CERVICAL & THORACIC SPINE Flashcards
(61 cards)
1
Q
NERVE ROOT NOMENCLATURE
A
- nerve root exits above the pedicle with the same number in the cervical spine
- C8 exits above the T1 pedicle and below the C7 pedicle
- nerve root exits below the pedicle with the same number in the thoracic & lumbar spine
2
Q
CERVICAL & THORACIC RANGE OF MOTION
A
- Cervical
⦁ 50% of cervical rotation is in C1-C2
⦁ only 10% rotation in subaxial levels - Thoracic
⦁ rib cage & facet orientation restrict motion
3
Q
AXIAL NECK PAIN
A
think mechanical
- axial neck pain is confined to the cervical, occipital or posterior scapular areas
- axial neck pain may also be associated with severe headaches with holocephalic radiation
axial pain = think mechanical pain - actually due to ligaments / joints / bones / their interaction
- Neck pain is very common
- Although frustrating, axial neck pain is usually self limited and will improve with time, conservative care and patience
- most get better within 6 weeks
4
Q
axial neck pain may also be associated with severe
A
headaches
5
Q
RADICULAR PAIN
A
- nerve root mediated
⦁ compression
⦁ chemical / inflammatory - experience a more dermatomal sharp pain, numbness, paresthesias
- associated with weakness & hyporeflexia
6
Q
MYELOPATHIC PAIN
A
- spinal canal narrowing (stenosis) & cord compression
- this is usually a PAINLESS process, however, some patients do describe an intermittent sharp shooting pain down the spine
- most patients describe painless, bilateral hand clumsiness & gait difficulty or fatigue
- WEAKNESS
Myelopathic pain = good candidate for laminectomy (cord compression - spinal stenosis)
7
Q
INTERVERTEBRAL DISC PHYSIOLOGY
A
- nucleus = metabolically active, hydrostatic proteoglycans, shock absorbing effect
- the nucleus is vascular in childhood via annular arteries. Starting with adolescence, nucleus nutrition is via diffusion only; proteoglycans degenerate and lose water content (dehydrate)
- this alters the biomechanical properties of the disc and the motion segment = loss of shock absorber
8
Q
how does normal aging lead to disc herniation
A
⦁ disc dehydration - disc narrowing
⦁ increased strain on annulus (ring around nucleus) –> diffuse bulging annulus, annular tears, and focal disc herniation
9
Q
most degenerative changes are ______ or _______
A
ASYMPTOMATIC or MILDLY ASYMPTOMATIC
10
Q
how does normal aging lead to stiffness / instability
A
stress transfers to uncovertebral and facet joints –> arthrosis (bone spurs), stiffness, instability
11
Q
what causes axial pain with aging
A
- very common phenomenon - can range from mild / intermittent to occasionally severe
- experience facet, uncovertebral joint arthritis
- loss of lordosis in cervical spine –> muscular pain
- instability
- discogenic pain…? - can a disc itself just cause pain? or only if torn / herniated / compressed?
12
Q
what causes neurogenic pain
A
- not as common
- Radiculopathy = pressure related nerve root dysfunction
⦁ disc herniation
⦁ uncovertebral, facet joint spurs - Myelopathy - pressure related spinal cord dysfunction
⦁ large disc herniation
⦁ spurs
⦁ congenitally narrow canal
13
Q
DISC SPACE & NERVE ROOT INVOLVED
A
⦁ C3-4 = C4 ⦁ C4-5 = C5 ⦁ C5-6 = C6 ⦁ C6-7 = C7 ⦁ C7-T1 = C8
14
Q
HISTORY QUESTIONS FOR PAIN
A
Axial vs Extremity complaints
⦁ Mechanical vs neurogenic
Axial Pain:
- Structural: dull, achy, paraspinal
- Referred: sharp, stabbing, intrascapular
- Are there constitutional symptoms?
Extremity pain:
- Radicular: dermatomal, sharp, N/T
- Are there signs/symptoms of myelopathy?
