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S3- Musculoskeletal > C-Spine Common Clinical Presentations > Flashcards

C-Spine Common Clinical Presentations Flashcards

1
Q

PART 1: RARE BUT SERIOUS HEALTH CONDITIONS

A

PART 1: RARE BUT SERIOUS HEALTH CONDITIONS

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2
Q

What are some infection risk factors?

A

-Immunosuppression, DM, Cirrhosis, Aids, Steroid Use, recent/current infection

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3
Q

What is meningitis and what are some signs?

A
  • Inflammation of brain and spinal cord membranes, typically caused by an infection.
  • Fever, neck stiffness, Kernig’s sign
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4
Q

What is Kernig’s sign?

A

Stiffness of hamstrings when hip flexed to 90 degrees.

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5
Q

What is neoplasm and what are some signs?

A
  • Abnormal growth of cells (tumor)

- Fever, night sweats

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6
Q

What is the biggest risk factor associated with neoplasm?

A

Prior Hx of cancer

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7
Q

__________ is the primary cancers responsible for 75% of all bone metastasis.

A

-Lead Kettle (Pb KTL) = prostate, breast, kidney, thyroid, lung

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8
Q
  • In men, _________ is the most common source of musculoskeletal metastasis.
  • Kidney neoplasms metastasize to the vertebrae, pelvis, and proximal femur in __% of cases
  • Metastases of thyroid effects women _x greater than men
A
  • prostate
  • 40%
  • 3x
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9
Q

________ is an autoimmune disease, possibly triggered by an infectious antigen in a genetically susceptible patient. It leads to _______ hypertrophy, destruction of ___________ cartilage and bone, synovial cysts, and ligamentous _______.

A
  • Rheumatoid Arthritis (RA)
  • synovial
  • articular
  • laxity
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10
Q
  • Are men or women more likely to develop RA?

- RA likely develops prior to the __ decade.

A
  • Women 3x more likely

- 6th

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11
Q

Patients with RA are at a greater risk for developing ____________ instability and ______ invagination.

A
  • atlantoaxial

- basilar

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12
Q

What is ankylosing spondylitis?

A

Chronic inflammatory spondyloarthropathy in which we see ossification of ligaments of the spine, IV discs/end plates, and facet structures.

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13
Q
  • Patients with ankylosing spondylitis are at a ____x risk of a spinal cord injury.
  • Is it more common in males or females?
  • Risk for osteoporosis increases __-__%.
  • Patients with ankylosing spondylitis are at a heightened risk for ___-________ trauma (most common C5-C7)
A
  • 11.4x
  • males
  • 46%-56%
  • low impact
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14
Q
  • Men are __x more likely to develop ankylosing spondylitis.

- It is most frequently observed in the ___ decade.

A
  • 10x

- 3rd

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15
Q

What are the complaints patients with ankylosing spondylitis will present with?

A
  • back pain (worse at night and in morning)
  • decreased chest wall expansion
  • back stiffness
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16
Q

What is the physical presentation of patients with ankylosing spondylitis?

A
  • “chin on chest” (excessive thoracic kyphosis, flattened lumbar curvature)
  • multi-directional ROM limitations of spine
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17
Q

What is Klippel Feil syndrome?

A

Congenital defect in which the C-spine segmentation fails.

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18
Q

What is the clinical presentation of patients with Klippel Feil syndrome?

A
  • 50% short neck
  • low posterior hairline
  • limited c-spine ROM
  • 50% have scoliosis
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19
Q

With Klippel Feil syndrome, fusion of C_ and C_ are the most common.

A

C2 and C3

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20
Q

What are some complications associated with Klippel Feil syndrome?

A
  • instability

- spinal stenosis

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21
Q

PART 2: CAD (CERVICAL ARTERIAL DYSFUNCTION)

A

PART 2: CAD (CERVICAL ARTERIAL DYSFUNCTION)

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22
Q

What is the pathophysiology of CAD?

A

Intimal tear with penetration of circulating blood into the vessel wall and formation of intramural hematoma which can lead to occlusion.

  1. ) Underlying abnormality of vessel wall
  2. ) Triggering factor
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23
Q

What are 2 triggering factors for CAD?

A
  • Trauma

- Infection

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24
Q

Where does CAD most often occur?

