Cervical Spine Anatomy and Pathology
Natural Course
- "Good Recovery": Initial mild-to-moderate disability after the accident, 45% of patients - "Moderate Recovery": Initial moderate-to-severe pain-related disability, 39% of patients - "Bad Recovery": Starts with moderate-to-severe disability, progress to some recovery with moderate-to-severe levels of disability at 1 year, 16% of patients
Uncovertebral joints
- (AKA Joints of Von Luschka, Joints of Luschka, or Luschka's Joints) - Present from C3-C7 - Superior projection from the lateral aspects of the vertebral bodies...Thought to reinforce the disc posterolaterally and provide protection for structures at risk of disc herniation - Allow motion in multiple planes and assist in limiting motion: Guides motion, Limit isolated lateral flexion
Tprticollis (acute/acquired)
- 20+ y.o. - spasm of 1+ mm (SCM, splenius capitis, semispinalis capitus, ant scalene) - common cause = trauma/muscle strain - other causes: URTI, viral infection, poor posture, hearing issues - presentation: unilat pain, decreased ROM, severe pain at end range testing, strong but uncomfortable resisted isometric strength testing - treatment: usually resolves in 7 days to 2weeks, 24 hrs rest/heat/ice, soft tissue and joint techniques/modalities/NSAIDS
Cervical Spondylosis
- AKA arthritis, degen disease - normal aging process: age 40+ - loss of mechanical integ of disc leading to instability to affected segment and degenerates from there - asymptomatic radiologic findings (50% spondylotic changes by age 50, 90% by age 65) - Disc degenerates: nucleus loses turgor, gel-like tissue begins to fibrose (becomes similar to annular fibrosis) - loss of disc height leads to overriding/overlapping of zygapophyseal jts/facet jt (damaging articular cartilage) - leads to translational instability and loss of arthrokinematic control - that leads to formation of protective osteophytes to limit the movement - anterior lipping, hypertrophy of uncovertebral jts/joint of von luschka (present in 85% >65 y.o., most common c5-6 and c6-7, symptoms between 35-55 y.o.) - OA is later stage --> can include hypertrophy of ligamentum flava, osteophyte encroachment into IVF of central canal - DDD goes from normal to loss of integrity which causes hyper mobility and then body responds to try to stabilize it
Whiplash
- AKA cervical strain, cervical sprain, acceleration/deceleration injury, WAD - Quick change in direction or movement, often with a snap - Common: Flexion often combined with some rotation followed by rapid extension or vice versa - Extent of injury depends on amount of force - Other factors: Position of head at impact, Awareness of impending impact, Condition of the neck tissues - Rear impact = greatest disability due to ext force and no bracing because blindsided
Lower Cervical Ligaments
- ALL - PLL - interspinous - supraspinous - ligamentum nuchae - ligamentum flavum - think about whiplash pt
8 pairs of cervical nn
- All exit above the corresponding numbered vertebrae with exception of C8 - C5 nerve root exits superior to C6 - C8 nerve root exits superior to T1 - All nerves from there down (thoracic and lumbar) exit below the corresponding vertebrae - bony structure: uncovertebral joints, joints of von luschka
Acute Pain (Including WAD)
- Also under the Neck pain with Movement Coordination Impairments - Symptoms: High pain and disability scores, Recent history of trauma, Referred symptoms into upper extremity
Common sites of compression with thoracic outlet syndrome
- Anterior/middle scalenes and first rib (scalene triangle) - Costoclavicular space - Pectoralis minor / coracoid process - Presence of cervical rib
Common pathologies in c-sp
- Cervical Hypermobility - Whiplash - Cervical Hypomobility - Degenerative Disc Disease - Herniated Disc - Spinal Stenosis - Torticollis - Cervical Radiculopathy - Headache - Vestibular/BPPV
Interventions with neck pain with headaches
- Cervical and thoracic mobilization/manipulations - Strengthening, endurance, and coordination exercises for the neck and postural muscles - Postural education
Interventions with neck pain with mobility deficits
- Cervical mobilization/manipulations - Thoracic mobilization/manipulations - Stretching and mobility exercises - Coordination, strengthening, and endurance exercises
Upper Thoracic Spine
- Clinically motion here assists cervical motion (up to 25%) - Examination and intervention here helps cervical spine
C2-C7
- Commonly refers into upper extremity - Superior facets (approx. 45 deg angle) -->Upward, backward, and medially - Inferior facets: Down, forward, and lateral - Facilitates flexion and extension - Side bending and rotation occur to some degree together: Couple movement pattern - "im down for that" = im down for lat (orientation of inferior facets (downward, forward, lat)...move ant and superior - flexion (BIL fwd/sup (ventral/cranial) - right SB (rot right, dorsal caudal on right and ventral cranial on left) - extension: bilat backward/downward (dorsal/caudal)
Thoracic Outlet Syndrome
- Compression of neurovascular structures as they course from the cervical region to anterior chest/shoulder.
