Cervical spine
3 Tests for Cervical Radiculopathy
1. Axial Compression Test 2. Distraction Test 3. Spurling's Test
Three treatment options for congenital torticolis
1. PT for a year 2. Change the infant's bed and changing table to encourage the infant to look away from the affected side 3. Surgery if persistent - surgery leaves a scar and the appearance of the lateral column of the neck is lost
Interossei, finger flexors nerve root
C8
What type of cervical radiculopathy? weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function), paresthesias in ring and little fingers
C8 radiculopathy (C7-T1)
50% of spinal cord injuries are in the _____________ spine.
Cervical spine
_____________ _________________ is arthritis of the cervical spine that is present in 50% of the population by age 45. Patients present with neck pain which can eventually become radiculopathy (shooting pain down arm due to pressure on a nerve root) and then could become myelopathy (pressure on spinal cord).
Cervical spondylosis
axial pressure on the top of the head increases symptoms and radicular pain; positive test is symptoms are reproduced
Compression test
A ____________ spinal cord injury is damage to neural tissue due to direct trauma and it is irreversible.
Primary spinal cord injury
What is ROB's rule of spine physical exams?
Rule out the bad stuff first
To determine the neurologic level of injury, you test the lowest spinal segment with intact sensation and antigravity muscle function test. In regions where there is no myotome to test, the motor level is presumed to be the same as the
Sensory level
What type of cervical radiculopathy? intrinsic hand muscle weakness, axillary numbness, ipsilateral Horner's syndrome
T1 radiculopathy (T1-T2)
Encroachment on the Spinal Cord Test
Valsalva's test - Valsalva's maneuver (patient attempts expiratory effort while closing their glottis by bearing down as if having a bowel movement) and this increases intrathecal pressure; if this causes pain, that is a positive result **may make cervical radiculopathies/myelopathies worse
Two x-ray views used to evaluate the cervical spine for trauma
1. AP view 2. Lateral view - in lateral view of c-spine one must visualize C7 (bottom of C7 and top of T1) and if C7 is not seen, utilize Swimmer's view or shallow oblique view - check the alignment of anterior vertebral body margins, posterior vertebral body margins, and posterior spinal canal
Intervertebral discs are like jelly donuts. What are the two components of an intervertebral disc?
1. Annulus (type 1 collagen) - peripheral or outer disc 2. Nucleus pulposus (type n collagen) - central part of disc; the jelly in the jelly donut
Five supporting ligaments of the spine
1. Anterior longitudinal ligament - covers a lot and is strong 2. Posterior longitudinal ligament - does not cover a lot and is a weak spot; discs tend to bulge out through this ligament 3. Ligamentum flavum 4. Interspinal ligament 5. Nuchal ligament - equivalent to the supraspinous ligament in the thoracic and lumbar spine
Three associated injuries of spinal cord injury
1. Closed head injuries - steroid not helpful with head injury 2. Noncontiguous spinal fractures 3. Vertebral artery injury - risk factors include atlas fractures and facet dislocations
You cannot evaluate neurologic deficit in a spinal cord injury until spinal shock phase has resolved. The end of spinal shock is indicated by the return of the bulbocavernosus reflex. What two types of injuries may lead to permanent loss of the bulbocavernosus reflex?
1. Conus medullaris injury 2. Cauda equina injury
ASIA Classification System is the American Spinal Injury Association standards for neurological classification of spinal injury patients. Classification levels are A, B, C and D, all with differing levels of function and/or lack thereof. What are four characteristics of a complete injury?
1. No voluntary anal contraction (sacral sparing) 2. 0/5 distal motor 3. 0/2 distal sensory scores 4. Bulbocavernosus reflex present (patient not in spinal shock during test)
Seven treatment options for cervical radiculopathy
1. Physical therapy 2. NSAIDs 3. Steroids - Methylprednisolone (Medrol dose pack) 4. Tricyclic antidepressants 5. Injections 6. Traction 7. Surgery - anterior cervical discectomy and fusion (ACDF) is the most common surgery for discs in the cervical spine, but the problem with this surgery is that after a while the problem is transferred to neighboring discs; cervical artificial disc is the solution for preventing adjacent disease but you can only correct one level (max two levels) at one time
Four classifications of spinal cord injuries
1. Tetraplegia - injury to cervical spinal cord leading to impairment in function of the arms, trunk, legs, and pelvic organs 2. Paraplegia - injury to the thoracic, lumbar or sacral segments of the spinal cord leading to impairment of function in the trunk, legs, and pelvic organs 3. Complete injury - injury with no spared motor or sensory function below the affected level 4. Incomplete injury - injury with some preserved motor or sensory function below the injury level
ASIA Classification System is the American Spinal Injury Association standards for neurological classification of spinal injury patients. Classification levels are A, B, C and D, all with differing levels of function and/or lack thereof. What are four characteristics of an incomplete injury?
