Cervical Spine Pathologies

Objectives

• A central objective is to comprehend the common pathologies of the cervical spine.
• Gaining proficiency in performing specific cervical spine tests comprises a key objective.
• Knowledge of developing clinical prediction rules for cervical spine disorders should be understood.

Overview of Cervical Spine Issues

• The material includes the Cervical Clinical Practice Guideline (CPG).
• Neck pain accompanied by radiating pain is tackled.
• It will consider neck pain including mobility deficits.
• Neck pain where movement coordination has been impaired is involved in content to study.

Cervical Clinical Practice Guideline

• The cervical clinical practice guideline was published in 2008 and updated in 2017.
• The guideline categorizes neck issues based on impairment.
• These classifications include neck pain with radiating pain.
• Further classifications list Neck pain with mobility deficits
• Neck pain with movement coordination impairments is included as a classification
• Neck pain with headaches is another classification listed
• Physical therapy diagnoses are included in the classifications.

Neck Pain with Radiating Pain

• Cervical radiculopathy refers to nerve root impingement.
• Radicular pain refers to pain along the nerve root pathway, not neurological dysfunction.
• Referred pain originates from a musculoskeletal source referring pain elsewhere.

Cervical Radiculopathy

• Cervical radiculopathy is a neurological condition where nerve conduction is blocked along a root.
• Specific myotome weakness indicates potential motor nerve involvement.
• Specific dermatome sensory changes suggest sensory nerve involvement.
• Diminished reflexes can indicate nerve compression or damage.
• Radiating symptoms, such as pain and paresthesias, may extend into the upper extremity or thoracic spine.
• Patients often describe the pain as achy, sharp, or lancinating.

Potential Causes & Prevalence

• Nerve compression may be caused by potential causes
  • Includes disc herniation
  • Considers changes in space between bones/bone stricture (such as DDD stenosis, osteophytes)
  • Includes trauma
  • Includes tumor (rare)
• The prevalence of cervical radiculopathy ranges from 1.1 to 1.3%.

Clinical Prediction Rule (CPR) for Cervical Radiculopathy

• Ipsilateral cervical rotation less than 60 degrees increases likelihood.
• A positive Spurling's test suggests nerve root compression.
• Relief of symptoms with distraction is a positive finding.
• Reproduction of symptoms with the Upper Limb Tension Test A (Median Nerve) is another diagnostic factor.

Cervical Radicular Pain

• Cervical radicular pain is similar to radiculopathy, but primarily involves pain.
• Symptoms involve pain radiating from the neck to the upper extremity, thoracic spine, or head.
• "Hard" neurological signs may be absent (myotomal weakness, sensory changes, reflex changes)
• Pain often presents as a narrow band following dermatomal patterns.
• Typical descriptions involve lancinating, shocking, or electric sensations.

Possible Causes & Prevalence

• Nerve root or dorsal root ganglion inflammation can cause squeezing or pulling
• Possible causes include all previous possible causes of impingement
• The prevalence is 1.2-5.8 per 1000 persons

Treatment

• Physical therapy is a superior treatment to "wait and see" in early stages
• Treatment options include traction.
• Manual therapy can help to alleviate pain and improve function.
• Exercise, focusing on direction-specific movements promoting centralization is an effective approach.
• Educate the patient so that they understand their condition and management strategies.

Cervical Referred Pain

• Referred pain is pain perceived in regions distal from the area of noxious stimulation
• Symptoms include diffuse pain in the neck, arm, and thoracic spine, and head
• Neurological signs are absent
• Dull, aching, gnawing pain is often the main complaint
• It is more prevalent than radiculopathy or radicular pain

Possible Causes

• Irritation of the muscles, connective tissue (including discs), or facet joints of the cervical spine can occur

Treatment

• Manual therapy focusing on joint and soft tissue is helpful
• Exercise focusing on Cervicothoracic strengthening, graded exposure and mobility may be useful
• Education may be required so that the patient understands this type of referred pain

Cervical Myelopathy

• Cervical myelopathy involves injury to the spinal cord due to compression.
• Upper motor neuron lesion signs include hyper-reflexia, spastic weakness, discoordination, and balance issues.
• It generally affects the lower extremities before upper extremities.
• This is caused by the position of motor neurons in the lateral corticospinal tract
• It is estimated to affect 15,000-20,000 people annually.

