Clinical Assessment of Neck and Cervical Spine

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Questions and Answers

What should a clinician observe during vertebral artery testing?

Decreased heart rate

Nystagmus and slurring of speech (correct)

Improved range of motion

Increased muscle strength

Which of the following is considered a contraindication to neck traction and manipulation?

Dizziness after testing the vertebral arteries (correct)

A history of neck pain

Mild headaches

Patient age under 30 years

Which condition does not fall under red flags for serious pathology in neck-related issues?

Muscle strain (correct)

Cervical myelopathy

Neoplastic conditions

Vertebral artery insufficiency

What age criterion is mentioned as a red flag for serious pathology in patients?

Age >50 years Signup and view all the answers

Which of the following symptoms could indicate vertebral artery insufficiency?

Dysphasia Signup and view all the answers

After ruling out serious pathology, how is neck pain often classified?

Neurological or non-specific Signup and view all the answers

Which vital sign is identified as a red flag when assessed?

Blood pressure >160/95 mm Hg Signup and view all the answers

Which symptom is specifically mentioned as a warning sign during vertebral artery testing?

Blurring of vision Signup and view all the answers

What unique feature do the transverse processes of the upper six cervical vertebrae possess?

Foramen transversarium Signup and view all the answers

What is the orientation of the articular facet joints in the middle and lower cervical spine?

Sagittal plane inclined upward and forward Signup and view all the answers

Which cervical segment is known to allow the greatest amount of rotation?

C1-C2 Signup and view all the answers

What type of motion coupling occurs during lateral flexion in the upper cervical spine?

Opposite side axial rotation Signup and view all the answers

What anatomical structures limit the movements of spinal segments?

Ligaments, intervertebral discs, and facets Signup and view all the answers

What is the shape of the occipital condyles in relation to the superior articular surfaces of the atlas?

Convex and concave respectively Signup and view all the answers

What does the performance index measure in cervical spine assessment?

The ability to maintain a pressure level through repetitions Signup and view all the answers

What type of movement occurs simultaneously due to anatomical structures in the cervical spine?

Lateral bending and axial rotation Signup and view all the answers

What characteristic describes the spinous process of a typical cervical vertebra?

Short and bifid Signup and view all the answers

Which of the following is a subjective feature of clinical cervical instability?

Fatigue and inability to hold the head up Signup and view all the answers

What is the purpose of strengthening stabilizing muscles in the cervical spine?

To enable better control of movement within the neutral zone Signup and view all the answers

What is the most common surgical treatment for severe cervical spine instability?

Anterior cervical fusion Signup and view all the answers

Which characteristic is NOT typically associated with poor neuromuscular control in cervical instability?

Absolute range of motion increases in standing Signup and view all the answers

What is a key goal of non-surgical treatment in managing cervical instability?

Improvement of controlled motion quality Signup and view all the answers

Which of the following is a possible objective feature of clinical cervical instability?

Hypomobility of the upper thoracic spine Signup and view all the answers

What type of exercises are beneficial for improving proprioception in the context of cervical instability?

Balance and coordination exercises Signup and view all the answers

What cervical spine position is most effective in provoking arm symptoms during Spurling's test?

Neck in extension, lateral flexion and axial compression Signup and view all the answers

Which condition is characterized by neck pain, irradiating arm pain, and a decrease in cervical spine range of motion?

Cervical radiculopathy Signup and view all the answers

What is a common symptom exacerbated by lateral flexion toward the affected side in cervical radiculopathy?

Decreased muscle strength Signup and view all the answers

What does the pathoanatomical model primarily focus on in understanding clinical conditions?

Structure that is dysfunctional within the body Signup and view all the answers

In treating cervical radiculopathy, which of the following is NOT a proposed intervention?

High-impact aerobic exercises Signup and view all the answers

What is defined as the inability of the spine to maintain its pattern of displacement under physiological loads?

Cervical instability Signup and view all the answers

Which classification is NOT included in the treatment-based classification for managing neck pain?

Chronic tension-type headache Signup and view all the answers

Which of the following is NOT a typical symptom of cervical radiculopathy?

Joint stiffness in the lumbar region Signup and view all the answers

What was the main purpose of the approach suggested by Werneke et al regarding acute spinal pain syndromes?

To enhance the identification of patients with improved treatment outcomes Signup and view all the answers

Which aspect has been emphasized with the shift towards a cost-effective model for diagnosis?

Separating patients into treatment-oriented subgroups Signup and view all the answers

Which intervention involves manual or mechanical methods to relieve symptoms of cervical radiculopathy?

Cervical traction Signup and view all the answers

How is clinical instability primarily characterized?

Increased size of the neutral zone Signup and view all the answers

In the context of neck pain management, what does 'WAD' stand for?