1. Voluntary anal contraction (sacral sparing) 2. Palpable or visible muscle contraction below injury level 3. Perianal sensation present 4. Bulbocavernosus reflex present (patient not in spinal shock during test)
Blunt force trauma to the suboccipital triangles can cause hemorrhage of which arteries?
Verterbal arteries - vertebral arteries pass through the suboccipital triangles
______________ is a cervical sprain usually caused by an acceleration/deceleration or flexion/extension injury.
Whiplash
What are these seven symptoms of? 1. Neck pain and stiffness 2. Axial neck pain (often absent) 3. Occipital headache - common 4. Extremity paresthesias - diffuse, bilateral non-dermatomal numbness and tingling 5. Weakness and clumsiness - bilateral weakness and decreased manual dexterity 6. Gait instability - patient feels unstable on feet, weakness walking up and down stairs, gait changes are most important clinical predictor 7. Urinary retention - rare and only appears late in disease progression
cervical myelopathy
What are these six symptoms of? 1. Occipital headache - common 2. Trapezial or interscapular pain 3. Neck pain - patients may present with insidious onset of neck pain that is worse with vertebral motion and pain may radiate to shoulders 4. Unilateral arm pain - aching pain radiating down arm; often global and not dermatomal 5. Unilateral dermatomal numbness and tingling - numbness and tingling in thumb (C6) and numbness tingling in middle finger (C7) 6. Unilateral weakness (follows myotome) - difficulty with overhead activities (C7) and difficulty with grip strength (C7)
cervical radiculopathy
There are seven cervical vertebrae and eight cervical nerve roots. Nerve roots exit above the cervical vertebra of the named level (C3 nerve root exits above C3 vertebra). Nerve root impingement by a herniated cervical disc will affect the exiting nerve root. What nerve root will a C6-7 herniated disc affect?
C7 nerve root
What is the most commonly affected nerve root in cervical radiculopathy?
C7 nerve root
In the cervical spine, you can have a herniation of the central disc or of the foraminal disc (lateral). Due to the horizontal anatomy, herniation of both discs affect the same nerve root. What nerve root will be affected by herniation of C6-7 central disc and what nerve root will be affected by herniation of C6-7 foraminal disc?
C7 nerve root will affected by both
What type of cervical radiculopathy? triceps and wrist flexion weakness, diminished triceps reflex, paresthesia in the middle finger
C7 radiculopathy (C6-7)
The vertebral arteries are a branch from the subclavian arteries and they supply the spinal cord and vertebrae in the spinal column. When we look up towards the sky and extend the cervical spine, the subclavian arteries get pinched off. What arteries supply the spinal cord, vertebrae, and brain when the subclavian arteries are pinched off due to the cervical spine being in an extended position?
Carotid arteries - dizziness when looking up is most likely due to carotid artery obstruction
____________ ________________ is impingement on the spinal cord in the cervical spine. Etiologies include spondylosis, HNP (herniated nucleus pulposus), ossification of the posterior longitudinal ligament (common in Japan), direct cord compression, repetitive trauma or vascular compromise and neuroischemia.
Cervical myelopathy
______________ __________________ is impingement on a nerve root in the cervical spine (nerve root is being mashed). Peak incidence is 50-54 years and risk factors include white race, cigarette smoking, and prior lumbar radiculopathy. Impingement affects the nerve root below (C6-7 disease will affect the C7 nerve root).
Cervical radiculopathy
_________ _____________ fracture is an avulsion of the spinous process of a lower vertebrae, usually C7. It is a stable fracture. **CAUSED BY FLEXION
Clay shoveler's fracture
_________________ ______________ is a neck deformity that involves shortening of the sternocleidomastoid (SCM) muscle which leads to limited range of motion. It is often associated with breech delivery, OB maneuvers or intrauterine compartment syndrome/fetal presentation.