OA (C0-C1)
- Convex occipital condyles on concave superior articular surfaces of atlas - Primary motion is flexion/extension (24-30 deg, "Nodding motion") - Smaller amounts of rotation/SB
Interventions with neck pain with movements coordination impairments
- Coordination, strengthening, and endurance exercises - Stretching exercises - Mobilization/manipulation above and below hypermobilities - Ergonomic corrections
Factors assoc with delayed recovery
- Decreased cervical spine mobility immediately after injury - Pre-existing neck trauma - Older age - Female - Psychosocial factors - Pending litigation
Disc
- Evidence of fibrosis of the nucleus pulposus by mid-teens - Annulus fissures by middle age from sheering forces with rotation
Pathological Considerations
- Facet degenerative changes: Bone spurs - Disc degeneration/herniation - Combination: Nerve Root Sandwich - Nerve stretch
Motion of C2-C7
- Flexion - Extension - Right Side Bending/Rotation
Intervention with Acute Pain (including WAD)
- Gentle AROM within patient tolerance - Activity modification to control pain - Relative rest - Physical modalities - Intermittent use of cervical collar - Gentle manual therapy and exercises but avoidance of pain-inducing manual therapy techniques or exercises
Internal Carotid dissection nonischemic s&s
- Head/neck pain - Horner's syndrome - Pulsatile tinnitus - Cranial nerve palsies - *Nonischemic s/s may precede ischemic events by a few days to several weeks*
Impairments with neck pain with headaches
- Headache pain elicited by pressure on posterior neck, especially at one of three upper cervical joints - Limited cervical ROM - Upper cervical (C1-C2) segmental mobility deficits noted with flexion rotation test - Strength and endurance deficits of the deep neck flexor muscles
Main S&S
- History of trauma - Catching, locking, giving way - Poor muscular control* - Excessive end feel - Signs of hypermobility on x-ray
Impairments with neck pain with movment coordination impairments
- Hypermobility with loose end feels of cervical motion segments - Strength, endurance, and coordination deficits of deep cervical spine flexor and extensor muscles - Aberrant motion with cervical AROM - Greater cervical AROM in supine (non-weight bearing) position - Neck and neck-related UE pain reproduced with provocation of the involved cervical segments
ICF: Neck pain with mobility deficity
- ICD Diagnoses: Cervicalgia, Pain in thoracic spine - Clinical findings to help classify this disorder: Younger individual (age <50 years), Acute neck pain (duration < 12 weeks), Symptoms isolated to the neck, Restricted cervical ROM
ICF: Neck pain with headaches
- ICD Diagnoses: Headache, Cervicocranial syndrome - Clinical findings to help classify this disorder: Unilateral HA associated with neck/suboccipital area that are aggravated by neck movements or positions, HA produced or aggravated with provocation of the ipsilateral posterior cervical myofascia and joints, Restricted cervical ROM, Restricted cervical segmental mobility, Abnormal/substandard performance on the cranial cervical flexion test
ICF Neck pain with radiating pain
- ICD Diagnoses: Spondylosis with radiculopathy, & Cervical disorder with radiculopathy - Clinical findings to help classify this disorder -- Upper extremity symptoms, usually radicular or referred pain, that are produced or aggravated with -- Spurling's maneuver and upper limb tension tests, and reduced with the neck distraction test -- Decreased cervical rotation (<60 deg) toward the involved side -- Signs of nerve root compression -- Success with reducing upper extremity symptoms with initial examination and intervention procedures
ICF Neck pain with movement coordination impairments
