MSK: Cervical Anatomy Quiz (Vizniak)

What can cervical strains/sprains do as far as cervical lordosis?Why?

Cervical strains/sprains can reverse or straighten cervical lordosis This is due to reactive/protective spasm of longus colli

What are some characteristics of pain with cervical facet syndrome?

Dull, achy pain although pain may be sharp during acute episodes Pain is localized, patient can usually locate pain Sometimes radiates down shoulder or mid back regions although does not often radiate beyond elbow or upper thoracic spine Pain relieved when supine

What is the pathophysiology of cervical meniscoid syndrome?

During flexion (joint distraction) the articular surfaces pull apart and the meniscoid might be drawn into the joint Then as you extend the spine the meniscoid might fail to withdraw and become trapped Meniscoid is compressed against articular surfaces causing pain + myospasms

What is the age of peak incidence of cervical sprains/strains?

Late 30s, early 40s

Talk to me about nerve root blocks and cervical radiculopathy

Selective diagnostic nerve root block is where local anesthetic is used to anesthetize nerve root and dorsal root ganglion to determine in patient's pain is coming from specific nerve root

Cervical sprain: if your exam shows pain in a single direction what structure is usually damaged? What if it shows pain in more than one direction?

Single direction = muscle or tendon damage Multiple directions = joint capsule damage

What does the pain from cervical meniscoid entrapement lead to?

The pain from the capsular distension results in muscle spasms and can lead to acute locked neck syndrome This spasms leads to fatigue and a cycle of ischemia, inflammation to more pain Prolonged immobility of joint causes articular surfaces to mold around the meniscoid, making it more resistant to release

What is a synomyn of cervical strain/sprain?

Whiplash! But it has negative connotations so don't use it

If you want to image C6-C7 what technique should you use?

CT!!! CT shows C6-C7 better than x-ray

What are some orthopedic tests you might perform in order to determine if someone has cervical spondylosis?

Cervical compression/distraction test Shoulder abduction test (as a reminder this test tests for cervical radicular pathology especially in the lower cervical spine (C5-C7)

What is cervical facet syndrome?

Cervical facet irritation or damage that may cause cranial, cervical or upper shoulder + back pain referral, often difficult to distinguish from other causes of neck pain

Talk to me about cervical facet syndrome and whiplash syndrome

Cervical facet joint pain after whiplash injury in approximately 60% of people (usually at C2-C3 and C5-C6)

What is a meniscoid? Function?

Combination connective tissue/adipose tissue component of articular capsule (occur at synovial joints of spine and extremities) Function = provide stability to the joint by filling space and having significant innervation by nociceptors

Talk to me about osseous mobilization/manipulation and cervical sprain/strain

Contraindicated during the acute stage but may be used in regions adjacent to the injury (this might improve healing) Anterior cervical mobilization to relax posterior muscles and stretch anterior neck structures FIRST MAKE SURE TO RULE OUT VBI, instability pathologic headaches, etc.

How many people with neck pain have cervical facet syndrome?

Estimated that 26-65% of neck pain complaints may have a cervical facet component

What is one possible medication you can use for cervical facet syndrome?

Facet injections with long-acting local anesthetic agent may offer short-term relief Facet joints have a dual-level innervation (medial branch of dorsal ramus exiting both the same level and the level above)

What percentage fiber damage does a grade 1 cervical sprain/strain? Grade 2? Grade 3?

Grade 1 = Greater than 10% damage Grade 2 = Between 10 and 90% damage Grade 3 = Complete tearing of multiple ligaments, muscles and joint ligaments may be involved

Talk to me about swelling with a grade 1 cervical sprain/strain? Grade 2? Grade 3?

Grade 1 = Mild swelling and point tenderness over the ligament, no bruising Grade 2 = Mild to moderate swelling (can't always see due to depth of tissue damaged) Grade 3 = Severe deep bruising and swelling- fracture instability and dislocation must be ruled out

What does recovery length look like for a grade 1 cervical sprain/strain have? Grade 2? Grade 3?

