MSK Spine Content

Similarities to entrapment?

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Nucleus -Hydro..? -Nutrition how?

1) *Hydrophilic* - likes water/attracts it 2) *Disc nutrition* through fluid diffusion -"*Imbibing*" fluid/bringing water in - achieved by the *weighting and unweighting* of the disc. -Which occurs through the *vertebral endplate* 3) So when lay down and take compressive body weight forces off the disc, it takes in water, so as a result in the am you are *¾ inch traller when wake up*

Scheurmann's Disease ( aka Adolescent Kyphosis) - -Normal curvature degrees? -Degrees of curvature to be Scheurmann's?

1) Is a condition related to the *curvature of the spine* 2) Normal curvature of thoracic, or upper, spine = 20-50 degrees 3) More than 50 degrees = constitutes Scheuermann's disease

ALL & PLL

1. ALL - limits extension; No attachments to disc 2. PLL - limits flexion; Attaches to disc! -Stops disc from a straight posterior herniation -Also provides protection to spinal cord

Sub-cranial Instability - Symptoms -Pain where/aggravated? -Difficulty doing what movements? -Say atypical things like?

1. Pain in *base of skull, upper neck radiating to occiput, temporal or frontal* aggravated by *jarring (shaking) movements* 2. Difficulty *returning head to neutral* after looking down or forward - Clunking sound (subluxing and then relocating) -They are wayyy too far anterior translated = hard for mm to pull it back 3. Feeling that their *head is "falling off"*

Cervical Radiculopathy - Clinical Findings

1. Poor posture - *Forward head and shoulders* 2. *Limited SB and BB* with *pain into UE* 3. *Neurological signs* in dermatome/myotome 4. Distraction *decrease pain* 5. Compression *increases pain* 6. Tenderness on *side of involvement*

Posture Related Neck Pain - Exercises

Chin tucks, pec stretches, thoracic spine extension over a chair

Myotomes (L1-S2)

L1/L2 - hip flexors L3/L4 - quads L4 - tibialis anterior L5 - EHL S1 - FHL/Peroneals S2 - Hamstrings

How would you reference movement between the 4th and 5th vert?

L4/L5 segment

Joint of Von Lushka

Part of uncovertebral joint

Reflexes

Reflexes C5/6 - biceps C6 - brachioradialis C7 - triceps

A T1/T2 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

T1 nerve root Dermatomes - Sensation over medial forearm lost Myotomes - intrinsics = decreased ABD/ADD of fingers Reflexes - N/A

Forces/Nucleus Position (another pic)

"Know forces" A is at rest supine when the disc would be imbibing fluid. B represents sitting in class here listening to this lecture C would be backward bending where it is being squeezed in the back and taut or fluid coming in front.

Facet Joints (Zygapophyseal Joints) Function? Plane? Capsule? Tropism?

-Formed by Superior & Inferior Articular Processes of adjacent Vert Function: 1) Jt. orientation *determines direction of motion* 2) Lumbar: *sagittal* plane orientation 3) Capsule *limits* motion - but can be *impinged*! 4) Tropism - *boney anomaly*; *could restrict motion*

Mid Cervical Mechanics: (45 deg facet plane) -Forward Bending -Back Bending -Side Bend Right -Rotation Right

-Forward Bending = Facets slide up -Back Bending = Facets slide back -Side Bend Right = Right facet slides down; Left facet slides up -Rotation Right = Right facet slides down; Left facet slides up *mechanics could be thrown off by myofascial tightness

Medical/Congenital Conditions of Cervical and Thoracic Spine

-Muscular Torticollis -Scheurmann's Disease

CERVICAL SPINE 2

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LUMBAR -1 ANATOMY & MECHANICS

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Cervical Spine Stenosis - Resulting in Myelopathy -Clinical Findings/Presentation

