Cervical Spine: Pathologies & Guidelines

Objectives

• Common cervical spine pathologies should be understood
• Clinicians should understand how to perform special cervical spine tests
• Development of clinical prediction rules and their application for patients with cervical spine disorders should be understood

Overview

• A cervical Clinical Practice Guideline (CPG) exists
• Neck pain can be associated with radiating pain
• Neck pain can be associated with mobility deficits
• Neck pain can be associated with movement coordination impairments

Cervical Clinical Practice Guideline

• The cervical guidelines were published in 2008 and updated in 2017
• Impairment-based classifications include:
  • radiating neck pain
  • neck pain with mobility deficits
  • neck pain with movement coordination impairments
  • neck pain with headaches
• Physical therapy diagnoses are provided in the guidelines

Neck Pain with Radiating Pain Overview

• Cervical radiculopathy
• Radicular pain
• Referred pain

Cervical Radiculopathy

• A neurological state where conduction is blocked along a spinal nerve or its roots
• Signs and symptoms include:
  • Specific myotome weakness
  • Specific dermatome sensory changes
  • Diminished Reflexes
  • Radiating symptoms (pain, paresthesias) into UE or thoracic spine, described as achy, sharp, or lancinating

Potential Causes of Cervical Radiculopathy

• Nerve compression
  • Disc herniation -changes in space between bones or bone structure such as DDD, stenosis, or osteophytes
  • Trauma
  • Tumor (rare)
• Prevalence is 1.1 to 1.3%

Clinical Prediction Rule (CPR)

• Ipsilateral cervical rotation less than 60 degrees is an indicator
• A positive Spurling's test is an indicator
• A positive Distraction Test is an indicator
• A positive Upper Limb Tension Test A (Median Nerve) is an indicator

Diagnosis Clustering

• Two positive tests for Cervical Radiculopathy have a post-test probability of 21%
• Three positive tests have a post-test probability of 65%
• All 4 tests are positive, the post-test probability is 90%

Cervical Radicular Pain

• Similar to radiculopathy, but pain only
• Signs and symptoms include:
  • Pain radiating from the neck to the UE, thoracic spine, or head
  • No "hard" neurological signs (e.g. myotomal weakness, sensory changes, reflex changes)
  • Narrow band of pain often following dermatomal patterns
  • Described as lancinating, shocking, or electric

Possible Causes and Prevalence

• Possible causes include squeezing or pulling an inflamed nerve root or dorsal root ganglion, or all previously listed causes
• Prevalence ranges from 1.2-5.8 per 1000 persons

Radicular/Radiculopathy Treatment

• Physical therapy is superior to “wait and see” in early stages
• Traction
• Manual therapy
• Exercise with direction-specific - centralization, general exercise, and cervicothoracic exercise
• Education

Cervical Referred Pain

• Perceived in regions distal to the area of noxious stimulation
• Signs and symptoms include:
  • Diffuse areas of pain in the neck, arm, thoracic spine, and head
  • No neurological signs
  • Dull, aching, gnawing pain
• More common than radiculopathy or radicular pain

Causes and Treatment

• Possible causes: Irritation of the muscles, connective tissue (including discs), or facet joints of the cervical spine.
• Treatment includes:
  • Manual therapy of the joint and soft tissue
  • Exercise including mobility, graded exposure and cervicothoracic strengthening
  • Education

Cervical Myelopathy

• Injury to the spinal cord in the cervical spine, due to compression
• Signs and symptoms include:
  • Upper motor neuron lesion signs
    • Hyper-reflexia, spastic weakness, discoordination, balance issues
  • Generally affects LEs first then UEs later, due to position of motor neurons in the lateral corticospinal tract.
• Prevalence: 15,000-20,000 people each year

Cervical Myelopathy Cluster

• Indicators include:
  • Gait Deviation
  • • Hoffmann's sign
  • Inverted supinator sign
  • • Babinski test
  • Age >45 years

