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Ortho - Cervical Triage > Triage > Flashcards

Triage Flashcards

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1
Q

Define neck pain.

A

Pain/ symptoms perceived to be emanating from the POSTERIOR and/or LATERAL regions of the neck below the occiput and above the scapula/clavicle/sternum.

Symptoms may be referred to the head or UE, BUT the source of these symptoms is perceived to be in the ‘neck’ region

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2
Q

Psychosocial issues are consistent with what broad categories?

A
  1. Pain-related distress (eg anxiety, depression, self-efficacy, kinesiophobia)
  2. Coping cognitions (ie, coping strategies)
  3. Causal beliefs
  4. Perceptions about the future
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3
Q

Clinical assessment of the cervical region should explore what questions?

A
  1. Is the pain coming from the spine, or is there evidence of systemic disease?
  2. Is there evidence of neurological compromise?
  3. Is there evidence of social or pyschological distress that may amplify or prolong pain?
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4
Q

What is thought to be responsible for SOMATIC referred symptoms?

A

The neurophysiological mechanism responsible for these symptoms is thought to be CONVERGENCE

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5
Q

Describe the process of convergence in regards to the cervical spine.

A

The afferent fibers from the cervical structures (eg facet joints) and from the topographically separate area of referred symptoms (eg shoulder region) CONVERGE to communicate/synapse with a common neuron within the dorsal horn.

As a result, a misinterpretation of input occurs so that nociceptive input from the cervical structures is perceived to be coming from topographically separate area of referred symptoms.

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6
Q

What could be another reason for somatic referred symptoms other than convergence?

A

It may also be due to the expansion of receptive fields associated with central nervous system sensitization.

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7
Q

Local symptoms with referral to the head and face are usually produced in what somatic regions?

A

Usually located within the upper cervical spine (occiput - C3)

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8
Q

Why would somatic referral to the face and temporomandibular region occur?

A

Due to the convergence between afferent fibers from C1-C3 spinal nerves and afferent fibers from the trigeminal nerves.

This convergence occurs in the caudal portion of the trigeminocervical nucleus located in the upper cervical spine.

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9
Q

What areas are capable of producing local symptoms with referral to the shoulder, scapular region, and upper extremity?

A

Somatic structures located within the mid and lower cervical spine segments C3-C7, but note referral pattern to the head associated with C3-4 facet joint in symptomatic subjects.

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10
Q

Somatic referral from the low cervical IVDs (Cloward’s areas) cna produce symptoms where?

A

It can produce symptoms along the medial border of the scapula or along the midline of the upper and middle thoracic spine

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11
Q

What is the most common form of nontraumatic headache encountered in the primary care setting.

A

Tension-type headaches (TTH)

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12
Q

How are TTH described?

A

Typically they are described as diffused tightness or pressing without any pulsating quality AND is often bilateral in distribution, (+) or (-) a ‘band around the head’.

Also note, TTH is slightly more common in women.

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13
Q

What are the precipitating factors for TTH?

A

It is often associated with stress.
Physical activity DOES NOT typically aggravate TTH headaches, and usually no relevant impairments will be found in upper cervical mobility.

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14
Q

When are TTH headaches considered CHRONIC?

A

When headaches present for >15 days/month for more than 6/12. Also, when chronic there may be associated symptoms of no more than one of the following:

  1. Nausea
  2. Photophobia
  3. Phonophobia

And typically, there is no vomiting.

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15
Q

What is the second most common form of headache encountered in the primary care setting?

A

Migraine headaches and these headaches are classified as migraine with or without aura.

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16
Q

What is a migraine?

A

Migraine is an episodic headache with certain associated features; such as sensitivity to light, sound, smells, and head movements.

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17
Q

Describe the neurophysiological process of TTH and migraine headaches.

A

Craniovascular nociceptive input reaches caudal portion of the trigeminocervical nucleus via ophthalmic division of the trigeminal nerve and C2 afferents; a complex combination of neural and biochemical mechanisms leads to peripheral and central sensitization of the trigeminovascular system that is manifested as migraine headache.

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18
Q

How are migraines different from TTH?

A

Migraine headaches are most commonly unilateral (may change sides between episodes), are typically more intense than TTH (ie often limit activity), and migraines often have a pulsating/throbbing quality.
Also, physical activity (such as climbing stairs) will typically aggravate migraine headaches.

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19
Q

What are the associated symptoms of migraines?

A

Associated symptoms during the headache include at least one of the following:

  1. Nausea or vomiting
  2. Photophobia
  3. Phonophobia
  4. Dizziness/ vertigo
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20
Q

How would a clinician distinguish a migraine without aura?

A

By asking the following 5 questions: POUNDing!