A
  • Internal Carotid Artery

- Vertebral Artery

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25
Q
  • The mean age of patients with CAD is __-__.
  • CAD accounts for __-__% of all ischemic strokes, however, it is attributed to = __% of strokes in patients <30yo.
  • Carotid dissection is associated with >__% stenosis, occlusion or intracranial obstruction.
A
  • 39-45
  • 2-3%, 20%
  • 80%
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26
Q

What is the biggest risk factor for CAD?

A

Hypertension

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27
Q

Other CAD Risk Factors:

  • “Past history of trauma to cervical ______/_________
  • History of migraine-type headache
  • _____tension
  • Hypercholesterolemia / hyperlipidemia
  • _______ disease, _________ disease, previous cerebrovascular accident or transient ischemic attack
  • Diabetes mellitus
  • Blood clotting disorders / alterations in blood properties
  • Anticoagulant therapy
  • Long-term use of steroids
  • History of ________
  • Recent ___________
  • Immediately post partum
  • Trivial head or neck trauma
  • Absence of a plausible mechanical explanation for the patient’s symptoms”
A
  • spine/vessels
  • HYPERtension
  • cardiac/vascular
  • smoking
  • infection
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28
Q

___________ tissue diseases should be on your radar when looking at CAD.

A

Connective

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29
Q

What symptoms may patients with CAD present with?

A
  • neck pain (60-80%)
  • face pain
  • HA
  • severe pain (>70%)
  • (Bilateral) neurological symptoms (dysesthesia, motor dysfunction, pain)
  • pulsatile tinnitus (ear ringing)
  • CN palsies
  • 5 D’s and 3 N’s
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30
Q

What are the 5 D’s and 3 N’s of CAD?

A 
D= Dizziness, dysarthria (motor speech), dysphasia (speech comprehension), diplopia, drop attacks
N= Nystagmus, nausea, numbness (face/lips)
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31
Q

50% of patients with CAD present with ipsilateral _________ syndrome.

A

-Horner’s Syndrome

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32
Q

What are the symptoms of Horner’s syndrome?

A
  • miosis (pupil constriction)
  • ptosis (drooping eyelid)
  • anhydrosis on one side (loss of sweating)
  • enophthalmos (sinking of the orbit)
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33
Q

What are some positional tests we can do to check for CAD?

A

After taking BP to check for HTN

  • Sustained end-range rotation (10s)
  • “Modified Sphinx”
  • VBI Test
  • “Pre-manipulative positioning
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34
Q

What are some neurological tests we can do to check for CAD?

A
  • CN (nystagmus, pupil asymmetry, coordination of eye movements)
  • UMN (pathological reflexes, coordination, hyper-reflexia)
  • LMN (motor, sensory, hypo-reflexia)
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35
Q

Are VBI tests a good way to test for CAD?

A

No

-More important to look at Hx, interview, BP, and neurological testing

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36
Q

PART 3: C-SPINE MYELOPATHY

A

PART 3: C-SPINE MYELOPATHY

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37
Q

What is c-spine myelopathy?

A

Spinal cord compression as a result of impingement from surrounding structures.

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38
Q

C-spine myelopathy is present in __% of individuals by the seventh decade of life. Ossification of ___ is common.

A
  • 90%

- PLL

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39
Q

C-Spine Myelopathy Symptoms:

  • Neck ____/ stiffness
  • _______ pain
  • __________/ fall Hx
  • (UE) __________
  • May involve ___ first (gait, weakness)
A
  • pain
  • shoulder
  • imbalance
  • dysesthesia
  • LEs
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40
Q

C-Spine Myelopathy Neurological Signs:

  • _____ impairment
  • Spasticity
  • _________ Reflexes
  • ______-reflexia
  • Dis-coordinated extremity movements
  • _________ signs (bilateral vs unilateral)
    • Weakness
    • Sensory impairment
  • Balance impairment (dynamic)
A
  • gait
  • pathological
  • hyper-reflexia
  • radicular
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41
Q
  • What are the 5 signs (if positive) lead us to think c-spine myelopathy?
  • How many need to be positive to have an infinite likelihood ratio of c-spine myelopathy?
A
  1. ) Gait Deviation
  2. ) Hoffman’s Sign
  3. ) Inverted Supinator sign
  4. ) Babinski Sign
  5. ) Patient age >45yo

-4/5 (3/5 still highly likely)

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42
Q

UPPER CERVICAL INSTABILITY

A

UPPER CERVICAL INSTABILITY

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43
Q

Upper cervical instability can result from what 2 things?