Cervical Myelopathy Cluster

• Gait deviation can occur
• A positive Hoffmann's sign indicates underlying myelopathy
• Additional indications include inverted supinator sign
• A positive Babinski test signifies upper motor neuron involvement
• It is more common in those aged 45 years & older

Treatment

• Treatment is reviewed systematically for any possible solutions
• Low evidence suggests conservative management for mild cases
• For moderate and severe cases surgery is recommended
• Manual therapies that include mobilization may be indicated
• Any trauma exposure, however small, should be watched for exacerbation of symptoms
• Exercises should be both direction and specific
• Education of the issue should be addressed

Special Tests for Neurological Symptoms

Spurling's Test

• The patient is seated, and the therapist stands behind them.
• The patient laterally flexes their head to the side exhibiting symptoms.
• The therapist applies a downward force through the top of the patient’s head.
• Distal symptom increase indicates a positive test
• A positive result indicates nerve root irritation.

Distraction Test

• Position seated: the therapist is either behind or to the side
• Action: Therapist places hands either under chin and occiput or under bilateral mastoid processes, slowly lifting the patient's head.
• Reduced symptoms indicates a positive test
• It also Indicates nerve root irritation

Upper Limb Tension Tests (ULTTs)

• Common tests focus on the median, ulnar and radial nerves

Median ULTT (ULTT1 or ULTTA)

• The patient is supine; the therapist stands on the side of symptoms.
• The shoulder blade is depressed, abducted to 110 degrees, ER to 90 degrees, elbow flexed to 90 degrees, forearm fully supinated, wrist neutral.
• Action: Maintain depression, ER, and supination, wrist fully extended then elbow extended.
• Hand and forearm symptom reproduction (paresthesias or pain) is a positive test.
• It Indicates median nerve mechanosensitivity

Radial ULTT (ULTT3)

• Patient supine; therapist stands on side of symptoms.
• The scapula is depressed, shoulder abducted 40 deg, shoulder IR, forearm supinated, wrist neutral.
• Action: With scapular depression, shoulder abduction & IR, maximally flex and ulnarly deviate wrist, fully extend elbow.
• Positive if it reproduces the symptoms
• It indicates radial nerve mechanosensitivity

Ulnar ULTT (ULTT4)

• Patient supine, therapist stands on side of symptoms
• The scapula must be depressed, the shoulder abducted to 90 deg and ER 90 deg
• Elbow and forearm are flexed to 90 deg, and forearm fully pronated, with wrist neutral.
• Keeping scapula depressed and shoulder ER, maximally extend the wrist and then flex the elbow until the palm faces the patient's ear
• Reproduction of symptoms is a positive test
• It indicates ulnar nerve mechanosensitivity

Shoulder Abduction (Relief) Test

• Patient can be either seated or standing
• They place their ipsilateral hand and/or forearm and the top of their head
• Test is regarded as Positive if relief of symptoms in the arm occurs.
• Test indicates extradural nerve irritation or compression.
• It often occurs in C4-C5 or C6-C7

Hoffman’s Sign

• Patient is seated, and the therapist stands in front of them, holding the ipsilateral hand
• The Therapist flicks the distal phalanx of patient's middle (3rd) digit
• Thumbs flexes or adducts with a positive test
• Sign can indicate an Upper motor neuro lesion (pathological reflex)

Inverted Supinator Sign

• Patient seated, therapist standing in front of patient with wrist supported
• Action: Tap near the styloid process of the ipsilateral hand using a reflex hammer (brachioradialis tendon)
• Produces finger flexion and slight elbow extension
• Indicates an Upper motor neuron lesion (pathological reflex)