1) *Aching* in neck and shoulders - *occasional* radiation into *Bilateral UE* 2) Bilateral *Parasthesias* UE and LE 3) Bilateral *weakness* in UE and LE, problems with *balance/coordination* 4) *Forward head* with thoracic *kyphosis* 5) Limited *AROM* 6) Permanent or transient *neurological signs* -(+) Babinski, clonus and general weakness of LE 8) Muscle *tightness*

Acceleration/DecelerationWhiplash - Clinical Findings/Presentation (7)

1) *Guarded posture* - not going to want to move - eyes and entire body move - thats it = Moving as 1 unit 2) *Limited AROM* with *muscle guarding* 3) *NO neurological signs* - check Babinski (-); *KEY FEATURE* 4) Abnormal *Muscle tone* 5) Joint *overstretch/hypermobility* 6) Weak *anterior neck musculature* 7) *Tenderness and increased tone* to palpation

Sub-cranial Instability: Symptoms from certain structures (Major Red Flags) -LBS, VA, SC, S, N

1) *Lower brain stem* symptoms -Changes in motor or sensory, dysarthria, dysphagia, lingual deviation, cardiac or repiratory distress 2) *Vertebral artery signs* -(Wallenberg's syndrome) dysarthria, dysphagia, staggering gait, vertigo, hypotonia, incoodination of movementnausea, nystagmus, slurred speech, vertigo 3) *Spinal cord* symptoms -Sensory changes motor, bilateral or quadrilateral 4) *Sympathetics* -(Horner's sydrome) potsis eyelids, pupils contracted myopis, nausea, dizzy, sweating lack of anhydrosis, strange and different sx. 5) *Nasopharyngeal* symptoms -Swallowing, talking, nasal drip *Especially if after car accident or trauma *Put in collar and send to doctor *Refer DIRECTLY to Physician

Muscular Torticollis

1) Etiology unknown 2) Minimal deformity at birth, firm swelling develops in SCOM 3) Swelling resolves leaving contracture and deformity - SB to same side and rotate away (action of SCOM) -the tone of the mm is high 4) Radiographs differentiate from boney torticollis 5) Stretching performed daily for first year -Pic = Right sided torticollis (side bent to right and rotated to left)

Headaches (MSK origin) - Clinical Findings/Presentation (5)

1) Forward head posture 2) Poor postural awareness/ergonomics 3) Upper trap/levator tightness 4) Increased tone and tenderness 5) NO neurological signs

"Spinal Motion Segment" -What is it? -Comprised of what?

1) Functional unit of the spine: where movement happens -we examine movement in region and by each segment in region 2) Its what we refer to when talking about problems with our patients 3) Name by both vertebrae: L2-3 segment Comprised of: 1) Adjacent halves of 2 vertebrae 2) Disc in between 3) Facet joints 4) Myofasicia, blood supply & nerves

Acceleration/DecelerationWhiplash -MOI? -General Symptoms?

1) History of *trauma* - usually MVA 2) Symptoms *minor to severe* 3) May be *bilateral* - but *usually worse on one side* (traumatic force is not usually symmetrical) 4) Various *anatomical structures* involved -more severe = more structures involved 5) May have *autonomic* symptoms 6) If traumatic - Must have *odontoid view* radiograph before treatment

Injury to Annulus & Healing

1) Injury to the *outer annulus* = it is possible that it will heal b/c there *IS BLOOD SUPPLY* to that area - And usually the part injured first. Which is good b/c have blood supply and can heal. 2) Often times *people think* it is the *nucleus injured first* and migrates out but is outer rings. 3) So the disc can heal usually 6 months progressing well and at 12 mos if no other abnormal stresses are placed, it should be pretty well healed. 4) Problem: pt. don't realize the significant abnormal stresses they are applying on their spine - *PT. EDUCATION* is crucial - Testament to education of patients

Layers of Annulus Fibrosis

1) It is made up of *6-10 concentric rings/fibers* 2) Looking on *outer layers* you can see the *oblique* fashion of fibers 3) So one will have fibers running one way then the next ring will have fibers going another way. 4) They run at *angles to each other*, so not up and down. 5) Move more centrally - Annual fibers are *less organized and more mobile near center to allow for nuclear movement in response to force*

Fracture & Fracture/Dislocation -MOI? -Treated? -SC involvement?