A
  • Ligamentous instability

- Fracture

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44
Q
  • Ligamentous instability can be a result of _________ or trauma.
  • Fractures can result from _______ fractures or trauma.
A
  • concomitant health condition that affects CT

- fatigue

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45
Q

Risk Factors Associated With Upper Cervical Instability:

  • History of ________
  • _______ infection
  • congenital collagenous compromise such as ___________
  • Inflammatory arthritides such as ______
  • Recent neck/head/dental _______
A
  • trauma
  • throat
  • Down’s Syndrome
  • RA
  • surgery
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46
Q

What are the symptoms of upper cervical instability?

A
  • neck pain
  • HA/numbness
  • Limitations at end-range c-spine ROM
  • radicular vs myelopathic symptoms
  • need to support head w/ hands
  • tires easily with prolonged upright head positioning
47
Q

How will a patient with upper cervical instability present during a physical examination?

A
  • limitation in c-spine ROM multidirectional
  • muscle guarding
  • radicular vs. myelopathic signs
48
Q

What are some tests to check for upper c-spine instability?

A
  • Modified/ Sharp-Purser
  • Alar Ligament Stability Test
  • Tectorial Membrane Test
  • Posterior AO Membrane Test
49
Q

If a patient has a history that is suggestive of upper cervical instability, is it safe to perform tests for it?

A

No because you could hurt the patient more.

50
Q

Upper cervical instability can result from fractures where?

A
  • occipital condyles
  • C1
  • C2
  • traumatic spondylolysthesis
51
Q

What are common mechanisms with upper cervical fractures?

A

axial loading

52
Q 
Presentation of upper cervical instability due to c-spine fractures:
-Limited \_\_\_\_ (multidirectional)
Neck pain
C-Spine \_\_\_\_\_\_
Difficulty \_\_\_\_\_\_\_\_\_\_
Radicular pain/ radiculopathy
\_\_\_\_ SxS
Myelopathy SxS
A
  • ROM
  • spasm
  • swallowing
  • CAD
53
Q

What is a Jefferson fracture?

A

4 part burst fracture at the anterior and posterior arch of C1

54
Q

What is the difference between spondylolysis and spondylolysthesis?

A
  • Spondylolysis refers to a defect of the pars interarticularis (degeneration), can progress to spondylolysthesis.
  • Spondylolysthesis refers to the anterior displacement of a vertebral body (most common at (C3/4 and C4/5)
55
Q

How is a spondylolysthesis graded?

A

Graded by the % of vertebral body slippage.

  • I: 0–25%
  • II: 25–50%
  • III: 50–75%
  • IV: >75%
56
Q

Spondylolysthesis can be both ___________ and __________.

A
  • degenerative

- traumatic

57
Q

What is a screening tool used to be more confident that a patient doesn’t have a c-spine fracture?

A

Canadian C-Spine Rules

58
Q
  • What question is Step 1 in the Canadian C-Spine Rules?

- What are some examples?

A
  • Any high risk factors that mandates radiography?

- Age >65, dangerous mechanism, paresthesias in extremities

59
Q
  • What question is Step 2 in the Canadian C-Spine Rules?

- What are some examples?

A
  • Any low-risk factors that allows safe assessment of ROM?

- Simple rear-end motor vehicle collision, sitting position in the emergency department, delayed onset of neck pain

60
Q

-What question is Step 3 in the Canadian C-Spine Rules?

A

Able to rotate neck actively? (45 degrees L and R)

61
Q

What is the NEXUS Low Risk Rule?

A

5 criteria in order to be classified as having a low probability of cervical injury.

62
Q

What are the 5 criteria of the NEXUS Low Risk Rule?

A
  • no midline cervical tenderness
  • no focal neurological deficit
  • normal alertness
  • no intoxication
  • no painful, distracting injury
63
Q

“The physical therapist must accept that the clinical decision is made in the absence of _______ and a decision based on a balance of __________ is the aim of assessment.”

A
  • certainty

- probabilities

64
Q

“An_______-________ _______-______ process is an opportunity for the therapist to consider the likelihood that such a condition is present.”

