C-Spine Evaluation PDF

cervical spine: Cervical Spine it can undergo degenerating changes like arthritic conditions have pathology related to discs, nerve roots can be subjected to traumatic conditions - have indirect (whiplash injury) or direct (load or spearing) trauma ...

cervical spine: Cervical Spine it can undergo degenerating changes like arthritic conditions have pathology related to discs, nerve roots can be subjected to traumatic conditions - have indirect (whiplash injury) or direct (load or spearing) trauma  Cervical Spine C1 - C7  typical - lamina, pedicles, spinous process, body, transverse process atypical lacks same distinction Atlas and Axis connects skull to cervical spine transmission of load from atlas to remaining spine weight of the head is heavy so to have the head above the spine, it must be situated properly. two sides of the atlas, are pillars - designed to receive the skull -> skull gets situated on a base - evenly distributes the force and provides stability odontoid process of axis - fulcrum both together translate the weight of the skull on the spine yet secures it in place  Ligamentous Anatomy Anterior longitudinal ligament runs anteriorly in front of all the bodies – Reinforces anterior discs, limits extension Posterior longitudinal ligament runs within the spinal canal, same time attached to disc. thats why disc is supported centrally – Reinforces posterior discs, limits flexion Ligamentum nuchae = supraspinous ligament – Thicker than in thoracic/lumbar regions – Limits flexion Interspinous/intertransverse ligaments – Limit flexion and rotation/limits lateral flexion acts as spring whenever vertebrae goes into flexion - prevents further flexion Ligamentum flavum and at the same time pulls back to extension so muscle does not have to work hard – Attach lamina of one vertebrae to another, reinforces articular facets – Limits flexion and rotation  Ligamentous Anatomy a = ligamentum flavum b = interspinous ligaments c = supraspinous ligament  Palpable C7 Anterior Curvature – Shock absorption Ligaments – Ligamentum Nuchae – Mostly injured in “Whiplash” Vertebral Arteries  C3 protection of spinal cord Spinal Nerves – C1-T1 – Cervical Plexus C1-C4 C4 -Phrenic Nerve - Breathing – Brachial Plexus uses nerve roots C5 and T1 sometimes it starts earlier from C4 - prefix C5-T1 sometimes it ends at T2 - post-fix  Dermatomes C1 – top of head C2 – Temporal C3 – Side of jaw/neck C4 – top of shoulders Myotomes C5 – Abduction C1-2 – Neck Flexion C6 – Elbow Flexion/Wrist Extension C3 – Lateral Neck Flexion C7 – Elbow Extension/Wrist Flexion C4 – Shoulder Elevation C8 – Finger Flexion T1 – Finger Abduction Brachial Plexus  lie in neck Brachial Plexus lie in axilla ROOTS TRUNKS DIVISIONS CORDS BRANCHES Dorsal Scapular Suprascapular C5 Anterior Upper Posterior Lateral Lateral Pectoral C6 Middle Anterior C7 Musculotaneous Posterior Posterior Axillary C8 Lower Anterior Radial T1 Posterior Medial Median Medial Pectoral Ulnar Long Medial Antebrachial Thoracic Medial Brachial Cutaneous Thoracodorsal Subscapular  Muscles Trapezius Sternocleidomastoid Scalenes Splenius Semispinalis, Spinalis, Longissimus  Cervical Injuries Fairly uncommon in athletics(6-7%) - but greater than 90% of all fatalities are cervical related. Cervical injuries are primarily technique related: – Spearing seen in american football – Tackling or falling head first. when the pt has car accident, expect the worst Must have an emergency plan: keep head fixed – All personnel know roles and equipment use. – All unconscious athletes - suspect head/neck – Always suspect the worse until proven otherwise injury in cervical injury --> doubt the worst first because we need to be extra cautious even in whiplash injury, head should be fixed. dont move it  Cervical Injuries all result in same outcome but severity is different Common MOIs – Axial Loading would bend the head – Flexion Force – Hyperextension Force – Flexion-Rotation Force – Hyperextension-Rotation – Lateral Flexion pushing head against fixed spine so force propagates until it finds the weakest point and results in fracture, mostly its near c5,c6 so its away from upper cervical can result in fracture or dislocation of odontoid process fracture is bad because the fragment can move and hurt anything dislocation is more severe because it resembles hanging --> weight of body goes down and the upper vertebrae splits so the odontoid process punctures the medullary centre of respiration so breathing is effected  C-Spine Injuries