ask about previous history - get baseline
symptoms: onset / duration / character / location / severity / inciting / relieving events
axial vs extremity symptoms
constitutional & neurologic ROS
treatment to date
15
Q
ANTALGIC VS TRENDELENBURG GAIT
A
- antalgic gait = caused by guarding for pain in the affected extremity due to hip and knee pathology or severe radicular symptoms (limping)
- Trendelenburg gait = caused by painful arthritis of the hip or gluteus medius weakness - weak abductor muscles of the hip - keep popping out (hip pop)
16
Q
OBSERVATION OF GAIT
A
- antalgic gait = caused by guarding for pain in the affected extremity due to hip and knee pathology or severe radicular symptoms (limping)
- Trendelenburg gait = caused by painful arthritis of the hip or gluteus medius weakness - weak abductor muscles of the hip - keep popping out (hip pop)
- wide base shuffling gait = due to neurologic disorder, including myelopathy
- steppage or lateral swing gait = method of gait compensation for foot drop (weakness in ankle dorsiflexion and to extension)
17
Q
most prominent spinous process
A
C7
18
Q
triceps dermatome
A
C7
19
Q
wrist extension / pronator teres dermatome
A
C6
20
Q
interosseous dermatome (finger adduction and abduction)
A
T1
21
Q
finger flexors dermatome
A
C8
22
Q
deltoid muscle, external rotators
A
C5
23
Q
scale ____ / 5 = against gravity
A
3/5
24
Q
thumb & index finger = dermatome
A
C6
25
middle finger = dermatome
C7
26
ring & pinky finger = dermatome
C8
27
biceps & deltoid dermatome
C5
triceps = C7
28
brachioradialis dermatome
C6
```
bicep = C5
tricep = C7
```
29
hyporeflexion = ______ lesion
root lesion
30
hyperreflexic = ___________ lesion
cord lesion
31
which dermatomes don't have a reflex
C8 and T1
32
wrist flexion dermatome
| finger extension
C7
finger flexion = C8
finger extension = C7
wrist flexion = C7
wrist extension = C6
33
UPPER MOTOR NEURON VS LOWER MOTOR NEURON
```
⦁ hyperreflexia (cord lesion)
⦁ clonus
⦁ spasticity / increased tone
⦁ gait, coordination, rectal tone
⦁ Hoffman (upper extremity equivalent of Babinski sign)
```
UMN = think brain / spinal cord - excessive firing
LOWER MOTOR NEURON
⦁ flaccid paralysis
⦁ absent DTRs
⦁ muscle atrophy & wasting
LMN = between UMN and end muscle; so UMN is firing, but not being received
34
hyperreflexia = ________ motor neuron
absent DTRs = ________ motor neuron
hyperreflexia (cord lesion) = upper motor neuron
absent DTRs = lower motor neuron
35
3 cervical spine tests
- Spurling test
- Hoffman sign
- Lhermitte sign
36
The examiner turns the patient's head to the affected side while extending and applying downward pressure to the top of the patient's head.
spurling's test
assesses for nerve root pain
37
barber chair phenomenon - flexion of neck sends zinger down spine
Lhermitte sign
indicative of spinal stenosis, disc impingement, MS or tumor
38
babinski of upper extremity - flick middle finger --> flexion/adduction of thumb
Hoffman's sign
indicative of UMN lesion
39
Adson test
tests for Thoracic Outlet Syndrome
40
what is thoracic outlet syndrome
- Idiopathic ompression of the brachial plexus (95% of the time), subclavian vein (5%) or subclavian artery (1%) as they exit the narrowed space between shoulder girdle & 1st rib
- MC in women 20-50
CLINICAL MANIFESTATIONS
- nerve compression = pain / paresthesias to forearm, arm and or ulnar side of hand
- vascular compression = swelling/discoloration of arm, especially with abduction of arm (erythema, edema or cyanosis of affected arm)
perform ADSON test = loss of radial pulse with head rotated to affected side
41
the largest group of unrecognized and among the most commonly overlooked causes of chronic pain and disability
myofascial cervical pain
42
MYOFASCIAL CERVICAL PAIN
- Cervical myofascial pain originates from neck muscle and surrounding fascia and is characterized by the presence of trigger points [hyperirritable areas located in a palpable, taut band of muscle]
- Myofascial pain syndrome is said to constitute the largest group of unrecognized and among the most commonly overlooked causes of chronic pain and disability.
- Described as steady, deep, and aching in quality, although it is not uncommon for patients to use words like burning or crushing.
- The pain patterns are not limited to a specific dermatome or peripheral nerve segment.
- The muscles most often implicated in cervical myofascial pain are the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus.
- Overuse of the muscles by repetitive use of the upper limb or trauma to muscles may lead to cervical myofascial pain.
- Lack of proper furniture in desk jobs, endocrine dysfunction, chronic infections, nutritional deficiencies, poor posture, and psychological stress may also be responsible.
