Phys med: Conditions of cervical spine

Question 1

The clinical encounter: OHIPMNRS: what does this stand for?

Answer 1

Observe
History
-LO DR FICARA
Inspection
Palpation
Motion
Neurovascular
Referred Pain (screening adjacent areas)
Special tests

Question 2

Observe:

Answer 2

Patient’s general appearance, posture & gait (how do they walk into the office?)

Emotional status (happy, sad): are they comfotable?

Question 3

History (basic considerations):

Answer 3

Where is the problem? Point to it exactly. When did it start?

What makes it better or worse? Prior to treatment or injuries?

Quality of issue? (numbness, tingling, sharp, ache)

Severity (scale from 0-10)? Gradual or sudden onset?

LoDrFicara

Question 4

Inspection(Visual):

Answer 4

Posture, gait, bony deformity, trouble with activities of daily living, (ADLs)

Obvious discomfort (painful expression, unable to sit comfortably, limp)

Bony & soft tissues (deformity, bruising, swelling, color, sweat/dry, scars, calluses, bunions, atrophy, ulcers)

Footwear (supportive, wear patterns on shoes, assisting devices such as orthotics or braces)

Question 5

Palpation (360 degrees around joint/painful area):

Answer 5

Please Note: Temperature, texture, tone, tenderness (4 T’s)

360 degrees around the joint

A bit above and a bit below the site of injury/complaint

Apply enough pressure to feel deeper tissues and recreate pain.

Anatomy review (bone, tendons, ligaments, fascia, blood vessels, nerves, lymph, viscera)

Question 6

Motion: AROM/PROM/RROM:

Answer 6

Order:
1) AROM (note any issues)
2) PROM Full ranges with over pressure for end feel
3) RROM Full strength but fully isometric (neutral/relaxed position)

Question 7

Neurovascular screen:

Answer 7

-Dermatomes
-Myotomes
-Deep Tendon Reflexes
-Pulses, Capillary Refill, Temperature

Question 8

Referred Pain (screen adjacent areas):

Answer 8

Is there pain in other areas?

Question 9

Special tests (orthopedic tests):

Answer 9

Start with tests for the specific area of pain/concern

Keep in mind nerve referral pathways. So if appropriate, perform special tests above and below the site of pain/concern.

Question 10

Cervical Spine Anatomy:

Answer 10

Joints of the cervical spine:
-Atlanto-occipital joints (C0-C1)
-Atlanto-axial joints (C1-C2)
-Facet joints (14 in total)
-Intervertebral discs

Question 11

Atlanto-occipital joints (C0-C1):

Answer 11

Principal motion=flexion/extension (15-20 degrees)

Rotation is negligible

Stabilized by several ligaments

Question 12

Atlanto-axial joints (C1-C2):

Answer 12

Most mobile articulation of the spine

Main supporting ligament is the transvers ligament holding the dens of the axis against the anterior arch of the atlas.

This ligament weakens or ruptures in rheumatoid arthritis.

Two projections of the ligament go superior to the occiput and inferior to the axis, together with the transverse is known as the cruciform ligament movements.
-Flexion
-Extension
-Lateral flexion
-Rotation

Question 13

Facet joints (14 in total):

Answer 13

Facilitates flexion and extension.

Limited rotation or side flexion

Greatest flex/Ext occurs at C5-C6 and next between C4-C5 and C6-C7

Because of this mobility degeneration is more likely to be seen at these levels.

Question 14

Intervertebral discs:

Answer 14

-Make up 25% of the height of the C/S

-No disc between C0-C1 and C1-C2

-Nucleus pulposus buffers axial compression

-Annulus fibrosis withstands tension within the disc

Question 15

Although there are 7 cervical vertebrae there are 8 cervical nerve roots, each is named for the vertebrae ABOVE it:

Answer 15

C5 nerve root is between C4 and C5, rest of the spine the root is named for the vertebrae BELOW.
ex) L4 nerve root is between L4 & L5

Question 16

Cervical spine assessment (Bony Palpation):

Answer 16

Anterior aspect:
-Thyroid cartilage (C4-C5)
-Cricoid Cartilage (C6)

Posterior aspect:
-Occiput
-Inion (EOP)
-Mastoid Process
-SP of the cervical vertebrae (C2-7)
-Facet Joints

Question 17

Cervical spine assessment (Soft tissue palpation-Anterior Portion):

Answer 17

1) SCM:
-Involved in torticollis
-Note discrepancies in size, tone/damaged
-Hyperextension damages
-May cause torticollis

