Cervicogenic Headaches and Cervical Instability Quiz

Cervical Spine Disorders

• These disorders involve the cervical vertebrae, encompassing anatomy, biomechanics, red flags, and treatment classifications.

Objectives

• Students should master the clinical anatomy related to the cervical spine.
• Students should understand the clinical biomechanics of the cervical spine.
• Students need to identify red flags associated with cervical spine issues.
• Students should understand the classification and treatment of cervical disorders.

Cervical Vertebrae Characteristics

• The transverse processes in the upper six cervical vertebrae contain a foramen (transversarium).
• Typical cervical transverse processes have anterior and posterior tubercles for muscle attachment.
• The body's superior surface projects upward, while the inferior surface is angled.
• The spinous processes are short and bifid (except the seventh).

Joints of Cervical Spine

• Craniovertebral (atlanto-occipital, atlanto-axial) joints connect the skull to the cervical spine.
• Zygapophyseal (facet) joints connect adjacent vertebrae, restricting excessive movement.
• Uncovertebral joints uniquely found in the cervical spine connect adjacent vertebrae.

Uncovertebral Joints

• These joints are located between the C3 and C7 vertebrae.
• They consist of unique processes (uncinate processes) that articulate with the level vertebra above.
• The facet joints comprise the superior and inferior articular processes of the adjacent vertebra.

Facet Joints

• In the middle and lower cervical spine (C2-C7), facet joints are in the sagittal plane, inclined upward and forward at approximately 45 degrees.
• The facet joints of C1-C2 are more horizontally aligned to facilitate greater neck mobility (roughly 50% of rotation occurs at this level).

Motions Available

• Spinal motions occur simultaneously and are coupled.
• In the cervical and upper thoracic regions, side bending is coupled with axial rotation moving in the same direction.
• In the upper cervical spine, relative rotation happens during cervical lateral flexion at the C1-C2 and occiput-C1 levels.

Ligaments of Cervical Spine

• Ligaments for the cervical and upper regions of the neck include the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, interspinal ligament, and nuchal ligament.
• The transverse ligament of the atlas encloses and lubricates the dens as the atlas pivots.
• The alar ligament runs from the dens' lateral borders to the occiput—part of the upper cervical spine stabilization.
• The apical ligament runs from the dens' tip to the occiput, taut in head traction.

Vertebral Artery

• The vertebral artery provides crucial blood supply to the brain stem and cerebellum.
• Occlusion of the vertebral artery, particularly with neck extension and rotation, can cause dizziness, nystagmus, slurring of speech, and loss of consciousness.
• Testing the arteries is essential before neck traction or manipulation.

Red Flags

• This is a list of features that could indicate a serious underlying condition needing further investigation.
• Conditions listed includes cervical myelopathy, neoplastic conditions, upper cervical instability, inflammatory/systemic diseases, and vertebral artery insufficiency.
• Specific symptoms such as sensory disturbances in the hands, muscle wasting, unsteady gait, hyperreflexia, bowel and bladder disturbances, specific ages, histories of cancer, unexplained weight loss, constant pain, and night pain are among the features.

Classification Types

• Neurological or non-specific pain: categorized as having neurological involvement or mechanical pain.
• Clinical condition: based on signs and symptoms (e.g., cervicogenic headache).
• Pathoanatomical: based on the structure dysfunction (e.g., facet joint issues).
• Based on response to movement: centralisation and changes in pain location with movement.

Treatment-Based Cervical Spine Classification

• 1-Cervical hypomobility: neck pain with restricted mobility.
• 2-Cervical radiculopathy: neck pain radiating into the arm.
• 3-Clinical instability: neck pain with movement coordination issues.
• 4-Acute pain (whiplash): pain related to movement coordination impairments.
• 5-Cervicogenic headache: neck pain with headache symptoms.

Examination Findings and Interventions for Cervical Hypomobility

• Examination frequently finds restricted AROM (active range of motion) and PROM (passive range of motion), PIVM (passive intervertebral motion) testing in the cervical and upper thoracic regions.
• Interventions often include AROM exercises, muscle energy techniques, mobilization/manipulation techniques, and in subacute and chronic patients.

Cervical Radiculopathy

• A common cause is foraminal encroachment due to factors like decreased disc height and degenerative changes in the uncovertebral or zygapophysial joints.
• Herniation of the intervertebral disc contributes about 25%.
• Symptoms usually involve pain in the neck and one arm, motor/reflex changes, and may be unilaterally or bilaterally present if severe "bony spurs" are present, impinging on nerve root(s)
• If peripheral pain, weakness, or "pins and needles" symptoms exist, they tend to match dermatomal (nerve root) patterns.

Clinical Instability

• This refers to the spine's inability to maintain proper placement during physiological activities.
• This can lead to spinal cord/nerve root damage, pain, and deformity.
• The larger the neutral zone and lessened passive resistance to movement, the greater the chance of clinical instability.
• Poor posture, repetitive trauma, acute trauma, and/or cervical musculature weakness can contribute.

Acute Pain and Whiplash-Associated Disorders

• Whiplash involves sudden acceleration-deceleration forces resulting in a complex array of issues affecting muscles, joints, ligaments, discs, and nerves.
• The Quebec task force categorizes whiplash-associated disorders by clinical presentations.

Physical Examination- Related Tests

• Positive Spurling test (cervical compression test), neck distraction test, Upper limb neurodynamic test 1 (ULNT 1), and limited ipsilateral neck rotation.
• Other assessments to measure cervical instability includes Sharp-Purser test, Transverse Ligament Stress Test, Neck Flexor Muscle Endurance, and Craniocervical flexion test.

Cervicogenic Headaches

• These headaches stem from musculoskeletal dysfunction in the cervical spine (14% - 18% of chronic headache cases).
• Physical examination typically involves the CCFT for evaluating the neuromotor control of deep neck flexors (e.g., rectus capitis anterior, rectus capitis lateralis, longus colli, longus capitis)
• The CFRT (Cervical Flexion-Rotation Test) is used to assess movement impairment in the cervical spine.
• Other symptoms of cervicogenic headaches could include restricted and/or painful movement towards the affected side, unilaterally restricted range of motion of 10+ degrees versus other side, pressure on posterior neck, and muscle tension of the upper traps, SCM, and/or levator scapulae.

Physical Therapy Management

• Emphasizes proper posture, spinal manipulation, strengthening deep neck flexors, and proprioceptive exercises.
• Activity modification and aerobic exercise can assist in pain management.
• Specific types of interventions for particular presenting complaints may include using craniocervical flexion training programs, biofeedback, cervical spine manipulation or mobilization, and exercises targeting thoracic spine, postural education.