worse than fracture Cervical Fracture or Dislocation – Weakness or Paralysis Cervical Nerve Root Injury – Herniated Disc disc protrudes out – Laceration – Cord Shock (Central Cord Syndrome) disc gets centrally in the spinal canal - cord shock – Hemorrhage – Contusion overstretching – Cervical Stenosis tissue of disc inside the spinal canal can dehydrate and dries inside and forms a bulge inside results narrowing of canal results in stenosis  there is no cervical convex curve - there is severe spasm of the muscle, protecting it from moving forward slippage of vertebrae severe trauma causing tear drop fracture leading to instability entire disc went forward  tear drop fracture small wedge of the corner of the vertebrae is broken curve although exists a bit because the pt is extending the skull but if seen properly the curve is not there  C-Spine/Neck Injuries partial or complete rupture of the fibers of muscle or tendon Cervical Strain active movt is painful, passive pain free – Active motion most painful ligaments Cervical Sprain (Whiplash) active and passive both painful during active contraction, ligament might be stretched – Passive and active motion painful Torticollis (WryNeck) can be congenital or acquired spasm of sternomastoid imbalance between the scm - one side is more contracted will result in passive joint limitation on the side of – Muscle spasm and facet irritation contraction Brachial Plexus Stretch or Compression someone can fall head first - head is bent so it stretched on one Contusions to Throat side and compressed on other side --> burner or stinger syndrome sustained pulling on the neck results in straining of anterior muscle of cervical lesion  Evaluation Techniques HOPS – History, Observation, Palpation, Special Tests Your first priority! assess shoulder as well – Establish the integrity of the spinal cord and nerve roots – History and several specific tests provide information History  History Location of pain Onset of pain Mechanism of injury (etiology) Consistency of pain Prior history of cervical spine injury important  Location of Pain inflammatory process Localized pain underlying problem – Typically indicative of muscular strain, ligamentous sprain, facet joint injury, fracture and/or subluxation or dislocation if pain changes with change in position - mechanical in nature like in the cases of disc injury Radiating pain pain along a neural pathway – Hightened risk of likely spinal cord, cervical nerve root and/or brachial plexus injury referred pain - pain referring to remote cause of origin eg ; angina pectoris, pain is in between the shoulder blades in the back but the problem is in the heart Onset of Pain/Mechanism of Injury Acute onset sudden happened on the spot – Generally associated with one specific mechanism of injury/event gradual Chronic or insidious (unknown) onset – Generally related to overuse injuries (accumulative micro trauma) and/or postural abnormalities and deficiencies  pain that is consistent refers to inflammation Consistency of Pain same spot same intensity - localized Pain from inflammation (strain, sprain, contusion) generally persists despite consistency - undergoing changes in cervical spine position problem is existing --> inflammation Pain of mechanical nature (nerve root compression) varies depending upon cervical spine positioning and can be minimized or eliminated there is an attitude formed compression in one direction provokes, releasing the compression reduces pain not consistent - mechanical  Prior History of Cervical someone had cervical disc 5 years back Spine Injury took physio, was okay then later had whiplash injury pt having same signs and symptoms in same signs and symptoms appeared again - not the past may not have the same same diagnosis diagnosis Must evaluate for residual symptoms associated with previous injury disc maintains space between the vertebrae. Once it is herniated, there is narrowing of joint spaces. Pt takes but that doesnt increase the space between vertebrae. with the slightest wrong position after 4 or 5 years, the compression might compress the nerve root which gives the same signs and symptoms. so history is very imp Must appreciate structural changes (scar tissue, etc.) which may predispose individual to current injury and symptoms if someone has lumbar disc, they are liable for spondylosis (OA of spine) and compression of neural element is expected Inspection  Inspection Cervical spine curvature Position of head relative to shoulders Soft tissue symmetry