Babinski Sign

• Patient seated with knee extended or supine with LEs extended, therapist at the patient's feet
• Action involves running a pointed object along the plantar aspect of the foot
• Produces great toe extension and abduction of other toes
• Indicates an Upper motor neuron lesion (pathological reflex)

Neck Pain with Mobility Deficits

• Mechanical neck pain comes from Irritation of joints, muscles, or other connective tissue of the neck
• It represents the most common type of neck pain
• Symptoms are either unilateral or bilateral
• Remember referral patterns of facet joints and trigger point referral patterns
• Can be insidious (no known cause) or have a mechanism of injury (MOI)

Treatment

• Strong evidence indicates conservative treatment of mechanical neck pain is helpful
• This includes Manual Therapy that focuses on Manipulation, Mobilization, or soft tissue mobilization

Special Tests for Facet Pain and Mobility

Quadrant Test

• The Patient sits while the therapist stands behind them.
• The patient rotates, laterally flexes, and extends their head to the ipsilateral side
• A force is applied directed inferior through their head
• Test is Positive if it reproduces of neck pain
• Likely indications include facetogenic mechanical neck pain.

Cervical Flexion-Rotation Test

• Perform this test with Patient supine, and the therapist at patient’s head end
• Maximally flex the cervical spine
• While maintaining extension, rotate the head to one side then the other
• Reduced rotation motion in one direction is a positive indicator
• It is associated with the side of cervicogenic headache
• Upper cervical joint restrictions (C1/2) are indicated with this test result

Overview of Neck Pain with Movement Coordination Impairments

• Cervical instability is hypermobility of the cervical joints
• It can be caused by inflammatory conditions (e.g. rheumatoid arthritis), trauma, or connective tissue disorders (e.g. Elhers-Danlos)
• Prevalence is placed at 0.6% (Beck et al 2004)
• Often presents with movement coordination impairments
• Feelings of “tightness” may be present despite normal and hyper-mobility occuring
• Symptoms are often paresthesia in the face or limb(s), dizziness, nystagmus,. or feelings of a lump in the throat

Treatment

• Treatment involves Variable effectiveness of conservative management
• Severity of instability and symptoms determines surgical appropriateness
• Manual therapy involves Low-grade mobilizations with monitoring patient response and targeting tissue with instability
• Exercises focuses on motor control and stabilization and Cervicothoracic strengthening

Whiplash Associated Disorder (WAD)

• Comprises a "collection of symptoms affecting the neck with an acceleration-deceleration mechanism"
• A WAD commonly occurs after a motor vehicle accident, but can occur after any trauma
• Symptoms include pain (hyperalgesia or allodynia), decreased ROM, dizziness, loss of balance, decreased strength, and paresthesia.
• Depression, PTSD, and financial considerations may impact recovery.

Other notes on WAD

• No tissue-specific tests exist
• Diagnosis depends on the collection of symptoms described earlier
• Rule out significant injury (e.g. fracture) must be done via the use of the Canadian C-spine Rules.
• Those that have suffered impact from the MOI must also be evaluated for concussion
• Grade 0-4 on the Quebec Severity Classification of Whiplash-Associated Disorders is used to diagnose WAD

Treatment

• Activity and exercise perform better than solely avoiding activity
• Education is useful in helping them understand their condition
• Therapeutic interventions that help soothe, such as manual therapy may be useful (determined by symptom irritability test.)
• Specific exercises can be focused through these avenues: increased mobility, graded exposure, motor control andCervicothoracic strengthening

Special Tests for Motor Control and Endurance

• Testing cervical motor control is a very common test to understand their condition

Cervical Motor Control

• Cranio cervical Flexion Tests assess deep cervical flexor control and endurance

Cervical Motor Control

• A craniocervical Flexion Test is completed
• The patient lies supine with a pneumatic pressure device inflated to 20 mm Hg
• Keeping the head/occiput stationary, the patient nods to increase cuff pressure
• Target pressure is 22, 24, 26, 28, or 30 mm Hg, holding each for 10 seconds (10 second rest)
• Test is considered dysfunctional if the patient cant increase the pressure to 26 mmHg, can't hold for 10 seconds, or utilizes compensations