- ICD Diagnoses: Sprain and strain of the cervical spine - Clinical findings to help classify this disorder: - Longstanding neck pain (duration > 12 weeks) - Abnormal/substandard performance on the cranial cervical flexion test - Abnormal/substandard performance on the deep flexor endurance test - Coordination, strength, and endurance deficits of neck and upper quarter muscles (longus colli, middle trapezius, lower trapezius, serratus anterior)) - Flexibility deficits of the upper quarter muscles (Anterior/middle/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor and major) - Ergonomic inefficiencies with performing repetitive activities
Impairments with neck pain with mobility deficits
- Limited cervical ROM - Neck pain reproduced at end range of active and passive motions - Restricted cervical and thoracic segmental mobility - Neck and neck-related UE symptoms pain reproduced with provocation of the involved cervical or upper thoracic segments
Impairments with Acute Pain (including WAD)
- Limited/guarded cervical AROM - Poor tolerance to manual examination procedures
AA (C1-C2)
- Most mobile articulation - Primary motion is rotation: Up to 40-45 deg, Odontoid process of C2 is pivot point for rotation, Some smaller amounts of flexion, extension, and side bending (lateral flexion) - One location where stress is placed on vertebral artery - Horizontal orientation of facets, rt rotation, right post, left ant
International Classification of Functioning, Disability, and health (ICF)
- Neck Pain with Mobility Deficits: Cervical Hypomobility - Neck Pain with Headaches: Cervicogenic Headaches - Neck Pain with Movement Coordination Impairments: Cervical Spine Instability - Neck pain with Radiating Pain: Cervical Radiculopathy
Impairments with neck pain with radiating pain
- Neck and neck-related radiating pain reproduced with the following: - Spurling A Test - ULNT Test 1 - Neck and neck-related radiating pain relieved with cervical distraction - May have UE sensory, strength, or reflex deficits associated with involved nerves
Vertebrobasilar Artery Insuff
- No common but significant if found - Injuries can lead to: Thrombotic occlusion, Artery dissection, CVA, Death - Arterial supply to the brain: Vertebral Artery = 20% , Internal Carotid = 80% - VA's course from C2 to entering the skull, Common area of "kink"
Vertebral Artery Dissection presentation
- Nonischemic s/s (Ipsilateral posterior neck pain, Occipital headache) - Ischemic s/s: Hindbrain TIA, Dizziness, diplopia, dysarthria, dysphagia, drop attacks, nausea, nystagmus, facial numbness, ataxia, vomiting, Hindbrain Stroke , Wallenberg's syndrome (lateral medulla)/ Locked-in syndrome, Cranial nerve palsies
C2-C3
- Not considered part of upper cervical spine, however, will have influence on the amount of motion occurring in upper cervical spine - Alar ligaments: Side bending of occiput results in opposite rotation of C2, Could give you a false positive for Alar ligament test, Check joint play at C2-C3 (C2/C3 must move appropriately to full ROM sidebend) - Why is this important? Restriction of either C2-C3 or C0-C1 can be mistaken for rotational motion loss at C1-C2, Need to accurately assess all 3 segmental levels - Don't just assume that only C1-C2 is responsible for rotational loss of motion
Cluster's Last Stand headache
- Occur in cyclical patterns (clusters) - One of the most painful types - Intense pain around one eye or side of head - Lasts from weeks to months - Remission - no headaches for months/sometimes years - tearing - redness in eye - stuff or runny nose - sweating - drooping eyelid
Cervicogenic Headaches