Congenital torticolis
Which Infant Brachial Plexus Palsy physical exam findings? What nerves are involved? -shoulder add. -Arm Int. Rot. -Elbow ext. -Forearm pronated -wrist flexed -Hand spared
Erbs C5,6 (most common)
Which cervical myelopathy test? -Ask the patient to hold his/her fingers in adduction and extension. The test is positive if the ring and small fingers gradually flex and abduct.
Finger escape test
_________ syndrome is the occurrence of atlanto-axial rotary subluxation (AARS) in association with inflammation of adjacent soft tissues, most often due to an upper respiratory infection.
Grisel syndrome
________________ fracture is a fracture of C2 pedicles with anterior displacement and it is common in diving accidents. It may be without neurological deficit but it is an unstable fracture. **CAUSED BY EXTENSION
Hangman's fracture - spondylolisthesis (slippage) of C2
Motor and sensory deficit of UE due to injury to the brachial plexus during delivery
Infant Brachial Plexus Palsy
______________ fracture is a fracture of C1. It occurs when occipital condyles are driven into C1, forcing the lateral masses apart. It is often associated with rupture of the transverse ligament and it is an unstable fracture.
Jefferson fracture
Which Infant Brachial Plexus Palsy physical exam findings? What nerve roots are involved? •Forearm supinated -claw hand (hyperextension at the metacarpophalangeal joints and flexion at the interphalangeal joints) +/-Horners syndrome*
Klumpkes: C7,8,T1
In the lumbar spine, nerve roots exit below the pedicle of their named root (L4 nerve root exits below the pedicle of L4). Nerve roots are impinged by a herniated disc above the pedicle. What nerve root will a L3-4 herniated disc affect?
L4 nerve root
The first thing to do in work-up for cervical myelopathy is to rule out other stuff. What is the best imaging modality for cervical myelopathy?
MRI
What is the diagnostic study of choice for cervical radiculopathy?
MRI
What type of steroid is used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals?
Methylprednisone
Spinal cord injuries are the result of significant trauma in young individuals. What about in older individuals?
Minor trauma compounded by degenerative spinal canal narrowing can cause spinal cord injuries.
Atlantooccipital and atlantioaxial dislocation with fracture can lead to internal decapitation which is highly unstable and has high ______________. It is incompatible with life.
Mortality
__________________ shock is characterized by hypotension and relative bradycardia in a patient with an acute spinal cord injury and it is potentially fatal. Circulatory collapse from loss of muscle tone leads to disruption of autonomic pathway within the spinal cord and lack of sympathetic tone. This results in decreased systemic vascular resistance, pooling of blood in extremities, and hypotension.
Neurogenic shock
The _______________ view x-ray is an AP open mouth view of the atlantoaxial articulation that is used to look at C1 & C2 vertebrae.
Odontoid view
Young patients with cervical spine issues tend to develop instability. What do older patients with cervical spine issues tend to develop?
Osteoarthritis
Four stages of spinal shock
Phase 1 - Hyporeflexic Phase 2 - Initial reflex return Phase 3 - Initial hyperreflexia Phase 4 - Spasticity
What is the goal of treatment for cervical myelopathy?
Prevention of continued neurologic decline
A ___________ ___________ fracture is a fracture of the anterosuperior end plate of the vertebral body. If it is associated with posterior ligament disruption, it is considered an unstable injury. It differs from a burst fracture in that there is no vertical element to the fracture.
Simple wedge fracture
__________ shock is the temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury. It is characterized by flaccid areflexic paralysis, bradycardia and hypotension (due to loss of sympathetic tone), and an absent bulbocavernosus reflex. Duration is variable but it usually resolves within 48 hrs.
Spinal shock
lateral flexion and rotation with compression causes nerve root encroachment and pain on the side of the nerve root encroachment; if positive, symptoms should reproduce the patients' radicular pain
Spurling's test
Encroachment on the Anterior Cervical Structures Test
Swallowing test - difficulty or pain on swallowing may be a sign of anterior cervical pathology; used to evaluate the articular masses
What is the Lhermitte test?
Tests for cervical myelopathy and multiple sclerosis Pt is asked to maximally flex the cervical and thoracic spine Positive: numbness or tingling -> pain
Two treatments for neurogenic shock
1. Swanz-Ganz monitoring for careful fluid management 2. Pressors to treat hypotension
What type of cervical radiculopathy? brachioradialis and wrist extension weakness, diminished brachioradialis reflex, parasethesias in thumb, index finger
C6 radiculopathy (C5-6)
Triceps, wrist flexors, finger extensors nerve root
C7
What type of injury can twisting and bending movement of the spine contribute to?