```
TREATMENT =
⦁ Physical therapy
⦁ Trigger point injections
⦁ Stretch/spray cycles
⦁ Medications: NSAIDS, MM relaxants, TCA’s
```
43
causes of spinal stenosis
- facet hypertrophy of the vertebra, vertebral body osteophytosis, vertebral body compression fractures and herniated nucleus pulposis
- can also be caused from secondary etiologies: such as neoplasm, acromegaly, paget's disease, and ankylosing spondylitis
44
SPINAL STENOSIS
- spinal canal narrowing with possible neural compression
CAUSES
- facet hypertrophy of the vertebra, vertebral body osteophytosis, vertebral body compression fractures and herniated nucleus pulposis
- can also be caused from secondary etiologies: such as neoplasm, acromegaly, paget's disease, and ankylosing spondylitis
SIGNS/SYMPTOMS
- Weakness or numbness. Hand weakness or numbness can get bad enough to affect grip. These symptoms could also be experienced in other parts of the body, such as the arms or legs.
- The person might encounter more trouble with typing, handwriting, buttoning a shirt, or putting a key in a door.
- Intermittent shooting pains resembling an electric shock may extend into the arms and legs, especially when bending the head forward (known as Lhermitte phenomenon).
- If a nerve root is also being impinged, cervical radiculopathy symptoms of pain, tingling, weakness, and/or numbness may also be felt down the arm and/or into the hand.
45
spinal stenosis treatment
```
⦁ NSAIDS
⦁ steroids
⦁ gabapentin (neurontin)
⦁ tramadol
⦁ PT
⦁ spinal cord decompression surgery - usually a last resort
```
46
compression fractures of the spine most commonly occur in which population
elderly osteoporotic population
can occur with acute trauma too
47
compression fractures are most often in the _____ spine and have a _________ shape
thoracic
wedge shape
48
hallmark symptom of lumbar compression fractures
midline back pain
49
wedge shape
compression fractures
50
COMPRESSION FRACTURES
- can occur with acute trauma, but most commonly occur in the osteoporotic elderly population
" WEDGE SHAPE" of the vertebrae
- can be severe - resulting in a burst fracture
- most often in the thoracic spine
most of the time, the pt is sore right where the compression fracture is located
**Midline back pain = hallmark symptom of lumbar compression fractures
- the pain is axial, non-radiating, aching or stabbing in quality; may be severe and disabling
- reports of lower extremity weakness or numbness are important signs of neurologic injury from the fracture
Compression fractures are often diagnosed when an elderly patient presents with symptoms such as progressive scoliosis or mechanical lower back pain and the clinician obtains routine lumbar radiographs.
Often, the compression fracture is the presenting symptom or finding that leads to the diagnosis of malignancy.
A detailed neurologic examination is essential
Typically has a kyphotic posture that cannot be corrected. The kyphosis is caused by the wedge shape of the fracture, essentially turning squares to triangles.
Palpation is important to correlate any reports of pain to the radiographic level of injury.
51
compression fractures treatment
⦁ Surgical intervention/referral if compression results in > 30% of the vertebral height and is associated with significant pain.
⦁ Conservative treatment consists of bracing (thoracic-lumbar-sacral orthosis (TLSO), analgesic medications, and bed rest
52
most common scoliosis curve
right thoracic
53
demographic of scoliosis
- most of the time = idiopathic
- girls > boys
- presents around ages 11-13; can get degenerative scoliosis at older age (bimodal distribution)
- Cause has been postulated to be genetic in nature.
54
scoliosis causes lateral curvature of the spine, greater than
10 degrees away from central axis
WITHOUT PAIN; so if pain present - consider alternatives
55
measure of the resulting scoliosis angle based on radiographs
COBB ANGLE
56
TEST FOR SCOLIOSIS
TEST = Forward Flexion Test - looking to see if shoulder blades both lay flat
- will see a high sided scapula
- most common curve = right thoracic
57
scoliosis treatment
⦁ if curve is < 25 degrees = observe with serial xrays over time
⦁ if curve is 20-25 degrees and rapidly progressing = bracing
⦁ curves 25-40 degrees = bracing
⦁ "inflexible" curves > 40 degrees and any curve > 50 degrees = surgery
58
cervical spine fracture imaging
CT usually ordered
59
CERVICAL SPINE FRACTURE
- Patients with cervical fractures typically have significant, localized neck pain and stiffness. However, patients who also have other injuries may complain of pain in other areas and won't notice the severity of neck pain
Plain x-rays of the cervical spine are essential to adequately evaluate a cervical fracture and dislocation. It is sometimes difficult to see a non-displaced or minimally displaced fracture or instability, therefore a Computed Tomography (CT) scan is usually ordered.
( 3 XRAYS ordered = AP, lateral, and odontoid - through mouth)
60
transverse process fracture is called a
clay shoveler's fracture - usually from direct trauma, and usually recovers fine
61
cervical spine fracture treatment
= PT, NSAIDS (perhaps narcotics), education, activity modification, reassurance
- operative = fusion
