Rat 5- 3/1/16

Question 1

True/ False

Primary bone tumors in L and T have a higher occurrence rate than C-spine

Answer 1

True

Question 2

what organs more frequently metastasis to the C-Spine?

Answer 2

Cervical metastatic occurs more frequently in cancers of breast, lung, prostate, and melanoma

Question 3

How frequent is metastasis to the C-Spine?

Answer 3

C-spine metastasis occurs in 8-20% of pts with known metastatic disease and is relatively uncommon

Question 4

What are some criteria for referral when cancer is suspected?

Answer 4

Clinical judgment
Low hematocrit
Elevated ESR
Previous hx of cancer

Question 5

Other criteria for referral when cancer is suspected?

Answer 5

Previous hx of non-skin cancer
Failure of conservative management in past month
Age >50
Unexplained wt loss of more than 4.5 kg in past 6 months

Question 6

What’s the incidence of infection in C-spine

Answer 6

rare

Question 7

Name and define one type of infection in C-spine

Answer 7

Cervical vertebral osteomyelitis- a type of bacterial infection inclusive of dis-kitis, spondylitis, and spondylodiscitis

Question 8

Name 3 common sources of Cervical vertebral osteomyelitis

Answer 8

TB,
urinary and respiratory tract infections,
IV drugs

Question 9

What are the risk factors for Cervical vertebral osteomyelitis

Answer 9

diabetes,
renal insufficiency,
heart or liver disease, alcoholism,
chronic immunosuppression

Question 10

Where are the neurological deficits located with Cervical vertebral osteomyelitis

Answer 10

Most cases are reported between C5 to C6

Least cases reported between C2-C5

Question 11

What are the lab tests used to diagnose Cervical vertebral osteomyelitis

Answer 11

ESR, WBC, C-reactive protein levels

Question 12

What imaging tests are recommended to diagnose Cervical vertebral osteomyelitis

Answer 12

Radiographs- end plate erosion 2-4 wks post onset.

MRI- gold standard

Question 13

True/False

C-spine fx. is rare.

Answer 13

Rare- prevalence of less than 4% of population

Question 14

What is the MOI for C-spine fx?

Answer 14

MOI- trauma related; Falls, Motor vehicle collision (MVC), or Sports injury

Question 15

What level is fx most commonly happening at?

Answer 15

Half occur at C6 or C7

⅓ at C2

Question 16

What is the algorithm used to determine who would benefit form radiography?

Answer 16

Canadian C Spine rule recommended to determine who would benefit from radiographic evaluation

Question 17

What are the 3 high risk factors that mandate imaging? (Canadian C Spine rule)

Answer 17

Age > or = to 65
 or 
dangerous MOI
or 
paresthesias in extremities

Question 18

What are the 5 low risk factors that allow safe assessment of ROM? (Canadian C Spine rule)

Answer 18

Simple, rear-end MVC
sitting position in ED (emergency dept.) 
ambulatory ate any time
delayed onset of neck pain
absence of midline C-spine tenderness

Question 19

What is the ROM value that added to the other two clusters of symptoms will help us decide whether imaging is needed or not?

Answer 19

45 degrees rotation bilaterally

able- no imaging needed

(after considering all the other symptoms:
Simple, rear-end MVC
sitting position in EO
ambulatory at any time
delayed onset of neck pain
absence of midline C-spine tenderness

and neither one of the following is present: 
Age > or = to 65
 or 
dangerous MOI
or 
paresthesias in extremities )

Question 20

What is cervical arterial dysfunction?

Answer 20

CAD describes potential adverse events involving both the vertebrobasilar system supplying the hindbrain (Pons, Brainstem, Vestibular apparatus, Medulla Oblongata and Cerebellum) and the internal carotids supplying the cerebral hemispheres and the retina.

Question 21

What are the 3 forms of CAD?

Answer 21

Stenotic
Occlusive,
Dissecting Aneurysms

Question 22

How does cervical rotation and extension affect the vertebral artery?

Answer 22

It can cause Internal Carotid Artery Dissection. These movements compress the artery against the transverse process of the upper cervical vertebrae
Vertebral Artery Dissection is assoc. with contralateral cervical rotation that stretches or compresses the artery between the 1st two cervical vertebra

Question 23

What are the symptoms of internal carotid artery dissection?

Answer 23

Ipsilateral frontotemporal headaches upper/mid cervical or anterolateral neck pain or facial pain

Neck pain occurs in 9% -20% of symptomatic pts

Facial pain present in 34%-53% of pts.