1) MOI = Due to *fall on head/neck, diving, MVA* - more traumatic cause 2) Fracture treated with *traction for reduction and immobilization* 3) SHOULD *spare the spinal cord* (unless significantly severe) 4) IF Fracture/dislocation involve spinal cord resulting in *quadrapalegia* -Immediate surgical case: Surgical fixation (ORIF or External Fixation w/ halo)

Ligaments - Functions (4)

1) Maintain *joint integrity* 2) *Allow & limit* motion 3) *Prevent excessive* movement 4) *Mechanoreceptors* in ligaments provide *proprioception*

Neuroanatomy -Most structures are innervated by how many levels? -Anterior (2) vs. posterior primary ramus (4)?

1) Most structures innervated by 2-3 nerve root levels (implications for referred pain) --So level at and level above and below so can be hard to tell where problem is coming from. So if have pain at L4/l5 could be coming from another As Spinal nerve comes out its divided into: 2) Anterior primary ramus --Lumbar and sacral plexus --Motor and sensory to LE 3) Posterior primary ramus --Facets --Outer disc --Back muscles --Ligaments and anything else in back

Nucleus Positions - Different positions will have different effects on disc Normal, Even, Uneven, Torsion

1) Normal = what will happen when lying down. Even distribution 2) Good, normal alignment through the day, upright 3) So if third picture is FB then getting squeezed in the front and pushed out in back. Reverse if wanted bb. Or postural abnormality leading to problems later 4) What is torsion? Compression and shear forces. In a torsional or twisting mode b/c of the orientation of the fibers, *only half of the fibers in the annulus will resist the motion* -So if I twist to the left only the fibers in that orientation will go taut (about 50% of them) -Result = *Most discal problems will result in some type of rotational movement.* Person bends down to pick up and twists. See lots with construction workers, airplane luggage handlers doesn't have to be something heavy

Scheurmann's Disease ( aka Adolescent Kyphosis)

1) Osteochondrosis of the spine 2) Begins at *puberty* and *progresses until growth complete*, males > females -Posture will change; thoracic curve will be exaggerated; looks slouched/very rounded shoulders 3) Form of *AVN* affecting *anterior epiphyseal plate* within the vertebra 4) Due to the Breakdown/necrosis/weakness = *disc becomes stronger than end-plate & projects into bony space/vertebra* - Schmorle's Nodes -Basically discs grow into vertebral bodies 5) Affects *3-4 levels* - marked *kyphosis*= increased convexity

Spinal Motion Segment - Functions (3) W, P, M

1) Weight bearing 2) Protection of spinal cord 3) Where movement happens: -Segmental motion is relatively small in degrees -Combined results in regional (lumbar) movement we see on AROM

Posture Related Neck Pain - Signs & Sympotoms

1. Pain - usually in neck, traps, inter scapular area, sub-occipital area 2. Gradual Onset 3. There is NO paresthesia or anesthesia - no loss of sensation 4. There is NO significant Hx or Trauma associated with it (probably just from prolonged posture)

Sub-cranial Instability -Transverse Lig function -Compression of what structures?

1. Transverse lig. of atlas *prevents excessive anterior translation of altas on axis* - holds dens firmly against atlas 2. *Normal* amount of anterior translation = 3mm adults, 4mm children; anything more = unstable 3. If excessive translation = *Important structures get Compressed* -Medulla, spinal cord, vertebral arteries, superior sympathetic ganglion

Painful (Capsular) Entrapment - Signs & Symptoms -What is it? -How does it happen? -When might they notice it?