2) Lymph node chain:
-Along medial border of SCM
-Enlarged nodes in SCM region indicated URTI

3) Supraclavicular fossa:
-Palpate for unusual swellings or lumps
-Swelling in the fossa might be secondary to trauma
-Small lumps may be due to enlarged lymph node

Question 18

Cervical spine assessment (Soft tissue palpation-Posterior Portion):

Answer 18

1) Trapezius muscle:
-Origin= Inion to T12
-Insertion = clavicle, acromion, spine of scapula
-Action = elevate retract, and depress shoulders

2) Lymph Nodes
-Anterolateral aspect of traps
-Enlarged with infection

3) Levator scapulae:
-Origin=Upper cervical TVP’s
Insertion = Superior angle of the scapulae
Action = shrug shoulders

4) Splenius and semispinalis capitus (Deep muscles)

5) Scalene (anterior, middle, posterior):
-Multiple attachments including ribs 1 and 2

Question 19

ROM (cervical spine/muscles/joints):

Answer 19

If pain is acute, some movements will be left out to avoid exacerbation of symptoms

Flexion = 45-50 degrees
-Bring the chin to the chest
-Can divide the flexion into two parts C0-C2 gives nodding, C2-C7 gives flexion
-If problem with nodding is upper restriction
-For lower normal can be chin touching chest with mouth closed or up to 2 finger width space between chest and chin

Extension = 70 degrees
-Bend the head backwards, lift the chin up without moving the neck
-Normally the nose and forehead can go nearly horizontal
-Tingling, loss of balance etc. Suggests serious complication of cord compression

Rotation= 70-90 degrees
-Look over your left and right shoulders
-Usually the chin does not quite reach the plane of the shoulder

Lateral flexion =20-45 degrees
-Bring each ear to the shoulder
-Be sure ear is moving to shoulder and not the reverse

Question 20

Neurological testing:

Answer 20

Dermatomes
Myotomes
DTR’s

Question 21

Dermatomes:

Answer 21

Question 22

Myotomes (upper limbs):

Answer 22

Best held for 5 seconds:

Question 23

Myotomes (lower limbs):

Answer 23

Must be held for 5 seconds:

Question 24

DTR’s:

Answer 24

Question 25

Cervical Degenerative Joint disease (DJD):

Answer 25

Cervical facet (zygapophyseal joint) irritation or damage that may cause cranial, cervical or upper shoulder & back pain referral; often difficult to differentiate from other neck issues.

Question 26

DJD Differential diagnosis:

Answer 26

Differential diagnosis: -Discogenic pain syndrome or sprain/strain -Cervical radiculopathy -fibromyalgia, myofascial pain syndrome -Infection, neoplasm, aneurysm

Question 27

DJD history:

Answer 27

-Dull, achy localized pain, although may be sharp during acute episodes, headaches and limited ROM: patient will often have pinpoint pain, neck muscle spasm/ torticollis -Sometimes radiates to the shoudler or midback regions, although does not often radiate beyond the elbow or upper thoracic spine Patient may report a history of whiplash injury Pain is reduced when supine

Question 28

DJD physical:

Answer 28

-Increased pain on extension & rotation (due to facet approximation) -Antalgia is typically away from the facet in acute patients resulting in slight flexion and lateral flexion position (torticollis like position) -Possible muscle splinting and guarding ROM -No neurological deficit (DTRs, motor, sensation)

Question 29

DJD special tests:

Answer 29

Cervical compression test: (+) local pain with compression Cervical Distraction test (+) DECREASED pain with distraction. Spurling's or Maximal compression test: (+) Local pain with compression

Question 30

Cervical radiculopathy:

Answer 30

Neurocompressive disorder of the cervical nerve roots resulting in various neurological findings (7 vertebrae & 8 nerve root) Pathogenesis occurs from the inflammatory process initiated by nerve root compression

Question 31

Cervical radiculopathy differential diagnosis:

Answer 31

-Peripheral Neuropathy -Facet syndrome, meniscoid, instability -Myofascial pain syndrome, trigger point referral -Cervical myelopathy, CNS lesions -Infection, neoplasm, fracture, rotator cuff injury

Question 32

Cervical radiculopathy history:

Answer 32

-Patient describes deep aching burning neck pain & radicular arm pain ("numbness, tingling, sharp, shooting, electrical") that may follow a neck injury or be of insidious onset -May be a history of multiple episodes of previous neck pain. Possible muscle weakness in the arm/hands or sensory changes along the involved nerve -Patient may state symptom relief when shoulder is abducted with hand held behind head (shoulder abduction test) Observation: Head tilt & neck posture; head tilt away from the side of injury & holds neck stiffly

Question 33

Cervical radiculopathy physical:

Answer 33

AROM: Limitations: extension, rotation & lateral bending either away or towards the affected nerve root (increased pain, numbness, tingling or electrical pain) -Pain away from the affected side = disc herniation -Pain towards affected side = impingement of nerve root at site of IVF Palpation: -Tenderness along cervical paraspinalis -Muscle tenderness along muscles where symptoms are referred (medial scapula, proximal arm, lateral elbow) and associated hypertonicity/spasm Motor weakness: -Grip and pinch weakness Sensory changes: -Decreased sensation to pain and light touch (dermatomal distribution) -Burners or stingers DTRs: -Hyporeflexia indicates peripheral neuropathy, hyperreflexia indicates CNS lesion

Question 34

Cervical radiculopathy special tests:

Answer 34

Valsalva test: (+) Reproduction of neck or radicular pain in case of disc herniation or SOL Cervical Compression Test: (+) Reproduction of neck or radicular pain due to nerve root compression Cervical distraction: (+) DECREASED radicular symptoms Brachial Stretch Test: (+) Reproduction of dermatomal pain referral

Question 35

TMJ syndrome:

Answer 35

Pain & tenderness due to a dysfunction of the TMJ or surrounding musculature & soft tissue. 3 subtypes: 1) Myofascial pain dysfunction 2) Internal derangement 3) Degenerative joint disease

Question 36

TMJ differential diagnosis:

Answer 36

-Headache (cluster, migraine, tension) -Temporal/Giant cell arteritis, trigeminal neuralgia -Dental infections, parotiditis

Question 37

TMJ history:

Answer 37

-Jaw or facial pain (80%), pain with mastication (chewing) -Locking or clicking or catching with motion, limited ROM, grinding & popping -Headache, earache (30%) & neck pain -History of neck or facial trauma (whiplash)

Question 38

TMJ physical

Answer 38

Observation: asymmetry, muscle hypertrophy, abnormal dental wear Palpation: tender (80%) over the muscles of mastication, can feel crepitus in the joint in late stages ROM: decreased jaw opening normal= 40mm or at least 3 knuckles inserted between upper and lower incisors Clicking or popping of TMJ, crepitus over joint (may indicate disc damage) Abnormal mandibular tracking (gait): lateral deviation of mandible, non-uniform pattern

Question 39

TMJ special tests:

Answer 39

Rule out DDXs: -Often special tests are done to rule out other conditions you are considering to make TMJ syndrome your most likely working diagnosis.

Question 40

Benign paroxysmal positional vertigo (BPPV):

Answer 40

A disorder arising from a problem in the inner ear where the underlying mechanism typically involves small calcified otolith moving around loose in the inner ear. Type of balance disorder

Question 41

BPPV differential diagnosis:

Answer 41

-Labyrinthitis -Meniere's disease

Question 42

BPPV history:

Answer 42

-Any nausea -Any head injury What is the patient's age? What are the symptoms: -Spinning sensation (vertigo) -Nausea/Vomiting -Symptoms worsen with movement of head -Is it paroxysmal (suddenly and short duration) -Per-syncope or syncope

Question 43

BPPV special tests:

Answer 43

Rule out DDXs: -Dix-Hallpike test -Is nystagmus observed

Question 44

BPPV treatment:

Answer 44

-Usually involves simple movements such as the Epley maneuver or other maneuvers based on direction of nystagmus -Prescription drugs to help with nausea

Question 45

Whiplash:

Answer 45

Injury to the neck due to sudden acceleration or deceleration Results in a flexion or extension deformation of the spine 2 common scenarios for whiplash A body as rest suddenly put in motion (ex: quarterback being hit from behind) A moving body suddenly stopped (ex: hockey player absorbing a hit in open hit)

Question 46

Types of whiplash:

Answer 46

-Posteroanterior (back to front) -Anteroposterior (front to back) -Lateral (right to left) -Lateral (left to right)

Question 47

Symptoms of whiplash:

Answer 47

-Neck pain -Onset can be immediate or hours later -Soreness, stiffness, fatigue -Nausea Symptoms if structural damage is found: -Sharper pain -Quicker onset -Pain may radiate anywhere -ROM can be severely limited