- Pain referred to the head from a source in the spine - C2-3 common source - Complex syndrome with varied pathophysiology - Musculoskeletal - Sensory nerves - Nerve roots - Ligaments - Discs - Dura mater - rectus posterior - Interconnections of the trigeminal nerve and 1st 3 levels of the c-spine - poor differentiation - Central sensitization of the CNS may explain chronicity - Occurs in up to 53% of patients after WAD - Most distinct criteria for diagnosis is presence of trauma
Non-coupled patterns for lower cervical
- SB and rot opposite
Coupled patterns lower cervical
- SB and rot same side
non-coupled patterns upper cervical
- SB and rot same side
Cervical Myelopathy
- Spinal cord compromise: Stenosis, spondylosis, disc, trauma, tumor - Leads to compression and ischemia of the spinal cord (Anterior > Posterior) - Disrupts normal neural transmission: Arms, Hands, Legs, Bowel/bladder - Signs/symptoms variable depending on level - Surgical Treatment: Anterior cervical discectomy and fusion (ACDF), May or may not result in clinical improvement
Cervical Spine anat
- Stability is sacrificed for mobility - Sits between a heavy head and stable thoracic spine - Levels with most mobility = more likely to see degeneration at those levels - Greatest flexion/extension C5-C6 (most mobility, generally fusion at this level for stability if needed) - Also C4-C5 and C6-C7. - Resting Position: Slight extension - Closed Packed Position: Bilateral: Full extension; Unilateral: Extension, SB, and rotation to same side - Capsular Pattern: Side flexion and rotation equally limited, extension - Divided between Upper and Lower Cervical Spine
Classic Findings with cervicogenic headache
- Symptoms primarily unilateral usually after some strain/movement to the cervical spine - Can be bilateral especially in more severe cases - Pain in neck/suboccipital region - Radiating to frontotemporal and orbital regions - Presents with limited ROM - Rotation in flexion (test we'll learn in lab) - Limited function in upper cervical segments - Validity of clinical diagnosis is questionable/contraversal: Controlled diagnostic blocks - Mixed headaches can occur - Most headaches occur in females
Vestibular complications
- Symptoms similar to vertebral artery dissection - Dizziness - Lightheadedness - Nausea and vomiting - Nystagmus
Internal Carotid Artery dissection ischemic S&S
- TIA - Ischemic stroke - middle cerebral artery - Retinal infarction
Interventions with neck pain with radiating pain
- Upper quarter and nerve mobilization procedures - Traction (manual and/or mechanical) - Craniocervical flexion exercises - Postural exercises - Thoracic mobilization/manipulation
S&S with thoracic outlet syndrome
- Vague shoulder pain/achiness - Sense of heaviness in the shoulder - Neurogenic signs are rare but can occur (Numbness, tingling, weak grip, loss of dexterity) - Vascular signs and tests that reproduce patient's symptoms along with decreased/diminished pulse -- Arterial: Cool pale extremity -- Venous: Swelling, mottled discoloration
Cervical hypermobility secondary to
- Whiplash - OA / RA - Segmental degeneration - Trauma - Genetic predisposition
Whiplash Associated Disorders
- Whiplash injury that leads to a variety of clinical manifestations - Symptoms can occur immediately or be delayed: Aching/stiffness of the neck, Possible difficulty swallowing, Injury to esophagus and laynyx, Headache (Most common in occipital area, can radiate to temples, vertex of skull or retro ocular), Pain into scapula, chest, and/or shoulders - Treatment of WAD varies based on the presentation - Concussion can occur also - Important to quantify and address mTBI symptoms early to target an appropriate treatment - For more details see my concussion advance topics course in approximately 1 week from now.