Disc tears
Simple wedge fracture with a flexion mechanism of injury is considered _________
stable
What type of mechanism causes a Jefferson fracture?
vertical axial compression & extension
What are these four physical exam findings of? 1. Sore neck with no radiation of pain 2. Decreased ROM 3. Neurologically intact neuro exam 4. No deformity
whiplash (cervical sprain)
Compression of a portion of the brachial plexus (most commonly the lower portion [C8, T1]) and the axillary artery
thoracic outlet syndrome
What are the two places where spine movement occurs?
Discs and facet (apophyseal) joints - facet joints are flat, so they are more moveable but less stable
traction on the head relieves radicular symptoms
Distraction test
A _____________ strain is a very common cervical spine strain. Patient presents with pain localized to the posterior cervical region and pain is reproducible with palpation of the trapezius muscles.
Trapezial strain
Three types of odontoid fractures
Type I - fracture at the tip superiorly; avulsion of the tip of the dens at the insertion site of the alar ligament and the fracture is stable Type II - fracture at the junction of the odontoid and the vertebral body; most common Type III - fracture through the superior portion of C2 at the base of the odontoid
What is a positive result from the Hoffmann reflex indicative of?
upper motor neuron lesion affecting the upper extremity in question - cervical myelopathy
Six causes of nerve root impingement
1. Degenerative cervical spondylosis - bone pressing on nerve root; discosteophyte complex (osteoarthritis) complex and loss of disc height due to jelly leaking out of disc; chondrosseous spurs of facet and uncovertebral joints 2. Disc herniation - soft disc pressing on nerve root; intraforaminal herniation with radicular pain predominantly 3. Posterolateral - most common; between posterior edge of uncinate and lateral edge of PLL (posterior longitudinal ligament); mostly motor symptoms 4. Midline herniation - usually presents with myelopathic (impingement on spinal cord) symptoms 5. Double crush phenomenon - combined cervical root compression and distal nerve compression (patient has problems in neck and also in arms or wrists); decreased axoplasmic flow from root compression predisposes downstream nerves to peripheral entrapment syndromes 6. Rare causes - intraspinal/extraspinal tumors, trauma with nerve root evulsion, synovial cysts, meningeal cysts, dural arteriovenous fistulae, tortuous vertebral arteries
Neck pain in cervical radiculopathy is due to nerve root irritation. What are two causes of nerve root irritation?
1. Direct compression 2. Irritation by chemical pain mediators (IL-1, IL-6, substance P, TNF alpha, prostaglandins)
Four tests for cervical myelopathy
1. Finger escape test 2. Grip and release test 3. Babinski Test 4. Sustained clonus
What are the results of the gait and balance, Romberg test, and provocative tests in a physical exam of a patient with cervical myelopathy?
1. Gait and balance - patient has difficulty performing toe to heel walk 2. Romberg test - patient stands with arms held forward and eyes closed and loss of balance is consistent with posterior column dysfunction 3. Provocative tests - Lhermitte sign positive (test is positive when extreme cervical flexion leads to electric shock like sensations that radiate down the spine and into the extremities)
In the lumbar spine, you can have a herniation of the paracentral disc (center) or the far lateral disc. Die to the vertical anatomy, each herniation affects a different nerve root. What nerve root will be affected by herniation of L4-5 paracentral disc? What nerve root will be affected by herniation of L4-5 far lateral disc?
1. Herniation of L4-5 paracentral disc will affect the L5 nerve root 2. Herniation of L4-5 far lateral disc will affect the L4 nerve root
3 Reflexes tested for cervical myelopathy
1. Hoffmann reflex - thumbnail presses down on pt's fingernail and move downward until nail clicks 2. Hyperreflexia - may be absent when there is concomitant peripheral nerve disease such as in diabetes or spinal stenosis 3. Inverted radial reflex - appreciated by tapping the distal brachioradialis tendon produces ipsilateral finger flexion
Three treatment options for Atlanto-axial rotary subluxation (AARS)
1. Initial management (< 1 week since onset) - immobilization in a soft collar and pain medications 2. If no relief with first option or if presenting at over a month since onset, then try traction 3. If the two options above don't work, try fusion (surgical approach for refractory cases)
What are three non-operative treatments of cervical myelopathy?