Grade 1 = functional recovery in 2-14 days Grade 2 = functional recovery in 14 days- 2 months Grade 3 = functional recovery time 1-3 months (structural healing 6 months plus)

What kind of stress test results will you get with a grade 1 cervical sprain/strain? Grade 2? Grade 3?

Grade 1 = negative stress tests, mild pain at extreme end ROM, no instability Grade 2 = mild to moderate instability may be demonstrated on stress test Grade 3 = Marked instability on stress tests, positive stress tests!

How might the patient with cervical radiculopathy present as far as posture?

Head tilt and neck posture (antalgic posture) Possible head tilt away from the side of the injury and holds neck stiffly

What is a common age group for spondylosis? Why?

Incidence increases above age 50 96-100% of adults over age 70 will have the condition Likely due to age related changes to proteoglycans (extracellular matrix filler) that decrease tensile strength of cartilage and also decreased nutrient/blood flow to cartilage

What are some diagnostic special tests of cervical facet syndrome?

Increased pain upon lateral bending with extension Local pain with cervical compression Decreased pain with cervical distraction test

How is cervical radiculopathy usually caused in older patients?

Intervertebral foramen narrowing from osteophyte formation Over age 40 decreases chance of herniation because vertebral discs become fibrous with age so then there is actually little nucleus pulposus to herniate

Talk to me about discogenic pain syndrome and ROM

Limited in most ROM If there is pain in multiple directions it suggests joint capsule damage (pain in a single direction indicates muscle or tendon damage)

What kind of osseous mobes/manipulations would you consider for a patient with cervical spondylosis?

Long axis traction (widen foramen, and decrease pressure) Mobilizations + manipulations focused on hypomobile segments may improve mobility + relieve some pain Avoid mobilization of hypermobile/unstable segment

What are the general treatment measures for discogenic pain syndrome?

METH- movement, exercise, traction, heat NSAIDs Short-term neck brace Cold therapy during acute, heat when subacute

What innervates the facet joint?

Medial branch of the dorsal ramus of the nerve exiting at the same level and also the medial branch of the nerve one level above

Do ligaments, discs or muscles heal faster?

Muscle injuries generally heal rapidly Ligaments and disc fibrocartilage is slow to repair, repair is often incomplete and full remodeling may not take place (this tissue is poorly vascularized)

What are the symptoms of vertebrobasilar insufficiency?

Nausea and vomiting, the 5 d's (dizziness, drop attacks, diploplia, dysphagia, dysarthria), and look for nystagmus

What is cervical radiculopathy?

Neurocompressive disorder of the cervical nerve roots resulting in various neurological findings Occurs from the inflammatory process initiated by nerve root compression

Cervical sprain/strain: What are some red flags indicating a more serious pathology?

No indication of improvement after one week Getting progressively worse after 1 to 2 weeks Symptoms or signs of symptom magnification Seeks rest, not involved with usual daily responsibilities Seeks more drugs, or drugs not having an effect (watch for addiction)

What kind of structures does hyperflexion damage? (cervical strain/sprain)

Nuchal ligament Interspinous ligament Trapezius Levator scapulae Sub-occipitals

What are some synonyms of cervical spondylosis?

Osteoarthritis, degenerative joint disease, degenerative disc disease

What are some pain descriptors of discogenic pain syndrome?

Pain and paresthesia may radiate down the shoulder, over scapula, or mid-back (non-dermatomal pattern): referred pain from local inflammation

Where does the pain come from with cervical meniscoid entrapment?

Pain is thought not to come from the presence of the meniscoid between the joint surfaces but rather the capsular distension

Talk to me about cervical strains/sprains and radiation patterns

Pain might radiate into occiput or down into shoulder/arm in a non-dermatomal pattern

What is the condition cervical meniscoid?

Pain origination in facet joints due to entrapment of joint capsule soft tissue Natural motion is deranged by the static misalignment entrapping the meniscoid and loss of motion due to entrapment of meniscoid

What would you look for on x-ray for cervical radiculopathy?