1. What is it? *Sudden painful catch* - crick in neck; The joint capsule is entrapped in the facet 2. How does it happen? While *turning head* or *returning from eccentric movement* 3. Noticed in *AM when waking up due to incorrect posture* 4. *Unilateral* Lec: -how do you differentiate that its not a nerve? there are no neurological signs;

Painful Entrapment on L side Iso Multifidus?

Want to contract L Multifidus -you put them SB and rotated R (and in flexion) -they will SB and rotate L to produce iso contraction (and extension)

Painful Entrapment on R side Iso Multifidus?

Want to contract R Multifidus -you put them SB and rotated L (and in flexion) -they will SB and rotate R to produce iso contraction (and extension)

Headaches: Migraines vs. MSK cause of headache

We can help people with headaches of MSK origin!

Disc Bulge Lateral vs. Medial *importatn concept - lateral vs. medial buldge how would pt. present to you - i.e. which side would they bend to?

Where bulge location: mostly likely postural position (but pt posture doesn't always positively correlated with imaging) Disc bulge is *LATERAL* to the affected nerve root = it will cause the patient to *shift away from the side of pain* Disc bulge *MEDIAL* to affected nerve root = will cause patient to *shift towards side of pain* Lec Notes: -dont see as much medial bulge; because PLL -bulging is normal wear and tear of discs - almost like arthritis; usually its protrusion/herniation that affects nerve -"lateral to nerve" or "medial to nerve"

Patellar - AKA knee jerk. Deep reflex from L3/L4 levels. Based on what talked about earlier, if L4 nerve root is involved, can the reflex still be present?

Yes based on fact innervated by more than one level.

Good pic

You can see how the L4/5 disc would impinge on the L5 neve root!

So think about it. Have you ever sat in class for a long time without a break and the when stand have a hard time standing up straight?

You will often hear that with patients, especially those with desk type jobs that require prolonged sitting. They or you can't straighten up is as sat forward bent squeezed fluid out of the front portion of disc and have more fluid in post aspect. So now have an uneven distribution and will be harder to straigthen b/c so much bigger in back. So takes a few minutes to get straight

A C6/C7 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C7 nerve root Dermatomes - Sensation over middle finger lost Myotomes - Triceps & Wrist flexors = decreased elbow extension & wrist flexion Reflexes - Triceps

A C7/T1 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C8 nerve root Dermatomes - Sensation over ulnar border of pinky lost Myotomes - Thumb extensors = decreased thumb extension Reflexes - N/A

Sub-cranial Instability -Causes (5)

Causes: really anything that would cause loosening of vertebral column/laxity to ligaments 1) RA 2) Ankylosing spondylitis 3) Down's syndrome 4) Corticosteroids 5) Post trauma -Always get A/P radiograph with open mouth - "odontoid view" -Open mouth x-ray only way to see if instability to view dens and relation to arch or atlas. b/c other views the mandible gets in the way. Ie patients in car accident make sure have done

Where do the cervical and lumbar nerve roots exit? How does this relate when describing a disc dysfunction/stenosis?

Cervical nerves = above the level of spinal cord Lumbar nerves = below the level of the spinal cord Disc Dysfunction/Stenosis: -Cervical = the same level will be affected i.e. C2/C3 - C3 will be affected -Lumbar = Stenosis/Disc

Facet Joint Capsule -What Structures prevent entrapment? (3)

Entrapment (pinch between jt. Surfaces): 1) Painful due to capsule innervation 2) Occurs with awkward movements Structures that prevent entrapment: *1) Ligamentum flavum (elastic fibers)* -Spring that pulls capsule out of facet joint *2) Multifidus* -Attachments to capsule; when contracted they pull capsule out of way- can be used to treat pinching -If multifidus is guarding it may swell and push against capsule, increasing pinching *3) Meniscus* -Provides physical block to being pinch -If extra meniscal tissue in facet joint = gets in the way = results in pinching the capsule more when it supposed to block capsule from being pinched in first place (usually degenerative process that creates extra tissue/meniscus)

Each facet joint is innervated by?