A

evidence-informed history-taking

65
Q

“Many testing procedures lack the diagnostic utility required to confidently _______ or _______ pathologies when used in isolation. However, use of procedures is indicated based on evidence related to best practice, pathomechanisms, and the on-going accumulation of clinical data to support or refute a hypothesis”

A

rule-in or rule-out

66
Q

CERVICAL SPINE ARTHROPATHY

A

CERVICAL SPINE ARTHROPATHY

67
Q

What is arthropothy?

A

Disease of joints

68
Q

Can c-spine arthropothy be acute?

A

Yes, it can be acute or degenerative.

69
Q

What are 4 examples of degenerative arthropathy?

A
  • Spondylosis
  • Osteoarthrosis
  • Central Canal Stenosis
  • Lateral Canal Stenosis
70
Q

Spondylosis affects the vertebral _______ and _______.

A

bodies and discs

71
Q

Osteoarthrosis occurs at the _________ joints and ____ joints.

A

zygopophyseal and A-A

72
Q

Central Canal Stenosis is a narrowing of the _________ canal and is likely insidious with a progressive onset of symptoms.

A

vertebral

73
Q

What are some things that can cause Central Canal Stenosis?

A
  • Z-joint hypertrophy
  • Bulging disc
  • Thickening/ossification of ligamentous structures
  • Spondylolysthesis
74
Q

Can Central Canal Stenosis cause Cervical Spine Myelopathy?

A

Yes

75
Q

Lateral Canal Stenosis is an encroachment on spinal nerve in _______ foramen/lateral recess of spinal canal and may cause _________ pain.

A
  • lateral

- radicular pain/ radiculopathy

76
Q

What are some things that can cause Lateral Canal Stenosis?

A
  • Loss of disc height with degenerative processes
  • Z-joint and uncovertebral joint hypertrophy
  • Spondylolysthesis
77
Q

Acute Zygapophyseal Joint Arthropathy is commonly associated with _______ mechanism.

A

extension

78
Q

Acute Zygapophyseal Joint Arthropathy Physical Examination:

  • Painful with joint ____________ ROM
  • Painful with segmental ___________
  • Cervical Compression and Spurling’s Tests likely provoke concordant pain, though differences are…
    • Pain observed in segmental distribution
    • Pain observed, not paresthesia/ anesthesia
A
  • compression

- provocation

79
Q

What is the difference between somatic referred pain, radicular pain, and radiculopathy?

A

Somatic Referred Pain= Altered pain perception in CNS, that will present as a dull ache pain in a fixed location. It is usually deep but generally presents more proximal.

Radicular Pain= Pain related to nerve root irritation that will present as a narrow band of sharp shooting. It can be both deep and superficial but generally presents more distally.

Radiculopathy= Conduction block of motor and sensory axons. Results in neurological defects.

80
Q

Radiculopathy is technically not painful, but is commonly associated with what?

A

Radicular Pain

81
Q

C_ and C_ are most commonly affected by c-spine radiculopathy.

A

C6 and C7

82
Q

Radiculopathy can be both ________ and _____________.

A

traumatic/acute and degenerative

83
Q

With c-spine radiculopathy, pain and limited ROM with motions that _______ foramen or place tensile load on nerve root.

A

compress

84
Q

What is Wainner’s Cluster?

A

Tests for the presence of cervical radiculopathy

85
Q

What are the 4 items in Wainner’s Cluster?

A
  • Ipsilateral C-spine rotation AROM <60 deg
  • Spurling’s Test +
  • Cervical Distraction Test +
  • ULTT +
86
Q

WHIPLASH ASSOCIATED DISORDERS (WAD)

A

WHIPLASH ASSOCIATED DISORDERS (WAD)

87
Q

Whiplash causes the trunk to thrust ________ causing an _______ moment on the lower c-spine segments.

A
  • upward

- extension

88
Q

With whiplash the _______ annulus is distracted, and results in the impact of ______ joints.

A
  • anterior

- facet

89
Q

With whiplash, what structures are strained?

A
  • Anterior annulus
  • ALL
  • facet capsule
90
Q
  • Whiplash can cause a __________ contusion.
  • It can cause intra-articular ________ of facets.
  • It can also cause fractures of ______ pillars, _____, laminae C2, and occipital condyles.
A
  • meniscoid
  • hemorrhage
  • articular, dens
91
Q

With whiplash we get ________ on the posterior component and ________ on the anterior component.