  1. Is it a Pulsating headache?
    2.Does it last between 4 and 72 hOurs without medication?
  2. Is it Unilateral?
    4,. Is there Nausea or vomiting?
  3. Is the headache Disabling?
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21
Q

What are some nonpharmacologic interventions for migraine sufferers?

A

Regularity in sleeping habits, EXERCISE, avoidance of dietary triggers, and attempting to avoid peaks of stress.

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22
Q

What pharmacologic interventions may be effective for mild to moderate migraine attacks?

A

NSAIDs or aspirin plus acetaminophen

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23
Q

What pharmacologic interventions may be effective for moderate to severe migraine attacks?

A

Triptans (serotonin receptor agonists)

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24
Q

How can you help minimize the chance to develop medication overuse headache?

A

By catching a migraine episode early and using a graded approach to medication

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25
How can you suspect potential MOH?
Experiencing headaches > 15 days/month related to using headache-specific medications such as triptans/opoids > 10 days/month or NSAIDs >15 days/month, both lasting longer than 3 months.
26
What type are cluster headaches?
A type of vascular headache related to vasodilation in the distribution of one external carotid artery. They predominantly occur in men between the ages of 20-50
27
How are cluster headaches described?
They are typically described as sharp, excruciating unilateral headaches of relatively short duration (eg 20-90 minutes compared to 4-72 hours). They can occur one or more times each day for several weeks (ie, cluster period) followed by a period of remission
28
What are associated symptoms of cluster headaches?
1. Forehead sweating 2. Tearing (most common) 3. Ptosis 4. Nasal congestion (most common) These OFTEN occur on the ipsilateral side of pain but occasionally occur on the contralateral side of pain.
29
Briefly describe presentation of cervicogenic headaches?
Pain is more likely to be in the frontal, retro-orbital, occipital, and temporal regions. Head pain is usually associated with neck pain, typically described as a dull ache, and less commonly exhibits a throbbing quality. Also, this type USUALLY DOES NOT limit daily activities.
30
What are symptoms commonly associated with cervicogenic headaches?
Symptoms most commonly unilateral, or unilateral with spread or bilateral that starts off as unilateral and then spreads. HOWEVER, if unilateral will not change sides. 1. Dizziness 2. Blurry vision 3. Nausea (these are not the main features of the headache)
31
What would the behavior and history of cervicogenic headaches reveal to you?
It will reveal a relationship to sustained positions and movements of the neck, and the onset may be insidious or related to trauma
32
What test can accurately identify C1/2 as the symptomatic segment?
Supine passive flexion-rotation test. This can assist in differentiating cervicogenic headache from other headache types.
33
What impairments are closely associated with cervicogenic headaches?
Impairments in strength and endurance of the deep upper cervical flexor musculature.
34
What are effective physical therapy interventions for cervicogenic headaches and tension-type headaches?
Mobilization of upper cervical segments and/or retraining of the deep upper cervical flexor musculature
35
For pts who present with non-traumatic headaches, what situations indicate the need for further diagnostic testing?
1. "First or worst" headache 2. Increased frequency and increased severity of headache 3. New - onset headache after 50 years of age 4. New - onset with history of cancer or immunodeficiency 5. Headache with mental status changes 6. Headache with fever, neck stiffness, and meningeal signs 7. Headache with focal neurologic deficits if not previously documented as a migraine with aura.
36
What are the main clinical features of cervicogenic headaches?
1. Unilaterally without side shift 2. Pain triggered by neck movements/ sustained awkward position 3. Pain elicited by external pressure over the ipsilateral upper, posterior neck region of occipital region 4. Reduced range of motion in the cervical spine 5. Moderate, nonexcruciating pain, usually of a nonthrobbing nature 6. Pain starting in the neck, eventually spreading to oculo-fronto-temporal areas, where maximum pain is usually located.
37
Symptoms of nausea, vertigo, and dizziness are often associated with headache complaints usually due to what?
Due to dysfunction in the peripheral vestibular apparatus, the central vestibular system and/or the cervical segments where proprioceptive input to the central vestibular system is altered.
38
What is vertigo defined as?
Vertigo is a false sensation that the body or the environment is moving, most commonly a rotational/ spinning type of motion.
39
What is true vertigo considered indicative of?
A vestibular problem
40
What is presyncope or near syncope described as?
A sensation of an impending faint associated with change in position such as supine-to-sit or sit-to-stand. As a result, cardiovascular issues need to be explored.
41
How is disequilibrium described as?
As a sense of imbalance with movement or ambulation not associated with a sensation in the head.
42
Disequilibrium may be related to what?
Often a neuromuscular, musculoskeletal, or sensory deficits but it may be related to vestibular disorder