Facet Joint Pathology
- aka apophyseal or zygapophyseal joint syndrome - increased load causes: synovial reaction (manifests itself as a muscle spasm and pain referred to a specific area), cartilage fibrillation, erosion of joint - possible catch/inflamm of meniscoid - clinical assessment: watching AROM and which motion causes pain, capsular pattern
Diagnostic Imaging in the Cspine
- can be performed as an adjunct to the clinical exam - degen changes in c sp are common, be careful! - doesn't necissarily relate to pts complaints though, dont assume...lack of correlation is common - open mouth xray for C1/C2
Grade 4 Whiplash
- cervical fracture or dislocation - neck pain - restricted ROM - abnormal possible UMN signs - film, has fracture or dislocation - CT scan/MRI may show same with area of SC involvement - 6% cases
Grade 2 Whiplash
- common one seen in clinic - muscle strain, ligament sprain - neck and/or back stiffness and pain - paraspinal tenderness and restricted ROM - normal - film, no fx or dislocation - 29-56% cases
4 stages of disc herniation
- degeneration: disc starting to near edge of annulus propulsus - prolapse: pushes annulus out and buldges the entire discal area outward (polyp of disc) - extrusion: pushes through annulus and the disc is lumping out of the segment - sequestration: disc has pushed out and down and everwher
Canadian C-spine Rule
- determines need for radiographs in stable trauma pts where cervical spinal injury is a concern - clearing the cervical spine without imaging - 3 main Qs: 1) any high-risk factor which mandates radiography? (age > 65, dang mech, paresthesias in extremities) 2) Any low-risk factors which allows safe assessment of ROM? (simple reared mvc, siting in ed, ambulatory at any time, delayed onset neck pain, absence of midline csp tender) 3) Able to actively rotate neck? (45deg l and r)
Cervical Radiculopathy
- disc herniation? less common than in lumbar spine... most commonly effected at C5-6, C6-7 - protrusion > prolaps > extrusion > sequestation - protrusion = buldge - posterior and posterolateral produce greatest number of clinical s&s (PL more common due to strength of PLL = unilat symtoms)
Clinical tests with upper cervical instability
- disputable and variable reliability/validity - sharp-purser test - transverse ligament test - rotation test of C3 coupled with side flexion
S&S of Upper cervical instability
- feeling like head is falling off - needing to hold head up with hands - torticollis, cock robin position (cardinal sign in early phase) - neurological signs and symptoms
Motion of Occiput on Atlas
- flexion/extension - rolls ant, glides post with flex - rolls post, glides ant with ext - rotation to right, left goes ant, right goes post
Hypermobility vs hypo pts
- hyper will keep neck moving - hypomobile can tolerate static but has pain with end range motion - moves but doesnt follow a patter, motor control or instability
Coupled motions help with what
- identify dysfunctional movement - take up slack - gap right and compressing left with SB L and Rot R.....basically a a crank and grind assessment of articular issue with - distraction will be an intervention
Grade 1 Whiplash
- muscle strain - neck stiffness, pain, tenderness - no physical signs - normal - unneccessary - 43% of cases
Cervical Instability S&S
- neck pain and headaches provoked by sustained WB posture (sitting) - relieved by non-WB postures (i.e. supine laying) - catching or locking of neck - weakness: poor strength of multifidi, longus colli, longus capitis - altered ROM: aberrant mvmt, shaking, poorly controlled - hypermobility and soft end-feel during PPIVMS
Coupled patterns upper cervical
- opposite SB and Rot - OCCIPUT = OPPOSITE
Upper Cervical Instability major issues
- paralysis - death
Grade 3 Whiplash
- possible disc protrusion - neck and/or back pain - restriction ROM - abnormal, possible upper motor neuron signs - decreased/absent STR, weakness, sensory deficits - film, no fracture, or dislocations - CT scan, MRI may show area of nerve - 2-3% cases
Motion of Atlas on Axis
- right rotation - remember combo of rot and SB
Traditional treatment with torticollis (congenital)
- stretching and over correction - teach parents - 2-4x a day up to a year - wear ear plugs
Treatment options with upper cervical instability
- surgical tx - especially with neurological signs - hyperreflexia - paresthesia - coordination problems with walking - spasticity or paresis
Causes of upper cervical instability
- trauma, MVA/fall - RA (50-70%) - Downs
Torticollis (congenital)
- twisted neck - Young children: Primarily females ages 6 months to 3 years - Involves SCM: Unilateral contraction (ischemic changes) of the muscle, SB toward, rotation away - Not painful itself but can lead to developmental/cosmetic problems: Asymmetry of the face may developed