Cervical and Thoracic Spine

• The notes relate to the cervical and thoracic spine

Epidemiology: Neck Pain

• Neck pain incidence ranges from 22-70%, with a prevalence of 30-50% over a 12-month period
• Neck pain becomes more common with age
• Neck pain is more prevalent in females in their 50s
• Neck pain results in billions of dollars in healthcare costs
• Risk factors include age over 40, co-existing low back pain, loss of hand strength, poor quality of life, and a worrisome attitude
• Clinical outcomes vary; simple cervical radiculopathy often has good outcomes, while "whiplash" incidents often have poorer outcomes
• Diagnosis and classification compares ICF classifications to TBC
• Imaging: Canadian Cervical Spine Rule may be used
• Cervical spine issues comprise ~25% of an orthopedic physical therapy caseload

Cervical Bony Anatomy

• The cervical spine consists of 7 vertebrae and 8 nerves
• The upper cervical spine includes C0-C1 and C1-C2
• The lower cervical spine includes C3-C7
• C1, also known as the Atlas, lacks a body and spinous process
• C2, also known as the Axis, features the dens
• A unique feature of the cervical vertebrae is the transverse foramen, which houses the vertebral artery

Thoracic Bony Anatomy

• The thoracic spine consists of 12 vertebrae and 12 nerves
• The upper thoracic spine encompasses T1-T3
• The middle thoracic spine includes T4-T7
• The lower thoracic spine includes T8-T12
• Special features of the thoracic vertebrae are facets for articulation with the ribs
• The costotransverse joint and costovertebral joint are present
• The vertebral foramen is narrow
• The thoracic ring has structural regions

Cervical Ligamentous Anatomy

• Key cervical ligaments include the anterior longitudinal ligament, posterior longitudinal ligament, alar ligaments, transverse ligament, and cruciform ligament
• The function of cervical ligaments maintain passive stability, keeping the dens away from the spinal cord
• The ligamentum nuchae is present

Cervical Spine Muscles

• Posterior upper cervical muscles include the superior oblique, inferior oblique, rectus capitis posterior major and minor
• Anterior upper cervical muscles include the rectus capitis anterior and lateralis, and longus colli
• Anterior lower cervical muscles include the sternocleidomastoid, longus capitis, longus colli, scalenes (anterior, middle, and posterior), and splenius capitis and cervicis

Arthrology

• Cervical spine flexion occurs at AO, AA, and C2-C7
• Cervical spine extension occurs at AO, AA, and C2-C7
• Cervical spine rotation occurs at AA and C2-C7
• Lateral flexion occurs at AO, C2-C7, and T1-T12

What Causes Neck Pain?

• Determine if the patient's symptoms indicate a visceral disorder or serious pathology
• Identify the source of the patient's pain
• Pathoanatomical diagnoses may be difficult to determine in the spine
• Rule out systematic condition as a possible cause for persistant pain
• Red flags include neoplastic conditions, systemic disease. upper cervical ligamentous instability, VBI and cervical myelopathy

Pathoanatomical Diagnoses: Cervical Myelopathy

• It's caused by compression of the spinal cord, sometimes due to osteophytes or disc degeneration
• Common symptoms include hyperreflexia, non-dermatomal sensory changes, clonus of the ankle, Babinski and Hoffman reflexes, weakness below the level of compression, and gait clumsiness

Inverted Supinator Sign Test

• The exam is performed on a sitting patient with resting forearm
• The examiner applies a stimulus with a reflex hammer just proximal to the styloid process of the radius
• A positive test is finger flexion or slight elbow extension

Cervical Spondylosis and Radiculopathy

• Spondylosis is degeneration of the cervical spine, common in 90% of people over 50
• Spondylosis differs from acute disc herniation
• Disc degeneration, longitudinal ligament degeneration, and osteophytes can compress nerve roots or the spinal cord
• Symptoms of Spondylosis include headache, loss of motion, crepitus, and pain
• Surgical options are available
• Cervical radiculopathy presents with a dermatomal/myotomal pattern
• It's the compression of nerve roots caused by osteophytes, disc, or tumor
• There is Clinical prediction rule to test, including Spurling Test, Distraction, ULTTA (Median nerve), Less than 60 degrees rotation involved side

Thoracic Outlet Syndrome

• TOS is compression of the neurovascular bundle in the thoracic outlet by bony and soft tissue structures
• The superior thoracic outlet, scalene triangle, area between the clavicle and rib 1, space between the pectoralis minor and thoracic wall are potential compression sites
• The disorder may be vascular (arterial/venous) or neurogenic
• Areas related brachial plexus, subclavian artery, veins and Vagus and phrenic nerves
• Vascular, arterial symptoms involve pain, numbness, coolness, and pale discoloration that worsens with cold temperatures
• Venous symptoms includes excruciating pain in the chest, shoulder, and upper extremity, heaviness after activity, cyanotic discoloration, and distended collateral veins with edema
• Neurogenic symptoms are pain, paresthesia, numbness, and/or weakness, which can be radicular or non-radicular
• Special tests include Roos' and Adson's tests
• Treatment includes manual therapy and NMR to address clavicle upward rotation, soft tissue mobility, shoulder flexion, scapular movements, thoracic position, rotator cuff strength, and core control
• After conservative measures, surgical options include Botox injections, first rib removal, scalenectomy, and anterior capsular plication

Non-Musculoskeletal Pathologies Causing Referred Pain to the Thoracic Spine

• Conditions include myocardial ischemia, thoracic aortic aneurysm, peptic ulcers, cholecystitis, neoplasms, inflammatory pathologies, and fractures
• Myocardial Ischemia risk factors include female/male age, known vascular disease, pain during exercise and believed to be of cardiac origin
• Thoracic Aortic Aneurysm risk factors are chest pain that refers to the back when descending aorta is involved and sudden onset of labored breathing
• Peptic Ulcers risk factors are pain referred to the mid-thoracic spine that changes after eating and a history of dyspepsia
• Cholecystitis risk factors involve pain in the RUQ with referral to the right scapula associated with nausea and vomiting
• Neoplasms risk factors include previous history of cancer, unexplained weight loss, failure to improve
• Inflammatory pathologies risk factors incude stiffness, and improvement in back pain symptoms with excercise
• Fractures risk factors include Prevalence of thoracic fractures, age, and history of major trauma

Examination

• Review patient's reported material (Neck Disability Index and FABQ) and radiological/other medical source information
• Initial observations and review lumbar section
• Cardiac, integumentary, musculoskeletal, neurological
• Decision to refer out/continue exam with structural and screening
• Perform Active and Passive Range of Motion tests
• Manual muscle tests for Muscle strength
• Perform length exams and specialized tests

Structural Inspection

• Review posture
• Creating a neutral lumbar spine
• Decreasing thoracic flexion
• Decrease low cervical extension
• Correct upper vs lower thoracic and lumbar region
• Work proximal to dial to achieve desired spinal motion

Resisted Test for Endurance

• The deep neck flexor endurance test determines patient ability to flex the next and duration
• The VBI test determines vertebral basilar Insufficiency
• Other tests test joint and ligament function

Clinical Practice Guidelines

• Neck pain with mobility deficits are associated with Central and/or unilateral pain, Motion limitations with symptom reproduction at end-range
• Neck pain with radiating pain is associated with UE numbness and weakness and Positive radiculopathy test-item cluster
• Neck pain with movement coordination impairments are associated with Trauma/whiplash and Neck pain with mid-range motion that worsens at end-range
• Interventions include advice to stay active, manual therapy