Diagnosis Clustering - Cervical Myelopathy

• 1 of 5 positive tests for Cervical Spine Myelopathy have a post-test probability of 43%
• 2 of 5 positive tests have a post-test probability of 64%
• 3 of 5 positive tests have a post-test probability of 94%
• 4 of 5 positive tests have a post-test probability of 99+%

Treatment Warranted

• Systematic Review
  • Low evidence for conservative management in mild cases
  • Surgery superior for moderate and severe cases
• If PT is warranted
  • Manual therapy
    • Mobilization likely more appropriate than HVLAT
    • Small likelihood trauma can exacerbate symptoms
  • Exercises - direction-specific
  • Education

Special Tests for Neurological Symptoms

• Spurling's
• Distraction
• Upper Limb Tension Tests (ULTTs)

Spurling's Test

• Position: Patient seated, therapist standing behind patient
• Action: Patient laterally flexes head to the side of symptoms. Therapist applies force through the top of the head directly inferior
• Positive: Increase in distal symptoms with force
• Indicates nerve root irritation

Distraction Test

• Position: Patient seated, therapist either behind or to the side
• Action: Therapist places hands either under chin and occiput or under bilateral mastoid processes. Slowly lift the patient's head
• Positive: Symptoms are reduced
• Indicates: Nerve root irritation

Upper Limb Tension Tests (ULTTs)

• Median
• Ulnar
• Radial

Median ULTT (Also ULTT1 or ULTTA)

• Position: Patient supine, therapist standing on side of symptoms. Shoulder blade depressed, shoulder abducted to 110 degrees, shoulder ER to 90 degrees, elbow flexed to 90 degrees, forearm fully supinated, wrist neutral
• Action: Maintaining depression, ER, and supination, wrist is fully extended then elbow is extended
• Positive: Reproduction of hand/forearm symptoms (paresthesias or pain)
• Indicates median nerve mechanosensitivity

Radial ULTT (ULTT3)

• Position: Patient supine, therapist standing on side of symptoms; scapula depressed, shoulder abduction 40 degrees, shoulder IR, forearm supinated, wrist neutral
• Action: Keeping scapular depression, shoulder abduction, and shoulder IR, maximally flex and ulnarly deviate wrist, fully extend the elbow
• Positive: Reproduction of symptoms
• Indicates radial nerve mechanosensitivity

Ulnar ULTT (ULTT4)

• Position: Patient supine, therapist standing on side of symptoms, scapula depressed, shoulder abducted to 90 degrees, shoulder ER 90 degrees, elbow flexed 90 degrees, forearm fully pronated, wrist neutral
• Action: Keeping scapula depression, shoulder abducted, and shoulder ER, maximally extend the wrist and then flex the elbow, palm of hand should end facing patient's ear
• Positive: Reproduction of symptoms
• Indicates ulnar nerve mechanosensitivity

Shoulder Abduction (Relief) Test

• Position: Patient seated or standing
• Action: Patient places ipsilateral hand and/or forearm on top of head
• Positive: Relief of symptoms in the arm
• Indicates: Extradural nerve irritation or compression problem, often in C4-C5 or C6-C7

Hoffman's Sign

• Position: Patient seated, therapist standing in front of patient, holding ipsilateral hand
• Action: Therapist flicks the distal phalanx of the patient's middle (3rd) digit
• Positive: Patient's thumb flexes and/or adducts
• Indicates upper motor neuron lesion (pathological reflex)

Inverted Supinator Sign

• Position: 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)
• Positive: Finger flexion and slight elbow extension
• Indicates: Upper motor neuron lesion (pathological reflex)

Babinski Sign

• Position: Patient seated with knee extended or supine with LEs extended, therapist at the patient's feet
• Action: Therapist runs a pointed object along the plantar aspect of the patient's foot
• Positive: Great toe extension and abduction of other toes
• Indicates upper motor neuron lesion (pathological reflex)

Neck Pain with Mobility Deficits

• Mechanical neck pain
  • Irritation of joints, muscles, or other connective tissue of the neck
  • Most common type of neck pain
  • Symptoms that 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 specific mechanism of injury (MOI)