Possible loss of disc height (signs of degenerative disc disease) Look for possible canal stenosis on lateral view Oblique view to examine intervertebral foraminal encroachment

What is the difference between primary and secondary spondylosis?

Primary = idiopathic (occupation, abnormal biomechanics, metabolic causes, genetics) Secondary = usually due to trauma (childhood anatomic abnormalities, joint trauma or fracture, repetitive action or motion, secondary to certain spinal surgeries)

What are the risk factors of discogenic pain syndrome?

Prior trauma or excessive axial loading, facet joint tropism (anatomical variation- angular asymmetry between the left and right facet joint orientation)

What is cervical spondylosis?

Progressive loss of articular cartilage and reactive changes at the joint margins + subchondral bone (joint space narrowing, subchondral sclerosis, osteophyte formation and ankylosis)

What are some general treatment ideas for someone with acute cervical spondylosis?

Rest + heat (hot pack, hot tun, sauna) Acute immobilization (short term, cervical collar) Isometric cervical exercises while wearing collar Consider cervical pillow while sleeping Pain free ROM (PFROM) and pain free isometrics

What are some general measures for treatment of cervical facet syndrome?

Same, same as cervical sprain/strain and cervical spondylosis Acute immobilization (short-term cervical collar) Consider cervical pillow while sleeping Pain free ROM (PFROM) and pain free isometrics Myofasical release, swedish massage

What are some risk factors of cervical facet syndrome?

Secondary to cervical injury Cervical disc injuries (disc pain at the same spinal level is associated with facet pain in 40% of cases) Whiplash, strain/sprain, osteoarthritis or RA Repetitive stress, poor posture (occupational)

What are some pain characteristics of patients with cervical spondylosis?

Slowly developing deep achy pain or pain following joint use; chronic recurrent type pain Morning stiffness + pain, aggravated by repetitive or heavy use Possible radiculopathy with nerve root compression (usually C6 or C7 nerve level)

Broad strokes, what is a cervical strain/sprain?

Soft tissue damage (stretch, tearing or rupture) to the ligaments, IV discs and other tissues surrounding the cervical spine that can lead to a variety of clinical symptoms

What is discogenic pain syndrome?

Soft tissue damage + associated irritation of the fibers of the IV discs between the vertebrae (disc sprain and inflammation without herniation)

What kind of accidents result in the worst cervical strain/sprains?

Sort of a trick question The clinical presentation + the perceived severity of injury do not correlate (lower speed impacts often result in more significant + potentially chronic injuries)

Talk to me about special tests and cervical meniscoid entrapment

Spinal compression tests increase local pain (pinch meniscoid) Spinal decompression tests relieve pain (free meniscoid pressure)

What is the most common joint disease in the cervical spine? Where?

Spondylosis Usually occurs at the C5/C6 junction and then the C6/C7 junction

What is the difference between spondylosis and ankylosing spondylitis?

Spondylosis = progressive loss of articular cartilage which leads to reactive changes at joint margins (like osteophyes, joint space narrowing, etc.) Ankylosing spondylitis = chronic inflammatory disorder of the axial skeleton resulting in the formation of new bone at the attachments of ligaments and tendons

What might an x-ray of a patient with discogenic pain syndrome show?

Straightening or reversal or the cervical curve Decreased IV space Associated facet joint and/or vertebral body degenerative changes

What might you find with palpation of cervical radiculopathy?

Tenderness along cervical paraspinals and usually more pronounced along ipslilateral side of affected nerve root Muscle tenderness along muscles where symptoms are referred (e.g. medial scapula, proximal arm, lateral elbow)

If a patient with cervical radiculopathy presented with increased pain with lateral bending away from the affected side what would this mean?

That perhaps this was causing increased displacement of disc herniation upon nerve root

Which is the thickest disc of the cervical spine?

C6-C7 disc

How is cervical radiculopathy usually caused in younger patients?