Facet joint = 3 spinal nerves 1) Local branch 2) Ascending branch from level below 3) Descending branch from level above Disc 1) Local branch 2) Ascending branch from level below

So a spinal nerve root injury at L2 would affect what?

Facet joints at 1) L2/L3 (local) 2) L1/L2 (ascending branch) 3) L3/L4 (descending branch) Discs at: 1) L2/L3 (local) 2) L1/L2 (ascending branch)

Foraminal Stenosis

Foraminal Stenosis: *Narrowing of lateral foramen = less space for nerve root exit = risk of impingement* - L4 nerve root impinged in L4/L5 foramen - L5 nerve root impinged in L5/S1 foramen

Achilles Reflex

If S1 root compressed this reflex will be effected. Stretch the tendon by dorsiflexing the foot and tap tendon with reflex hammer to induce involuntary plantar flexion of the foot And s1 is achilles hit back of achilles and will get plantar flexion.

Stenosis of L1/L2 would result in what nerve root injury? What dermatomes would be impaired? What myotomes would be impaired?

L1 L1 = ? thigh/groin area

Dermatomes Levels Affected with Spinal Nerve Root Injuries - Lumbar Level (L2-S1)

L2 - lateral thigh L3 - medial knee L4 - medial calf L5 - lateral calf S1 - lateral foot General info: -Distal to proximal -Have a use in our neurological assessment when we detect a loss or diminution of skin sensation. Knowing the dermatome can tell us which sensory nerve is being compromised - *NOT correct to say pain is referred into dermatomes*

An L2 nerve root impingement is caused by stenosis where? What dermatomes would be impaired? What myotomes would be impaired? What reflexes would be impaired?

L2/L3 *Note: this is the level you'd want to apply distraction at Derm L2 = lateral thigh Myo L2 = hip flexors - flex hip Reflexes = n/a?

An L2/L3 Disc impingement affects which spinal nerve root? What dermatomes would be impaired? What myotomes would be impaired? What reflexes would be impaired?

L3 Derm L3 = medial knee Myo L3 = quads - straighten knee Reflexes = Patellar reflex

An L4/L5 Stenosis impingement affects which spinal nerve root? What dermatomes would be impaired? What myotomes would be impaired? What reflexes would be impaired?

L4 Derm L4 = medial calf Myo L4 -quads = straighten knee -tibialis anterior = DF ankle Reflexes = Patellar reflex

An L5/S1 stenosis impingement affects which spinal nerve root? What dermatomes would be impaired? What myotomes would be impaired? What reflexes would be impaired?

L5 Derm L5 = lateral calf Myo L5 = EHL - extend big toe Reflexes = n/a?

A S1 nerve root impingement by a disc would be caused at what level? What dermatomes would be impaired? What myotomes would be impaired? What reflexes would be impaired?

L5/S1 Derm S1 = Lateral foot Myo S1 -FHL = flex big toe -Peroneals = evert Reflex = Achilles

A Stenosis of C2/C3 would affect what spinal nerve root?

Local level = C3! (local level = vertebra below because nerves exit on top)

Whats the key difference in Lumbar Stenosis Resulting in Myelopathy vs. Cervical?