Mechanical Neck Pain Treatment

• Strong evidence for conservative treatment of mechanical neck pain
• Manual Therapy: mobilization, HVLAT manipulation, soft tissue mobilization
• Exercise: mobility, graded exposure, motor control, cervicothoracic strengthening

Special Tests for Facet Pain and Mobility

• Quadrant Test
• Cervical Flexion-Rotation Test

Quadrant Test

• Position: Patient sitting, therapist standing behind patient
• Action: Patient rotates, laterally flexes, and extends head to ipsilateral side. Therapist applies force directly inferior through the head
• Positive: Reproduction of neck pain
• Indicates facetogenic mechanical neck pain

Cervical Flexion-Rotation Test

• Position: Patient supine, therapist standing at patient's head
• Action: Maximally flex the cervical spine. While maintaining full flexion, rotate head first to one side then the next
• Positive: Reduced rotation motion in one direction ;correlates with side of cervicogenic headache
• Indicates upper cervical (C1/2) mobility restrictions

Neck Pain with Movement Coordination Impairments

• Cervical Instability
  • Hypermobility of the cervical joints
  • Can be caused by inflammatory conditions, trauma, or other connective tissue disorders
  • 0.6% prevalence
  • Often present with movement coordination impairments
  • Feeling "tight" despite normal and hyper-mobility
  • Paresthesia in the face or limb(s), dizziness, nystagmus, feeling of a lump in the throat

Treatment for Cervical Instability

• Variable effectiveness of conservative management, but is generally considered first-line treatment
• Severity of instability and symptoms determines surgical appropriateness
• Manual therapy: low-grade mobilizations while monitoring patient response, targeting tissues remote to instability
• Exercise: motor control and stabilization, cervicothoracic strengthening

Whiplash Associated Disorder (WAD)

• "Collection of symptoms affecting the neck that are triggered by...an acceleration-deceleration mechanism"
  • Commonly occurs after MVA or other various forms of trauma
  • Signs and symptoms: Pain (including hyperalgesia or allodynia), decreased ROM in multiple directions, dizziness, loss of balance, decreased strength, paresthesia, Yellow flags–Depression, PTSD, financial considerations, etc.

Diagnosis and Evaluation WAD

• No tissue-specific tests, the diagnosis is based on "collection of symptoms"
• Must rule out significant injury (e.g. fracture) – Canadian C-spine Rules
• Should also be evaluated for concussion due to the MOI
• Grade 0-4 on the Quebec Severity Classification of Whiplash-Associated Disorders

Factors of Delayed Recovery WAD

• Decrease in cervical spine mobility immediately after injury
• Preexisting neck trauma
• Older age
• Female gender
• Psychological factors
• Pending litigation

WAD Treatment

• Activity and exercise is better than avoiding activity
• Education
• Manual therapy; intensity determined by irritability of symptoms
• Exercise: mobility, graded exposure, motor control, cervicothoracic strengthening

Special Tests for Motor Control and Endurance

• Craniocervical Flexion Test
• Cervical Muscle Endurance

Craniocervical Flexion Test

• Tests deep cervical flexor control and endurance to determine movement coordination impairments
• Patient supine with pneumatic pressure device inflated to 20 mmHg
• Keeping head/occiput stationary, patient nods head to increase pressure in the cuff
• 22, 24, 26, 28, and 30 mm Hg, holding each for 10 seconds with a 10-second rest
• Considered dysfunctional if cannot increase pressure to the 26 mm Hg step, cannot hold for 10 seconds, or utilizes compensations

Cervical Muscle Endurance Tests

• Deep Neck Flexor Endurance Test is one way to assess muscle performance and identify endurance impairments
• Patient supine with knees bent (hook or crook lying), mouth closed
• Maximally retract chin, then lift head 2-5 cm and place the examiner's hand on plinth under patient's head while watching skin folds
• Test ends when skin folds are lost or head touches hand
• Normal is 39 seconds or greater
• Patients with neck pain average = 24 seconds
• Cervical Extensor Endurance Test is another way to assess muscle performance and identify endurance impairments
• Patient prone with head off end of the plinth, mouth closed; retract head and hold for 20 seconds while maintaining chin tuck (“bring back of head up toward ceiling”)
• Test ends if neck moves into extension, less than 20-second hold indicates decreased muscle endurance