Disc herniation (acute injury causing foraminal impingement) Sports injury (forced extension, lateral bending, or rotation mechanism)

What do people with cervical meniscoid entrappment typically have when returning to an upright position?

A "catch" in movement

What kind of structures does hyperextension damage? (cervical strain/sprain)

ALL Longus colli SCM Scalenes TMJ

What are some general treatment measures of cervical meniscoid entrapment?

Acute pain + inflammation control Acute immobilization (patient will most likely be doing this instinctively) Consider cervical pillow while sleeping Pain free ROM (PFROM) and pain free isometrics Myofascial release, Swedish massage

What are some general things you should do for an acute cervical sprain/strain?

Acute pain + inflammation control (PRICE) Acute immobilization (patient most likely will be doing this instinctively)- consider a cervical collar for short-term use Consider cervical pillow while sleeping Pain free ROM and pain free isometrics Stretching/myofascial release/Swedish massage with focus on SCM, scalenes, and posterior neck musculature

What orthopedic tests would you do for discogenic pain syndrome?

Any test that challenges the IVD will be positive Positive cervical distraction and compression test Negative Lhermitte test (I think because not a nerve thing) Negative arm abduction test (I think because not a nerve thing)

What are some special tests to test for cervical sprain/strain?

Any test that challenges the injured tissue Cervical distraction might increase local pain Spurling's test (foraminal compression test)- Vizniak has this as three tests: compression in neutral, compression in mild extension and compression in extension and lateral flexion

What are the associated nerves and muscles for the C5 reflex? C6? C7?

Biceps (C5)- musculocutaneous nerve Brachioradialis (C6)- radial nerve Triceps (C7)- radial nerve

What are the most common nerve roots involved in cervical radiculopathy?

C6 (C5-C6) C7 (C6-C7)

What is the most widely available and definitive diagnostic tool or cervical spondylosis?

DIAGNOSTIC IMAGINING (x-ray most commonly used but MRI is starting to become more popular because it is radiation free and still 90% sensitive)

What are some things you might see on an x-ray if someone has cervical spondylosis?

Decreased disc height Osteophyte formation Loss of cervical curve Subchondral bone/end-plate sclerosis Subchondral cysts (geodes) Subluxation (possibly joint instability) Potential IVF encroachment

What will patients describe the pain like for cervical radiculopathy?

Deep aching to burning neck pain and radicular arm pain (numbness, tingling, sharp, shooting, electric) Possible muscle weakness in the arm/hand or sensory changes along the involved nerve root

What are some special tests for cervical radiculopathy?

Dejerine's triad (cough, sneeze, strain) may increase symptoms (because they increase intrathecal pressure) Cervical compression/Spurling's increase neck or radicular pain and distraction decreases Shoulder abduction test shows pain relief (same with cervical spondylosis) Brachial stretch tests cause dermatomal pain referral L'hermiite/Soto-Hall sign (the one where you flex your hip and your neck and pain shoots down your spine)

What are some key points of a forrest plot?

Diamond shows the pooled result Vertical line is the line of no effect (if the diamond touches the vertical line then the combined result is not statistically significant- meaning that the overall outcome rate is the same as the control group) Right of the line = the outcome of interest occurred more frequently in the intervention group than in the control group (unless otherwise noted) Left of the line = the outcome of interest occurred less frequently in the intervention group than the control group (unless otherwise noted) Horizontal line though squares = the confidence interval (if this crosses the vertical line the study does not demonstrate a statistically significant result)

What are the 2 main mechanisms of injury for cervical strains/sprains?

Direct trauma- falls, MVAs, sports injury, sudden unguarded motion Overuse, fatigue, repetitive microtrauma- over hours, days, months of the same motion

What innervates the annulus fibrosis?

The sinuvertebral and vertebral nerves

Are the annulus fibrosis/nucleus pulposus thicker anteriorly or posteriorly? What does this lead to

Thicker anteriorly which contributes to normal cervical lordosis