Headaches usually reported in the frontotemporal or hemicranial regions.

Question 24

What are the symptoms of vertebral artery dissection?

Answer 24

Neck pain: usually sudden, severe & sharp ipsilaterally in the upper posterior to middle cervical spine, usually with or without occipital headache alone.

Neck pain occurs in 34%-46% of symptomatic pts.

Facial pain not usually present

Headaches usually reported as an ipsilateral, constant ache in the occipital or parieto-occipital regions

Rarely C5-C6 nerve root impairment

Question 25

What are the classic symptoms of vertebral artery insufficiency?

Answer 25

``` 5 Ds Drop attack, Dizziness, Diplopia, Dysarthria, Dysphagia), ``` Ataxia, Nausea, Numbness of the unilateral face, Nystagmus NB: strict use of these signs and symptoms may be misleading and lead to poor understanding of the pts. presentation. Some non-classic s/s: also hindbrain stroke (also known as wallenberg syndrome) Cranial nerve palsies

Question 26

What factors raise the index of suspicion that a patient may have cervical arterial dysfunction?

Answer 26

Careful history and review of cardiovascular risk factors, such as hypertension, hypercholesterolemia, coagulation abnormalities, direct vessel trauma, DM, a hx of smoking, bacterial infection and family hx of cardiovascular disease (CVD). Other pertinent info includes a history of trauma (MVC, fall, lifting or coughing), recent cervical spine surgery, nerve blocks, radiation therapy, intubation, central venous catheterization, or connective tissue disorders.

Question 27

What is the course of action for the PT when CAD is suspected?

Answer 27

Therapists should develop a high index of suspicion with acute onset of neck and head pain described as “unlike any other,” and consider the signs & symptoms associated with nonischemic and ischemic phases of CAD. If the index of suspicion is high, based on the pts. hx, - end range provocative test is not indicated and the patient is referred appropriately……….

Question 28

How successful are the provocative tests for identifying arterial dysfunction?

Answer 28

In general, functional positioning tests have poor diagnostic utility as predictors of risk and will not assist the clinician with decision making related to the presence or absence of CAD

Question 29

What are the 4 stages recommended by the Australian Physiotherapy Association in assessing for the presence of S/S associated with VBI

Answer 29

during 4 stages: 1. History 2. Physical examination 3. During Treatment 4. Following C-spine Tx

Question 30

What are the 4 types of dizziness other than Cervicogenic Dizziness (CD)

Answer 30

Presyncope Vestibular Disequilibrium Dizziness

Question 31

How can a PT differentiate cervicogenic dizziness from other types?

Answer 31

Cervicogenic Dizziness (CD) is considered a diagnosis of exclusion. When all other causes of dizziness have been ruled out.,CD is considered. Therefore a thorough Hx and physical exam are necessary to identify pts. with CD, MSK impairments and vestibular disorders appropriate for PT.

Question 32

Define Presyncope

Answer 32

Lightheadedness, impending faintness, Tiredness from altered blood supply, oxygen or glucose

Question 33

What is vestibular dizziness

Answer 33

Vertigo (spinning sensation)

Question 34

What is Disequilibrium?

Answer 34

unsteadiness, imbalance, weakness & sense that fall will occur. Assoc. with poor vision, Peripheral neuropathy or MSK disturbance.

Question 35

What is dizziness?

Answer 35

reports of floating, anxiety, depression & fatigue, suggesting a psychiatric disorder

Question 36

which two types of dizziness will need a referral?

Answer 36

Symptoms of - presyncopal and -other dizziness may indicate the need for a referral.

Question 37

Define Cervicogenic Dizziness

Answer 37

-“a specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activities from the neck"

Question 38

What words would a pt use to complain of dizziness?

Answer 38

Lightheadedness, Faintness, Heavy headedness, Falling, Waving, Imbalance, Swimming sensation, Floating, Unsteadiness or Spinning.

Question 39

Which types of dizziness are appropriate for PT and which are not?

Answer 39

Dizziness caused by cardiovascular or metabolic disorders may result in precautions or contraindications to PT and require medical referral., whereas dizziness related to the cervical spine, musculoskeletal impairments, and the vestibular system may be appropriate for PT intervention

Question 40

Why is cervical spine ligamentous instability so important to identify and

Answer 40

CSI (Cervical Spine Instability) may be a life threatening instability appreciated with imaging

Question 41

What typical disvascular or metabolic disorders may result in precautions or cont?

Answer 41