Lumbar spine myelopathy = only affects LE Cervical spine myelopathy = UE & Bilateral (can also be LE/bilateral) Lec notes: Lateral stenosis affecting SC in cervical = Myelopathy -hits SC = UMN - hypereflexia -Key marker for cervical myelopathy = UMN; (+) Babinsky (tests for UMN), Clonus test positive Lateral stenosis affecting SC in lumbar = Neurogenic claudication -Claudication = cant walk they have pain in legs because vascular issues or nerve issues; -Cauda equina = LMN - hyporeflexia

Headaches - MSK Origin

MSK Origin: 1) Pain begins/*originates in cervical, suboccipital or thoracic region* and *radiates upward to head* - Temporal, occipital, frontal 2) Key thing is if you can *affect symptoms by change in position, movement or cervical provocation* - probably MSK in origin! 3) May have *history of trauma*

Picture - Facet joint & menisci

Meniscus- Dark contrast on picture......... looks like a little seed Dark long areas are facet contact Here we are looking at a cross-sectional view of a vert Can see a caudal and cephalad meniscus, They block the capsule *importance of multifidus to prevent pinching Plane of facets---------- lumbar spine are oriented 90 degrees from the transverse plane and 45 degrees from the frontal plane So everyne bring arms up and the out which clinically is important so know where to manip

Ligamentum Flavum

Now the anterior vertebral bodies have been cut off Looking at lig flavum which attaches into the capsule as we mentioned earlier in preventing the nipping of the capsule b/c of elastic quality it has. Elastin makes it yellow, springy type of collagen

Difference with Cervical?

Only affects locally - but remember exits on top!

Sprain/Strain/Synovitis -MOI & Pain

Overstretch of facet joint capsule causing inflammation 1. MOI = Awkward movement or overstretch 2. Pain worsens over 2-3 days 3. Pain CENTRAL in upper trap/levator to interscapular and/or subcranial region

Sprain/Strain/Synovitis - Exercises

Pain free ROM on pillow, stretch trap, levators, scalenes

Supraspinous Ligament

Runs down bet each spinous processes then blends into the TH/L fascia at L2/3 region

Pic of disc in segment

So here we are looking at a vertebrae above and a vertebrae below. And this is the disc in between the two vertebrae #1 = Nucleus is this inner gel-like substance. #2 Is the annulus on the outside.

What might this do to a person that has symptoms with swelling?

So may tell patients to lie down during the day intermittently to increase nutrition, cyclical loading, but that waking in the morning may be more stiff and painful due to the swelling at the posterior disc Fluid affected by change in position, and so is pain due to innervation of swollen or over stretched ligament (annulus) Outter 1/3 of the disc is innervated by recurrent nerve, sinu vertebralis

A T2/T3 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

T2 nerve root Dermatomes - Sensation over medial arm lost Myotomes - N/A Reflexes - N/A

Disc Innervation

posterior outer 1/3 being innervated; L4 spinal nerve root runs through foramen

A pt. who has a medial bulge on the left side will shift to what side to avoid pain?

they will shift to the left (symptoms will also be on left)

A pt. who has a lateral bulge on the left side will shift to what side to avoid pain?

they will shift to the right (symptoms will be on left)

Discs in relation to Nerve Roots

Discs LIE BELOW the corresponding nerve root L4 nerve root exits above L4/L5 disc L4/L5 disc impinges L5 nerve root L5/S1 disc impinges S1 nerve root -Netter's pic shows it well -*Stenosis is much different case

Scheurmann's Kyphosis - Pic

Discs are wedge shaped/triangle shaped. Theres thickening of ligaments to try and control movement - compensating. You can see the disc protruding into the vertebral bodies.

Painful Entrapment - Treatment: Multifidus Isometric

(Right sided problem) Stabilizing R shoulder; Grabbing base of Occiput and isometric contraction of R multifidus (he's standing on her left to facilitate isometric contraction on right hand side) Lec notes: -multifidus attaches to joint capsule in C-spine; this treatment is just a theory but it seems like people have pain relief - but no one really knows if it actually pulls capsule out or not -Multifidus -its role is to stabilize by compression; if you create too much contraction = could cause too much compression = more pain -pain/symptoms on right side - want to stimulate R multifidus - you are putting them in flexion, SB and rotation to other side while they are resisting it by producing extension, SB and rotation to same side = isometric contraction

Cervical Spine Stenosis - Resulting in Myelopathy (myelopathy = disease of *spinal cord*, not nerve roots- looking more centrally)