Whiplash Associated Disorders Signup and view all the answers

What does the treatment-based classification model emphasize for therapists?

Matching interventions to specific patient subgroups Signup and view all the answers

Which of the following is a characteristic of the symptom response-based approach known as centralization?

It assesses how movement impacts symptom location Signup and view all the answers

What was updated in 2008 as part of the APTA Orthopedic section ICF Guidelines?

The classification categories for neck pain Signup and view all the answers

What is the purpose of the Sharp-Purser test in relation to the Transverse Ligament Stress Test?

To reproduce symptoms before reducing them Signup and view all the answers

Which of the following is NOT a sign of a positive test result for the procedure involving the C1 vertebra?

Increased neck strength Signup and view all the answers

During the Neck Flexor Muscle Endurance Test, which position does the patient assume?

Supine in hook lying Signup and view all the answers

What defines the activation score in the Craniocervical Flexion Test (CCFT)?

The activation of deep cervical flexor musculature Signup and view all the answers

What is a normal endurance time for men during the Neck Flexor Muscle Endurance Test?

38.9 seconds Signup and view all the answers

What commonly occurs in patients with neck pain due to clinical instability during deep neck flexor activation?

Altered neuro-motor control strategy Signup and view all the answers

Which aspect of the Neck Flexor Muscle Endurance Test is MOST critical for its termination?

Separation of skin folds due to loss of chin tuck Signup and view all the answers

What is indicated by soft end-feel during the examination of the C1 vertebra?

Potential ligamentous laxity or instability Signup and view all the answers

Study Notes

Cervical Spine Disorders

Objectives: Students should be able to memorize clinical anatomy and biomechanics, identify red flags of the cervical spine, and understand classifications and treatments for cervical disorders.

Cervical Vertebrae Special Characteristics

Cervical vertebrae have transverse processes with foramina (foramen transversarium) in the upper six.
Typical cervical vertebrae have anterior and posterior tubercles for muscle attachment.
The body's superior surface projects upward, while the inferior surface is beveled.
The spinous process is short and bifid, except for the seventh spinous process.

Joints of the Cervical Spine

Craniovertebral Joints: Include the atlanto-occipital and atlanto-axial joints.
Zygapophyseal Joints: Also known as facet joints, comprised of the superior articular process of one vertebral body and the inferior articular process of the adjacent vertebra.
Uncovertebral Joints: Unique to the cervical spine (C3-C7), these joints are formed by the uncinate processes.
Intervertebral Joints: Joints between adjacent vertebral bodies of the spine.

Uncovertebral Joint

Located between C3 and C7.
These joints are formed by the projections of the superior surfaces of the vertebral bodies called the uncinate processes.

Facet Joints Orientation

Articular facet joints of the middle and lower cervical spine (C2-C7 to T1) are situated in the sagittal plane, angled upward and forward approximately 45°.
C1-C2 facet joints are oriented more horizontally to allow for increased mobility.
C1-C2 also allows for the greatest amount of rotation (approximately 50%).

Motions Available

Motions in the spine, including flexion, extension, translation, axial rotation, and lateral bending, occur simultaneously.
The exact pattern of coupling depends on regional anatomical variations.
In the cervical and upper thoracic spine, side bending is coupled with axial rotation in the same direction.

Occiput-C1 Joints

Formed by the occipital condyles and the concave-shaped superior articular surfaces of the atlas.
Occipital condyles glide in the opposite direction of the motion, following the convex/concave rule.

Ligaments

Ligaments of the upper cervical spine: Include the transverse ligament, alar ligament, and apical ligament.
The transverse ligament encloses the dens and provides lubrication as the atlas rotates around the dens.
The alar ligament is a major portion of the stabilization system of the upper cervical spine.
The apical ligament becomes taut when traction is applied to the head.

Important Considerations

Upper cervical spine ligaments can be damaged in high-velocity accidents, weakened by rheumatoid arthritis, or congenitally absent.
Before any mechanical treatment, the integrity of the upper cervical ligaments should be tested. Tests include the Sharp-Purser test, lateral flexion alar ligament stress test, and transverse ligament stress test.

Vertebral Artery

The vertebral arteries supply blood to the posterior brain stem and cerebellum.
Occlusion of the vertebral artery can cause a reduction in blood flow to the brain stem leading to dizziness, nystagmus, slurring of speech, and loss of consciousness.
Before any traction or manipulation techniques on the upper cervical spine, carefully test the vertebral arteries by placing and holding the neck in rotation, extension, and lateral flexion for approximately 1 minute.
Clinicians should observe the patient for potential warning signs, including dizziness, nystagmus, slurring of speech, and loss of consciousness, during vertebral artery testing.