CSI (Cervical Spine Instability) is often related to the transverse ligament in RA, AS, Down Syndrome, Klippel-Feil Syndrome, Congenital presence of an immature dens leading to compression of neurovascular structures, or described as a minor non-radiographic clinical instability.

Question 42

How would you describe a minor clinical CSI?

Answer 42

A minor clinical CSI is considered a movement impairment with subtle clinical features theorized to involve the active and neutral stabilizing systems without disruption of the passive systems.

Question 43

Why is rheumatic disease important to identify?

Answer 43

RA is the most common inflammatory disease that affects the C spine.

Question 44

What structures are mostly affected by Cervical RA?

Answer 44

The diarthrodial joints are primarily affected, but extra-articular features manifest in the skin, eyes, lungs, and nervous system.

Question 45

What are the risk factors for RA cervical disease?

Answer 45

Male gender, Seropositive rheumatoid factor, rheumatoid nodules, early bone erosion, long standing disease, prolonged steroid use.

Question 46

How does ankylosing spondylitis affect the risk of cervical fracture?

Answer 46

Neck pain can become more of a complaint than LBP in older individuals who have had the disease longer due to bony ankylosis and osteoporosis, the cervical spine is at increased risk of spinal fracture. Low energy falls such as trips and slips involving hyper-extension, may result in neurological deficits from these unstable fractures.

Question 47

What are the symptoms of acute coronary syndrome in both men and women?

Answer 47

Chest pain most common symptom for both men and women.

Question 48

What is acute coronary syndrome?

Answer 48

ACS, caused by insufficient blood supply to the myocardium, is a spectrum of clinical presentations, ranging from--- unstable angina, to MI with non-ST elevation segment elevation myocardial infarction, or ST segment elevation

Question 49

What are the symptoms of acute coronary syndrome

Answer 49

A key sign of ACS in women is: unexplained severe, episodic fatigue that interferes with performing daily activities. Less common signs of MI, especially in women, include: Chest pain (angina) that feels like burning, pressure or tightness Pain elsewhere in the body, such as the left upper arm or jaw (referred pain) Nausea Vomiting Shortness of breath (dyspnea) Sudden, heavy sweating (diaphoresis) Women more likely to have atypical symptoms (compared to men) Younger women more often experience dyspnea compared to younger men.

Question 50

What are the symptoms of cervical myelopathy in the LE and UE?

Answer 50

Clinical features of CM varies, making early diagnosis difficult. The LEs may be affected first with weakness and spasticity, or hyperreflexia affecting gait, often producing a wide-based gait and balance problems. UE changes present as weakness, atrophy, and problems with finger fine motor control. Sensory changes, although inconsistent, may occur later rather than early in the UE and more than in the LE, but UE symptoms have also been an early presentation.

Question 51

What are the 5 tests of the cluster used to rule in or rule out cervical myelopathy?

Answer 51

Hoffman, Babinski’s, Clonus, and Deep tendon reflexes associated with hyperreflexia are more specific than sensitive, and therefore considered better tests for ruling in CM. The inverted supinator sign (i.e. finger flexion or elbow extension during the brachioradialis reflex test) may be the most sensitive test for ruling out CM.

Question 52

What are some additional manifestations of cervical Myelopathy?

Answer 52

Additional manifestations include neck stiffness or pain, pain in the upper quarter region (shoulder, scapula), widespread numbness, paresthesias in both arms or hands, and sensory and ataxic changes of the LE.

Question 53

What are the symptoms of advanced CM?

Answer 53

Advanced CM findings may include paresthesias, quadriparesis and bowel and bladder changes.

Question 54

Talk briefly about the incidence of Cervical myelopathy

Answer 54

Cervical Myelopathy is the most common spinal cord dysfunction in persons over the age of 55., and is present in persons 70 or older, affecting most often persons of Asian descent and males.

Question 55

How can the cluster of 5 tests be used to rule in or rule out cervical myelopathy?

Answer 55

Absence of a + finding, or presence of 1 of 5 tests, provides a moderate level of confidence that the patient does not have CM, whereas 3 of 5 positive test findings assists with ruling in CM. If CM is suspected. based on clinical examination, a referral for additional testing is warranted.

Question 56

What are the 5 Findings that assist in the diagnosis of CM

Answer 56

Age > 45 years Positive Babinski sign Positive inverted supinator sign Positive Huffman Gait dysfunction described as spastic, wide-based gait, or ataxic