*1) Degenerative Disc Disease (DDD)*- DISC changes - Lose disc *height* = Vertebra slide *posteriorly* = *narrow central canal* = *Pressure* on SC (picture) *2) Degenerative Joint Disease (DJD)* - JOINT changes -*Osteophytes* (spondylitic changes) form at *posterior* aspect of vertebral bodies = *Compress anterior aspect* SC 3) Encroachment on SC may *mimic ALS, MS, Parkinson's*

Test Cluster - Most predictive of Cervical Radiculopathy (4) UCDS

*1. ULTTA - Upper Limb Tissue Tension Assessment* -(+) Median Nerve = Shoulder abd, elbow ext, supin, wrist ext, finger ext 2. *Cervical rotation* to affected side *limited to less than < 60* 3. *(+) Distraction test* - distraction decreases symptoms 4. *(+) Spurling test* - Cervical extension and rotation to same side (loads side) with axial load (form of compression) - Refers increases symptoms = more radiculopathy - Locally increases symptoms = maybe more facet related

Subcranial Instability: Symptoms 5 D's & 3 Ns

*5 D's* 1) Diplopia = Seeing double 2) Dizziness 3) Drop Attacks 4) Disarthia = difficult or unclear articulation of speech that is otherwise linguistically normal 5) Dysphagia = difficultly swallowing *3 N's* 1) Numbness 2) Nausea 3) Nystagmus

Cervical Radiculopathy - what is it?

1. Due to *lateral foraminal stenosis* or *disc herniation* 2. *Higher incidence* of CR due to spondolytic changes (bony, degenerative changes) than cervical disc herniation -Usually due to *foraminal stenosis* than disc protrusion b/c of discs being smaller and b/c of unoverterbral joints as seen in this picture 3. May see normal processes that may become exositosis "Lateral inter body articulation" = "uncinate process" = "joint of von lushka"

Posture Related Neck Pain - Clinical Findings

1. Forward Head and shoulders 2. Limited cervical AROM 3. Tight upper trap, levator, suboccipt, pecs (decreased length) 4. Tenderness/increased tone ^^ (abnormal tone) 5. Weak middle and lower trap 6. Poor postural awareness/ergonomics -body not giving you feedback loop telling you you're not in position 7. No neurological signs - no dermatomes/myotomes

Sprain/Strain/Synovitis -Clinical Findings

1. Forward head posture 2. Limited AROM -SB and rotation in ONE direction! (same direction tends to be limited) 3. Upper trap and levator tight involved side/mm guarding 4. Tenderness/increased tone -Paraspinals, suboccipitals, upper trap/levator, interscapular muscles

Cervical Radiculopathy - Signs & Symptoms -Who does it occur in? -Where is it most common? -What kind of pain? - where, when, during what motions etc.

1. Most often occurs in *females during 4th/5th decade* of life (time for degeneration) 2. *C6 and C7* most commonly involved - affecting C7 spinal nerve root 3. Gradual onset of *pain - Central @ neck, upper trap* and can *spread/refer into UE* 4. Difficulty *falling asleep* due to pain and *parasthesias* in UE 5. Increased *pain* with "look up" *BB or SB to affected side*

Painful Entrapment - Clinical Findings

1. Postural Shift of neck *away from painful side* & tons of muscle guarding 2. AROM *limited SB, rotation to involved side and BB* -Why? Due to downslide - further pinch/entrap capsule = very painful; -if problem on the right then SB Right, Rotation Right and regular BB = painful 3. Triggers a *swollen facet capsule* 4. Pain and *muscle guarding* paraspinals and levator 5. NO neurological signs - nerve root not involved

Vertebral Disc -%? -Functions?(3)/Components?