43
What can be effective for treating pts who have cervicogenic dizziness?
Manual therapy (including P-A mobilizations)
44
Somatic referral from C3-C7 motion segments can affect what?
The neck, scapular, shoulder and upper extremity regions.
45
What are the main clinical features of cervical somatic referred pain?
Mechanical behavior of symptoms with corresponding movement impairments in appropriate structures of the cervical spine; also neurodynamic examination and neurological exam for conduction block would be negative.
46
What would cervical nerve root irritation involve?
Nerve root irritation situations involve the upper quarter symptoms related to the cervical spine include relevant findings of nerve sensitivity during neurodynamic testing without deficits in neurological conduction.
47
What would cervical nerve root compromise involve?
It involves evidence of neurological conduction block on clinical examination along with findings or nerve sensitivity during neurodynamic testing.
48
What cluster of tests are identified as being the most useful physical examination procedures?
1. Spurling's test (ipsilateral sidebending with manual compression 2. UNLT1 median 3. Cervical rotation to the involved side < 60 degrees 4. Supine distraction test
49
Radicular symptoms are most common at what cervical levels?
C6 and C7 nerve roots
50
Why could changes at C4/5 levels affect C6 root as well as the C5 root?
Lower cervical rootlets (below C5) pass downward and obliquely before exiting their respective intervertebral foramen; because of this obliquity these rootlets could be affected by changes at a segment above their 'exit level'
51
In younger patients, cervical nerve root problems may be due to what?
Due to disc pathology or some other injury/ process that inflames the nerve root complex
52
In older patients, cervical nerve root problems may be due to what?
Foraminal narrowing secondary to spondylotic osteophytes
53
What anatomical issues provide a partial explanation for the clinical variation in segmental distribution of symptoms associated with cervical nerve root problems?
1. Lower cervical rootlets (below C5) pass downward and obliquely before exiting their respective intervertebral foramen 2. Intradural connections exist between different segmental levels of ventral and dorsal rootlets
54
Age-related changes associated with cervical spondylosis are most common at what levels?
C5/6 and C6/7; fits with C6 and C7 nerve roots being most often involved in patients with cervical nerve root problems.
55
What IVD levels will exhibit irregular pattern of fissuring related to smaller uncinate processes?
IVDs at C5/6 and C6/7 motion segments typically exhibit an irregular pattern of fissuring with subsequent loss of disc space between adjacent vertebrae.
56
What IVDs develop horizontal fissures across the posterior annulus that extend medially; AND what is this due to?
IVDs at C2/3, C3/4, and C4/5 motion segments. And this is due to larger uncinate processes that localize shearing forces during movement.
57
Data suggests that symptoms associated with cervical nerve root problems may depend more on what?
More on changes in the dimensions of the intervertebral foramina, and/or pressure within the UVF, and/or movement of neural tissues within the IVF rather than the size of herniated discs
58
Neuroforaminal pressures decreases with what movement(s)?
Shoulder abduction, which correlates with the 'shoulder abduction relief maneuver' or Bakody's sign
59
What is the most common form of cervical myelopathy?
It is related to the degenerative processes that affect the cervical spine, which is termed cervical spondylotic myelopathy.
60
In cervical spondylotic myelopathy, the degenerative changes in the cervical spine lead to what?
Progressive narrowing of the spinal canal and eventual compression of the spinal cord.
61
What are typical signs and symptoms of cervical myelopathy?
1. Neck and upper limb pain are variable 2. Sensory impairment of upper and lower limbs, latter will not exhibit a dermatomal pattern 3. Lower limb weakness (non-myotomal) and velocity dependent hypertonia (spasticity) 4. UMN signs in the LE 5. UMN related symptoms of bowel and/or bladder dysfunction may also be present
62
What appears to be the most common clinical presentation of cervical spondylotic myelopathy?
A temporal pattern of an initial subtle gait disturbance followed by upper extremity numbness and loss of fine motor control in hands.
63
What has been proposed to be the most sensitive and accurate tests for diagnosis of cervical myelopathy?
Presence of + Hoffman's reflex and hyper-reflexia
64
What systems should be screened in patients with cervical, scapular, and upper/middle thoracic area symptoms?
The cardiovascular, pulmonary, and gastrointestinal systems.
65
The heart can be a common cause of what kind of symtpoms?
It can be a common cause of chest, neck, and arm pain. And it may refer symptoms to the jaw, posterior thorax and epigastrum
66
The lungs and associated structures may cause what type of symptoms?
May cause local thoracic or chest pain, and may refer to the cervical and shoulder regions
67
What could indicate the presence of Pancoast's tumor?
On an AP radiograph, the lack of pulmonary air at the top of the lung combined with other clinical information such as smoking history and/or lack of sustained response to conservative therapy.
68
The GI system may cause pain where?