1. Medications (NSAIDs, Gabapentin) 2. Immobilization - hard collar in slight flexion 3. Physical therapy for neck strengthening, balance, and gait training
Non-operative treatment for cervical myelopathy includes observation, NSAIDs, therapy, and lifestyle modifications. What are three indications for non-operative treatment?
1. Mild disease with no functional impairment 2. Function is a more important determinant for surgery than physical exam finding 3. Patients who are poor candidates for surgery
Three treatment options for cervical spondylosis
1. NSAIDs 2. Cervical pillows (C-pillows) 3. Surgery for increased pain and neuro deficits due to radiculopathy or myelopathy
The treatment for a trapezial strain is supportive. What are two treatment options?
1. NSAIDs 2. Physical therapy
Work up for whiplash includes x-ray with flexion extension views prn. You need to rule out other stuff such as spinal cord injury without radiographic abnormality (SCIWRA) in children. What are two symptoms that a child with SCIWRA will have that differentiates it from whiplash?
1. Neuro deficits 2. May have spinal shock
Four tests used for TOS
1. Supraclavicular Pressure Test 2. Halstead Test 3. Wright's Test 4. Cyriax Release Test
Four stages of disc herniation
1. Protrusion/degeneration - disc protrusion with nucleus pulposus penetrating asymmetrically through annular fibers but confined within the annular margin 2. Prolapse 3. Disc extrusion - nucleus pulposus extends beyond the annular margin 4. Sequestered disc - disc sequestration with nuclear fragment separated from extruded disc
Characterization of three main symptoms seen in cervical spine issues
1. Radicular pain - pain that radiates (shoots down) peripherally along the distribution of an affected nerve root (herniated nucleus pulposus, cervical spinal stenosis) 2. Mechanical pain - instability, disc disease 3. Mechanism of injury/onset of symptoms - onset is normally not as clear with cervical spine issues compared to lumbar spine issues (patient may say they just woke up that morning with neck pain)
What are three indications for operative treatment for cervical myelopathy?
1. Significant functional impairment 2. 1-2 level disease 3. Lordotic, neutral or kyphotic alignment
Two components of treatment for whiplash (cervical sprain)
1. Soft collar for 1-2 weeks with NSAIDs and muscle relaxants - most improve by 4-6 weeks but if it is severe, it may take 6-12 months 2. Encourage early return to ADLs so that patients don't develop a disability mindset
Two acute phase conditions of spinal cord injury
1. Spinal shock 2. Neurogenic shock
___________-________ __________ subluxation is a rotational displacement of C1 and C2. Children ages 2-12 are most commonly affected. It is associated with minor trauma or URI (Grisel syndrome).
Atlanto-axial rotary subluxation (AARS)
The __________________ joint is the articulation between C1 (atlas) and C2 (axis). It does rotational movement.
Atlantoaxial joint
An ______________ _____________ fracture is a teardrop fracture with an anteroinferior vertebral body fracture. It is associated with anterior cord syndrome. If it is associated with complete disruption of ligaments, it is considered an unstable fracture.
Anterior teardrop fracture **UNSTABLE FX
Brachioradialis, Wrist extensors nerve root
C6
Arm abduction sign is used to test for cervical radiculopathy. The patient's cervical radiculopathy symptoms are relieved when the patient does what?
Bakody/Arm abduction sign When the patient abducts their arm and holds the top of their head with their arm
What reflex do you check to determine if a patient is in spinal shock?
Bulbocavernosus reflex - I squeeze you, you squeeze me
A _________ fracture is a fracture that occurs when an axial load causes the vertebral body to burst. It involves both end plates and may intrude into the spinal cord. It is an unstable fracture.
Burst fracture
There are seven cervical vertebrae and each has foramina in each transverse process. What makes C1 (atlas) and C2 (axis) special and different from the other cervical vertebrae?
C1 (atlas) has no body or spinous process. C2 (axis) has the odontoid process (dens) and both superior and inferior articular facets.
What type of cervical radiculopathy? scapular winging, numbness and pain at the base of the neck
C4 radiculopathy (C3-4)
Deltoid & Biceps nerve root
C5
What type of cervical radiculopathy? deltoid and biceps weakness, diminished biceps reflex, pain and numbness in the superior shoulder and lateral upper arm
C5 radiculopathy (C4-5)
Which cervical myelopathy test? -The patient is asked to grip and release the fingers as rapidly as possible, with the arm in the same position. Normal adults can perform such rapid grip & release movements more than 20 times in 10 seconds
grip and release test