25% height of spine overall /33% of lumbar spine (discs are thicker - take up more volume/height) Function: 1) Allows motion in all planes 2) Can also restrict motion like ligaments 3) Transmits shock - doesn't absorb the shock but transmits it t/o the spine Components: 1) Annulus - outer ring 2) Nucleus - water-filled center of disc

Subcranial biomechanics: -Forward Bending -Back Bending -Side Bend Right -Side Bend Left -Rotation

ATLAS moves with the head! -Forward Bending = Atlas slides forward -Back Bending = Atlas slides back -Side Bend Right = Atlas slides right -Side Bend Left = Atlas slides left -Rotation = Occurs at A/A

Pic - Annulus Fibrosis

Annulus fibrosis fissuring during breakdown of disc -this then slowly allows the NP to migrate out of posterior annulus

Subcranial Instability - Flattening of occipito-cervical curve

As fwd bend don't normally have the bump b/c of sub occ moving on c-spine. This shows bulge posterior if too much movement -Basically C2 is just staying posteriorly (thats the bulge you see) -This is person with down syndrome

Nachemson's Disc Pressure Studies - Know what positions have most pressure on Disc!

By measurement of intradiscal pressure in vitro, the hydrostatic properties of the nucleus pulposus of normal lumbar intervertebral disc was established. Least pressure --> Greatest Pressure 1) Supine = least pressure (no surprise) 2) Sidelying 3) Standing 4) Sitting with good posture 5) Standing + FB 6) Sitting + FB 7) Standing + weighted FB 8) *Greatest Pressure = Sitting + weighted FB* -Interesting to note that sitting has increased pressure vs. standing Look at supine vs sitting and lifting a weight

A C5/C6 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C6 nerve root Dermatomes - Sensation over thumb lost Myotomes - Biceps & Wrist Extensors = deceased elbow flexion & wrist extension Reflexes - Biceps & Brachioradialis

A C1(Atlas)/C2 (Axis) stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C2 nerve root Dermatomes - N/A? Myotomes - N/A? Reflexes - N/A?

A C2/C3 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C3 nerve root Dermatomes - N/A? Myotomes - N/A? Reflexes - N/A?

A C3/C4 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C4 Dermatomes - Sensation over UT lost Myotomes - UT = Decreased scapular elevation, retraction & upward rotation; Decreased head extension, lateral flexion (SB), and rotation to opposite side Reflexes - N/A

Dermatomes (C4-T2)

C4 - upper trap C5 - lateral delt C6 - thumb C7 - middle finger C8 - ulnar border of the hand/pinky T1 - medial forearm T2 - medial arm

Myotomes (C4-T1)

C4 - upper trap C5/6 - biceps C6- wrist extensors C7 - triceps, wrist flexors C8 - thumb extensors T1 - intrinsics (finger add/abd)

A C4/C5 stenosis/bulging disc will affect what nerve root? What dermatomes will be impaired? What myotomes will be impaired? What reflexes will be impaired?

C5 nerve root Dermatomes - Sensation over lateral deltoids lost Myotomes - Biceps = Decreased elbow flexion Reflexes - Biceps

Reflexes (DTR & Pathologic reflexes)

Deep Tendon Reflexes (DTRs): -L3/L4 - patellar -S1 - Achilles -Decreased with nerve root impingement -May be increased with n. root irritation Pathologic Reflexes (CNS implicaitons): -Clonus response to DTR test -Babinski

Cervical Radiculopathy - pic

They are sitting where the disc normally protrudes back, so if bony stop then won't be able to herniate. More room and less structure in way in lumbar spine. It canhappen but usually foraminal stenosis. Will start to get osteophyte (black part) and wearing away which will cause nerve symptoms

Disc Vs. Foraminal Stenosis

Think about location & REMEMBER FRACTION! Discs - put pressure behind where the beginning of the following nerve begins; Its the LOWER of the 2 segments Stenosis - its trapping the nerves that are leaving at the level - the bone lays down osteophytes at this higher location and affects the nerve going to the HIGHER of the 2 segments