Anywhere in the torso from the throat to the rectum
69
Peptic ulcer and esophagitis may cause pain where?
In the upper and middle abdomen, midback, chest and neck
70
Diseases of the liver and gallbladder may present with referred pain where?
R shoulder/scapula region
71
Why would Kehr's sign (pain in the left shoulder) occur?
This may occur because of free air or blood in abdominal cavity, such as ruptured spleen causing distension
72
When are primary benign bone tumors of the cervical spine most likely to occur?
In the first two decades of life, and the incidence of primary malignant tumors increases with age
73
Metastatic disease is least and most likely affect what?
It will LEAST likely to affect the cervical spine, but MOST likely affects the thoracic and thoracolumbar regions followed by the lumbar and sacral regions
74
The most likely primary tumors to metastasize to the cervical spine are from where?
Breast, lung, and prostate
75
Identification of cervical metastatic disease on average occurs when?
29 months after the initial cancer diagnosis
76
The route of metastatic spread is most commonly where?
The venous system
77
What is the primary site of metastatic deposits in the cervical spine with spread to other portions of the vertebra as the metastatic disease progresses.
The posterior portion of the vertebral body
78
Regardless of the presence of primary or metastatic disease, what is the most common symptom associated with cervical spinal tumors?
Pain! and severe night pain that is not relieved by position change
79
In the atlanto-axial region, what is more commonly affected and why?
C2 is more commonly affected than C1 due to the relatively large spinal canal in this region. Any neurological involvement in this area is often associated with subsequent instability of the upper cervical segments as opposed to being from direct compression of the tumor.
80
Primary cancer types that are most likely to metastasize to the brain from where?
1. Lung 2. Breast 3. Melanomas
81
What is the most common inflammatory disorder to affect the cervical spine?
Rheumatoid Arthritis
82
What segments of the cervical spine is most commonly affected in RA and why?
The upper cervical segments (Occuput - C2) because the articulations within these segments are purely synovial, including the articulation formed by the transverse ligament between the posterior aspect of the arch of atlas and the base of the odontoid.
83
What is the most common form of upper cervical instability in pts who have RA and what is it due to?
Atlantoaxial subluxation and the majority of them will be anterior; this is due to destruction and laxity of the transverse, alar, and apical ligaments of upper cervical spine
84
How does basilar invagination occur?
This occurs as a result of bone and cartilage loss in the O-C1 and C1-C2 articulations, consequently the cranium starts to descend on the cervical spine and the odontoid process migrates superiorly to potentially compress the brainstem,
85
Bone loss within the lateral masses of C1 and the dens of C2 may be due to what?
A combination of disease processes and decreases in mechanical loading of bony structures which occur as a result of cartilage and ligament degeneration
86
Subaxial subluxations occur at segments?
It occurs at levels below C2 (usually at C2/3 and C3/4). Note that these typically occur late in the disease process
87
What is the most reliable screening tool and predictor of progressive neurological deficit?
The posterior atlantodental interval (PADI), also referred as "space available for the cord" (SAC)
88
What is the most common and earliest clinical indication of cervical involvement in rheumatoid arthritis?
Pain
89
What are all factors correlated with more extensive cervical involvement in rheumatoid arthritis?
1. Multiple joint involvement 2. High seropositivity 3. history of corticosteroid therapy 4. Male
90
What is contraindicated for pts with rheumatoid arthritis who have upper cervical involvement or even suspected upper cervical involvement?
Passive mobilizations; physical referral is required
91
What should be avoided with rheumatoid arthritis pts who have upper cervical involvement and why?
Upper cervical flexion (whether through physiological flexion or neck retraction) and end range rotation should be avoided in order to not faciliate any adverse effects of potential atlantoaxial instability, BUT intermittent use of a cervical collar and gentle isometric exercise may be useful for reducing pain.
92
Describe temporal arteritis/ giant-cell arteritis.
It is the most common vasculitis affecting older people, headache is the most common symptom, and occurs at least twice as often in women than men. RARE THOUGH!
93
Why is awareness of giant-cell arteritis/ temporal arteritis?
Failure to recognize this condition in patients over 50 years of age who present with new type of sudden onset headache of significant intensity CAN LEAD TO PERMANENT VISUAL LOSS since branches of the temporal artery provide blood supply to the retina
94
What is the most practical example of an ongoing pain state where central sensitization may make the dominant contribution to the pt's pain experience?
Persistent symptoms s/p MVA/whiplash associated disorder (WAD)
95
What is recommended for pts who have WAD, regardless of time since onset?
Advised to return to activity, exercise, and impairment-based manual therapy

Ortho - Cervical Triage (1 decks)

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