Question 57

What are the two main causes of cervical radiculopathy?

Answer 57

Most common is degeneration of the c-spine (which includes loss of disc height, degeneration of disc, osteophytes), second most common is due to disc herniation.

Question 58

What ages does cervical radiculopathy peak at?

Answer 58

Peak age: 4th or 5th decade (50-54 females>males)

Question 59

What is the relative frequency of cervical radiculopathy by level?

Answer 59

C6-7 most common level , 70% of cases (affecting 7th spinal nerve). C5-6 next most common level (affects 6th spinal nerve).

Question 60

What are the typical symptoms for cervical radiculopathy?

Answer 60

Severe burning, shooting, stabbing, or lancinating pain traveling distally into the extremity to a dull ache in the neck and UE

Question 61

How can the cluster of 4 tests help identify cervical radiculopathy ?

Answer 61

4 cluster test CPR: - ULTT A (most useful test when used alone for ruling out CR) - Cervical rotation less than 60 degrees to the involved side - Distraction test - Spurling test A If 3 items are positive, the probability of CR increases 65% If all 4 items are present, the probability of CR increases to 90%. The test item cluster produces larger posttest probability changes for diagnosis of CR than any single test item.

Question 62

Which is more reliable, valid and responsive in neck pain, the NDI or the PSFS?

Answer 62

PSFS

Question 63

Is the interpretation for the FABQ the same in neck pain as for back pain?

Answer 63

NO. The relationship between. Fear related behavior and pain and disability among patients with neck pain is weaker than among LBP.

Question 64

In what age ranges does neck pain peak?

Answer 64

35 to 49 and declines later in life. Younger persons have a better prognosis

Question 65

What body areas should be cleared when examining a patient with neck pain?

Answer 65

Neck circumferentially and thoracic spine Both UE circumferentially Chest and abdomen Head and neck

Question 66

What are some things we should ask for when evaluating C-spine?

Answer 66

Specifically ask for: Numbness, tingling, ``` Other sensory symptoms like: cold, heaviness, dizziness, unsteady nausea, visual disturbances Areas that do not feel normal ```

Question 67

What are the typical areas of pain referral from somatic structures of the cervical spine?

Answer 67

Local to the neck or referred into the thorax, head, face or upper extremity (perceived in an area that shares the same segmental innervation as its source)

Question 68

What is the MCID for neck pain on the NPRS?

Answer 68

MCID of 1.3 = meaningful improvement has occurred from the pt’s perspective In a population with CR the MCID is 2.2

Question 69

Describe the mechanical pattern of night pain

Answer 69

Pt reports inability to lie on the involved side | Symptoms relieved by change in position

Question 70

What do we have to consider if the Pt reports: "pain is most intense at night and is unsure of what wakes her"; reports she must get up and walk around, and has difficulty returning to sleep

Answer 70

Active inflammatory component Neoplasm

Question 71

What do you need to determine about the 24 hour behavior of pain for a good differential diagnosis?

Answer 71

Need to determine: frequency, provocative position and symptoms produced

Question 72

True/False Most musculoskeletal conditions are better in the morning

Answer 72

True

Question 73

True/False If degenerative- stiffness relieved with movement after 30-60 min,

Answer 73

True

Question 74

True/False AS stiffness lasts longer than 60 min

Answer 74

True

Question 75

What is your evaluation of Symptoms that do not vary with daily activities

Answer 75

are minor mechanical problems or suggestive of more serious pathology…

Question 76

Pain Worse in the morning may be due to ........

Answer 76

poor sleeping posture

Question 77

Pain Unchanged in the morning is...

Answer 77

nonmechanical or minor mechanical

Question 78

Improved in the morning and remain better with movement is.....

Answer 78

mechanical with good prognosis

Question 79

Pain Worsen in the morning is .....

Answer 79

mechanical with limited prognosis

Question 80

what is Klippel-Feil syndrome

Answer 80

Klippel-Feil syndrome is a bone disorder characterized by the abnormal joining (fusion) of two or more spinal bones in the neck (cervical vertebrae). The vertebral fusion is present from birth.

Question 81

What is a diarthroidal joint?

Answer 81

A synovial joint, also known as diarthrosis, joins bones with a fibrous joint capsule that is continuous with the periosteum of the joined bones, constitutes the outer boundary of a synovial cavity, and surrounds the bones' articulating surfaces. The synovial (or joint) cavity is filled with synovial fluid.