Special Tests for Cervical Instability

• Sharp-Purser Test
• Transverse Ligament Stress Test

Sharp-Purser Test for Cervical Instability

• Position: Patient seated with neck slightly flexed, therapist standing behind and to the side with one hand on the forehead and one hand on the spinous process of C2.
• Action: Force is applied posteriorly through the forehead and anteriorly through the spinous process of C2 Positive: Examiner feels the head slide posteriorly and/or relief of symptoms.
• Indicates upper cervical instability likely due to disruption of the transverse ligament

Transverse Ligament Stress Test for Cervical Instability

• Position: Patient supine. Therapist supports occiput with palms and 3rd-5th fingers. Index fingers placed over the neural arch of C1 (between occiput and spinous process of C2).
• Action: The head and C1 are lifted anteriorly together and held for 10-20 seconds.
• Positive: Soft end-feel, muscle spasm, dizziness, nausea, nystagmus, paresthesias of face or limb, or a lump sensation in throat
• Indicates: Hypermobility of C1/2 articulation

Overview of Neck Pain and Headaches

• Located in the head, above the orbitomeatal line and/or nuchal ridge (International Headache Society, 2018)
• 40% of the world's population are affected by headaches (WHO, 2021)
• Estimated global prevalence of active headache disorder is 52% (Stovner et al, 2022)
• More than 150 different types: Cervicogenic, migraine, and tension

Cervicogenic Headache

• 4-16% of headache disorders
• Clinical Presentation:
  • Predominantly unilateral
  • "Rams horn" presentation of pain
  • Limited ipsilateral ROM
  • Provoked by pressure to suboccipital region

Mechanism of Cervicogenic Headaches

• Convergence of afferent signals from trigeminal nerve branches (particularly Ophthalmic) and C1-3 in the trigeminocervical nucleus leads to
• A common signal propagates to the higher nociceptive processing centers which results in referred pain to the head and neck

Migraines

• 14% of headache disorders
• Clinical Presentation:
  • Unilateral
  • Nausea, photophobia, phonophobia
  • Pulsating pain
  • Common triggers include stress, hormonal changes, weather, neck pain, food, or exercise

Migraine Mechanism

• A "trigger” sets off a cascade of proinflammatory factors that sensitize the trigeminal afferents around vessels in the pia mater
• Series of cortical, meningeal, and brainstem events, provoking inflammation in the pain-sensitive meninges and resulting in headaches through central and peripheral mechanisms
• Sensitization of the ophthalmic division of the trigeminal nerve is likely the cause of headache symptoms
• Cortical spreading depression is a wave of neuronal and glial depolarization that spreads throughout the brain hemisphere and is likely the cause of migraine auras

Tension Headaches

• 26% of headache disorders
• Clinical Presentation:
  • Bilateral
  • Non-throbbing
  • Not exacerbated by routine physical activity or posture

Tension Headaches Mechanism

• Peripheral tissue irritation (sensitive, taut bands of muscle) particularly in the muscles of the neck, scapula, suboccipital region, jaw (i.e upper trap, SCM, temporalis) leads to
• Chronic irritation can lead to hypersensitivity and chronic headaches

Treatment

• Manual Therapy: manipulation involving the upper cervical and thoracic spinal segments, mobilization targeting the same areas, and dry needling involving suboccipitals, upper trapezius, levator scapulae, temporalis, and SCM
• Exercise: Focus on motor control, endurance, and strengthening

Cervical Flexion-Rotation Test

• Used as a special test.
• Position: Patient supine, therapist standing at patient's head
• Action: Maximally flex the cervical spine. While maintaining full flexion, rotate head first to one side then the next
• Positive: Reduced rotation motion in one direction . Correlates with side of cervicogenic headache.
• Indicates: Upper cervical (C1/2) mobility restrictions