Red Flags (Features for Further Investigation)

Cervical Myelopathy: Sensory disturbance of hands, muscle wasting of hand intrinsic muscles, unsteady gait, hyperreflexia, bowel and bladder disturbances, and night pain.
Neoplastic Conditions: Age >50 years, history of cancer, unexplained weight loss, constant pain.
Upper Cervical Ligamentous Instability: Post-trauma, RA, Down Syndrome, occipital headache, and numbness.
Inflammatory or Systemic Disease: Temperature >37°C, drop attacks, blood pressure >160/95 mmHg.
Vertebral Artery Insufficiency: Dizziness, lightheadedness related to head movements, resting pulse >100 bpm, and resting respiration >25 bpm.

Classification Types

Neurological or non-specific: Pain often described as having neurological involvement or being non-specific.
Clinical condition: Classifies based on signs and symptoms, such as cervicogenic headaches.
Pathoanatomical: Categorized based on the dysfunctional structure, such as facet joints or intervertebral discs.

Response to Movement (Centralisation)

This classification system is based on how movement changes symptoms.
It allows for improved treatment outcomes and planning of conservative treatment.

Treatment-Based Classification

1-Cervical Hypomobility: Neck pain with mobility deficits.
2-Cervical Radiculopathy: Neck pain with radiating pain.
3-Clinical Instability: Neck pain with movement coordination impairments.
4-Acute Pain (including whiplash): Neck pain with movement coordination impairments.
5-Cervicogenic Headache: Neck pain with headache.

Cervical Hypomobility

Stiffness as a primary dysfunction, noted during active, passive, and passive intervertebral motion testing.
No symptoms beyond shoulder.
Examination findings include:
- Restricted AROM, PROM.
- Restricted PIVM testing cervical or upper thoracic.
- No UE radicular symptoms.
- Sudden or gradual onset.
- Deficient in cervicosaculothoracic strength and motor control

Cervical Radiculopathy

Disorder of the spinal nerve root, often caused by foraminal encroachment, decreased disc height, and/or degenerative changes in the uncovertebral and zygapophysial joints.
Characterized by unilateral pain in the neck and arm, loss of motor function, and/or reflex changes in the distribution.
Can be caused by herniation of the intervertebral disc.

Whiplash Associated Disorders (WAD)

Injury resulting from sudden acceleration and deceleration forces on the neck.
Includes several issues affecting muscles, joints, bones, ligaments, discs, and nerves.

Quebec Task Force Classification for Whiplash-Associated Disorders

Classification system for whiplash-associated disorders based on clinical presentation (0-4).
Grade 0: No complaint or signs.
Grade 4: Complaints and fracture/dislocation.
Note: Musculoskeletal signs include decreased range of motion and point tenderness. Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits.

Physical examination Tests for Cervical Instability

Sharp-Purser test, Transverse Ligament Stress Test, Neck Flexor Muscle Endurance Test, C-R Flexion Test.

Acute Pain and Whiplash Associated Disorders

This is a complex condition with various disturbances that impact motor, sensorimotor, and sensory functions, and psychological distress.

Cervicogenic Headaches

Headaches originating from musculoskeletal dysfunction of the cervical spine.
Common clinical tests include CCFT, a test of the deep flexors of the cervical spine, and the CFRT, used to identify movement impairment.

Special Tests

Cervical Flexion-Rotation Test: Assess cervical spine rotation.

Clinical Presentation (Cervical Disorders)

General presentation: Symptoms, including pain, radiating pain, muscle weakness, paresthesia, headaches, and potentially referred symptoms to the upper body.
Cervical Radiculopathy: Pain in the neck and one arm, along with other symptoms.
Cervical Instability: Poor coordination, aberrant movements, pain relief through non-weight-bearing, fatigue, and external support.

Physical Therapy Management

Proper posture, spinal manipulation (on hypomobile segments below the level of instability), strength to deep flexor muscles, strengthening the stabilizing muscles, proprioception exercises, and ergonomic corrections for managing cervical disorders

Treatment Considerations

Surgical interventions (anterior cervical fusion) may be necessary.
Post-surgical rehabilitation involves low-level strengthening exercises for anterior cervical and parascapular muscles.
Avoid any lifting greater than 4 kg for at least 6 weeks post-surgery.
Avoid any cervical dynamic strengthening or ranges of motion exercises for the first 6 months.

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Description

This quiz focuses on key observations and assessments related to vertebral artery testing, contraindications to neck manipulation, and red flags in neck-related conditions. It is essential for clinicians to understand these critical aspects to ensure patient safety and effective treatment. Test your knowledge on cervical anatomy and clinical signs relevant to neck pain.