for **C/S Disc Patho**
**A**nterior **C**ervical **D**iscectomy and **F**usion
ACDF
* req's retraction of midline structures **including trachea and esophagus**
* ANT. approach req's **disruption of longus coli/longus capitis**
* so train them!!!
* Discectomy and resection of foraminal exostosis
* Bone graft inserted into tractioned disc space; fusion plate screwed into ANT. VB's
59
Pot. Comps of **Sx or Post-Sx Pd.**
* Inf.
* dysphagia
* esophageal injury
* **Nerve injury**
* laryngeal nerve; SCI; nerve root inj.
* Vascular comps
* **vert aa.**
* skin breakdown and/or mm atrophy and/or swallowing dysf due to **long term collar use**
* graft failure
* **graft displacement; nonunion; instrumentation failure**
* **chronic pain**
60
Rehab of Pts who have undergone **ACDF Sx**
* **Post-op:**
* HOB elevated to dec swelling
* sore throat and pain w/ swallowing first few days
* **Avoid** overactivity before fusion “takes”; **avoid strenuous ex's in 1st 12wks post-op**
* \***OK to gently mob. nerves,** but AVOID tension/stretching of nerves
* \*Cervical collar for up to 12wks (typically LESS or NOT AT ALL)
61
**ACDF Sx:**
**Phase I**
* **Acute Inflamm Phase→ 0-14days**
* Use CS collar to protect sx site
* **ADLs w/ correct body mechs and neutral CS**
* DAILY walking 5-15min
* UE mvmts below 90degs
62
**ACDF Sx: Phase II**
* **Reparative Phase→ 3rd week post-op**
* Start gentle chest stretch in corner
* Gentle **UE AROM ex's**
* AROM, pulleys, finger ladder
* **Gentle trunk stabilization ex's (**Neutral CS)
* DAILY walking 15-20mins
* UE mvmts below 90degs
\*NOTE: **Aerobic ex's correlated w/ healing post-sx**
63
**ACDF Sx: Phase III**
**Consolidation and Maturation Phase→ from post of Wk 4 to 24wks**
**Weeks 4-8**
* PROM shoulder above 90degs
* **active still BELOW 90**
* Begin gentle CS AROM
* Begin gentle UE neural glides/mobs/flossing
* Begin strengthening of **DCFMs**
* Begin UE PREs w/ shoulders _below 90degs_
* Progress trunk stabilization ex's (**neutral CS)**
* Mobs to MID and LOWER T/S segments
* INC WALKING TO 30mins
64
**ACDF Sx: Phase III**
**Consolidation and Maturation Phase→ from post of Wk 4 to 24wks**
**Weeks 9-12**
* Continue **prior exercises (4-8wks),** progressing UE PREs to above 90degs
* ADD CS **isometrics and strengthening of TS paraspinals and scapular mm's**
65
**ACDF Sx: Phase III**
**Consolidation and Maturation Phase→ from post of Wk 4 to 24wks**
**Weeks 13-24**
* progress resistance and reps of above ex's
* ADD **functional retraining (work; sports) IF** approved by surgeon