A
  • compression

- tensile loading

92
Q

What symptoms are associated with WAD?

A
  • Neck, shoulder, UE pain
  • Radicular vs Referred symptoms
  • Glove-like distribution paresthesia
  • Weakness (myotomal vs pain inhibition)
  • Dizziness
  • Difficulty focusing vision
  • Tinnitus
93
Q

WAD Physical Examination:

  • _________ signs possible
  • C-spine motion limited ________ planes
  • Weakness
  • Muscle ________ (UT, Lev Trap, paraspinals, anterior c-spine musculature)
  • Tinnitus
A
  • radicular
  • multiple
  • guarding
94
Q

CERVICOGENIC HEADACHES

A

CERVICOGENIC HEADACHES

95
Q

What is cervicogenic headaches?

A

referred pain perceived in the head from a source in the c-spine

96
Q

The prevalence of cervicogenic headaches is generally ___ in the general population, but increases to __% following whiplash.

A
  • low

- 53%

97
Q

The main diagnosis for cervicogenic headaches includes _______ headaches without side-shift, pain starting in the ______ and spreading to oculo-fronto-temporal areas.

A
  • unilateral

- neck

98
Q

What are some other differential diagnosis we should be thinking about when considering cervicogenic headache?

A
  • Migraine
  • Dissecting aneurysms (VA or ICA)
  • Posterior Cranial Fossa Lesions
  • Greater Occipital Neuralgia
  • Neck-tongue syndrome
  • C2 Neuralgia
99
Q

CERVICOGENIC DIZZINESS

A

CERVICOGENIC DIZZINESS

100
Q

What are the 3 pathophysiologic mechanisms that have been proposed for cervicogenic dizziness?

A
  1. ) “Ischemic process affecting the vertibrobasilar system”
  2. ) “Vasomotor changes caused by irritation of the cervical sympathetic nervous system”
  3. ) “Altered proprioceptive input from the upper cervical region” **
101
Q

What is common history associated with cervicogenic dizziness?

A
  • concomitant neck pain

- Hx of whiplash may increase suspicion

102
Q

How will a patient with cervicogenic dizziness present?

A
  • dizziness with neck motion (especially rot. and ext)
  • dizziness with deep palpation
  • dizziness with joint mobility testing
    • Head-Neck Differentiation Test
103
Q

C-SPINE SURGICAL PROCEDURES

A

C-SPINE SURGICAL PROCEDURES

104
Q

What is discectomy/microdiscectomy?

A

Taking out part of the disc

105
Q

What is laminoforaminotomy?

A

Removing parts of c-spine that might be impinging structures in lateral canal.

106
Q

What is laminoplasty?

A

Surgical procedure to enlarge the spinal canal (“open the door”)

107
Q

What is a laminectomy?

A

Removal of spinous process and bilateral laminae with <25% of z-joint removal

108
Q

What is arthrodesis (Anterior Cervical Discectomy and Fusion (ACDF))?

A

Removal of structures causing compression on nerve tissue, prevents motion at disc level to improve stability via bone graft to ensure adequate space.

109
Q

What is arthroplasty?

A

Reconstruction/replacement of joint.

110
Q

Anterior Cervical Arthrodesis:

  • With an anterior cervical arthrodesis, the adjacent vertebral levels require increased ______ requirements.
  • Gradual increase in LE/UE __________ training (per toleration) without ______ resistance training and _____ progression.
A
  • ROM

- resistance, overhead, UBE (bike)

111
Q

What is the process of a cervical disc arthroplasty?

A
  • cervical discectomy
  • the disc space is distracted to “typical” disc height
  • prosthetic implanted into disc space
  • d/c 24-48 hours typically, minimal restrictions
112
Q

What are the risk factors of cervical procedures?

A
  • Surgical site infection: 0.7% and 12% of spinal surgery
  • Myositis ossificans
  • DVT
  • Spinal Cord/ nerve Injury
  • Muscular dysfunction
  • Hardware failure (if applicable)
  • Pseudoarthrosis (if applicable)
113
Q

Post-op Considerations:

A
  • Communication with surgeon
  • Pt Education
  • Monitor for SxS of complications
  • Pain modulation
  • Restoration of functional movement
  • Progression to coordination/ strengthening as appropriate (pt status, procedure, impairments, etc)

S3- Musculoskeletal (27 decks)

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