Cervical Muscle Endurance

• An alternative involves the Deep Neck Flexor endurance test and cervical Extensor Endurance Test
• These tests help assess muscle performance and identify any impairments

Cervical Muscle Endurance

• Complete the Deep Neck Flexor Endurance Test
• With this test have the patient lying supine with knees bent (hook or crook lying) and mouth closed
• The patient should fully retract their chin and lift their head 2-5cm
• An examiner's hand is placed in order to keep the head 2-5 cm off the plinth
• Watch for skin folds to lose contraction
• This tests ends when skin folds are lost or the head touches the plinth
• Typically someone will hold fully functional for 39 seconds or longer
• Patients that suffer from neck pain only last 24 seconds

Cervical Muscle Endurance

• Complete the cervical Extensor Endurance Test
• Start with the patient in their prone position with their head off the end of the plinth and their mouth closed
• The patient should then retract their head for 20 seconds
• Test ends if the neck moves into extension which means the patient isn't focused and maintaining the chin tuck
• A hold of under 20 seconds indicates decreased muscle endurance

Special Tests for Cervical Instability

Sharp-Purser Test

• Patient is seated with neck slightly flexed, and the therapist stands behind and to the side, placing one hand on the forehead and another on the spinous process of C2.
• Action: Apply posterior force through the forehead and anterior force through the spinous process of C2.
• Positive when the head slide posteriorly and relief of symptoms
• Indicates upper cervical instability due to disruption of the transverse ligament

Transverse Ligament Stress Test

• Patient lies supine while the therapist supports their occiput with palms and 3rd-5th fingers.
• Position index fingers over the neural arch of C1 (between Occiput and spinous process of C2.)
• Lift the head and C1 anteriorly together, holding for 10-20 seconds.
• Test is positive when you feel a soft end-feel, muscle spasm, dizziness, or any nystagmus with a lump sensation.
• likely indicates a hypermobility of C1/2

Overview of Neck Pain with Headaches

• Describes pain (qv) located in the head above the orbitomeatal line and/or neck ridge (International Headache Society, 2018)
• World Health Organization reports show that 40% of the world's population has dealt with headaches as of 2021
• 52% of the earth's population have a headache (2022)
• 150 different types of headaches occur, including the Cervicogenic, migraine and tension headaches

Cervicogenic Headache

• Cervicogenic headaches account for 4–16% of all headache disorders (2009/2000)
• Patients often have predominately unilateral pain (rarely switches) and a “rams horn” pattern of pain
• Test results may show Limited ipsilateral ROM (particularly cervical rotation)
• The headaches are often provoked when pressure is exerted around the suboccipital region

Mechanism of Headache

• Convergence of afferent signals can occur between trigeminal nerve branches (particularly opthalmic) and C1-3 in their trigeminocervical nucleus
• Then the common signal propagates to higher nociceptive processes
• Pain then refers towards the head and neck regions

Migraines

• Migraines make up 14% of all headaches
• Headaches will be unilateral, and may often change sides repeatedly
• Patients may complain of nausea, and have sensitivity to sound and sight
• Pulsating pain may occur, and common triggers can include hormonal changes, neck pain, food and exercise

Mechanism

• A trigger then activates a wave of proinflammatory properties
• This sensitizes the trigeminal afferents vessels in the areas
• Then the trigeminal nerves spread a "cortical spreading depression" wave
• Nerve irritation causes some of their known headache symptoms

Tention Headaches

• Tension accounts for 26% of all headache disorders
• Headaches will be bilateral
• Pain is described not as throbbing, but as a dull ache
• Headaches will note be accelerated by activity/exercise

Mechanism

• There may be peripheral tissue irritation on the sides
• This causes sensitive muscles on the areas of the neck, scalpula, and sub Occipital
• Irritation then causes hypersensitivity and then long term chronic headaches