Level of shoulders  Cervical Spine Curvature Normal cervical spine has lordotic curve Increased lordotic curve (forward head) indicative of poor posture and muscular weakness or imbalance Lessened lordotic curve indicative of muscular spasm/guarding and/or nerve root impingement Lordotic Curve  Position of Head Relative to Shoulders Head should be seated symmetrically on cervical spine Lateral flexion from unilateral spasm of muscles – strain and/or spasm (guarding) Rotation from unilateral spasm of sternomastoid muscle – strain and/or spasm (guarding) or torticollis Torticollis  Soft Tissue Symmetry Observe for bilaterally comparable muscle mass, tone and contour – Dominant extremity may be hypertrophied vs. non-dominant extremity – Excessive tone indicative of possible strain/spasm – Atrophy indicative of neurological injury  Level of Shoulders Inspect height of: – Acromioclavicular (AC) joints – Deltoids – Clavicles Dominant extremity often appears depressed relative to non-dominant extremity Injuries Palpation  Anterior Palpation Hyoid bone – At level of C3 vertebrae, note movement with swallowing Thyroid cartilage – At level of C4/C5 vertebrae, also moves with swallowing, protects larynx – Aka – “Adam’s apple” Cricoid cartilage – At level of C6/C7 vertebrae, point where esophagus and trachea deviate, rings of cartilage  Anterior Palpation Sternomastoid – Sternum (near SC joint) to mastoid process Scalenes – Posterior/lateral to sternomastoid muscles – Difficult to differentiate, palpate collectively Carotid artery – Primary pulse point Lymph nodes – Only discernable if enlarged due to illness  Posterior and Lateral Palpation Occiput – Posterior aspect of skull, many ms. attachments Transverse processes – Can only palpate C1 transverse processes approx. one finger below mastoid processes Spinous processes – Flex cervical spine, C7 and T1 are prominent – Can palpate C5 and C6, maybe C3 and C4 Trapezius – Upper fibers from occiput and cervical spinous processes to distal clavicle Special Tests  Special Tests Range of motion testing – Active – Passive – Resisted Ligamentous/capsular tests Neurological tests – Brachial plexus evaluation – Reflex tests – Upper motor neuron lesions  Active Range of Motion Best done in sitting or standing Flexion – touch chin to chest Extension – look straight above head Lateral flexion – approximately 45 degrees Rotation – nose over tip of shoulder  Passive Range of Motion Best done laying supine Flexion – firm end feel Extension – hard end feel (occiput on cervical spinous processes) Lateral flexion – firm end feel (stabilize opposite shoulder) Rotation – firm end feel  Resisted Range of Motion Easiest to perform all in seated position – stabilize proximally to avoid substitution Flexion – resistance to forehead Extension – resistance to occiput Lateral flexion – resistance to temporal and parietal regions Rotation – resistance to temporal region or side of face  Ligamentous/Capsular Testing No specific named tests for cervical spine End feels associated with passive ranges of motion essentially become end points for joint capsule and ligamentous stress tests  Neurological/Vascular Tests Brachial plexus evaluation – Dermatomes = sensory map – Myotomes = motor function – Reflex tests – Brachial plexus traction test – Cervical distraction/compression tests – Spurling test Upper motor neuron lesions – Babinski test – Oppenheim test – Loss of bowel and/or bladder control Vertebral artery test  Brachial Plexus - Dermatomes All based upon anatomical position C5 – lateral arm C6 – lateral forearm, thumb, index finger C7 – posterior forearm, middle finger C8 – medial forearm, ring and little fingers T1 – medial arm  Brachial Plexus - Myotomes Minor differences will exist from one resource to another C5 – shoulder abduction C6 – elbow flexion or wrist extension C7 – elbow extension or wrist flexion C8 – grip strength (shake hands) T1 – interossei (spread fingers)  Neurological Testing Dermatomes Reflexes – Babinski – Oppenheim – Biceps – Brachioradialis – Triceps Myotomes  Brachial Plexus – Reflex Tests C5 – biceps brachii reflex (anterior arm near antecubital fossa) C6 – brachioradialis reflex (thumb side of forearm) C7 – triceps brachii reflex (at insertion on olecranon process)  Brachial Plexus Traction Test Mimics mechanism of injury Cervical spine laterally flexed and opposite shoulder is depressed Positive if radiating/”burning” pain in upper extremity – If traction injury, symptoms noted on side of depressed shoulder – If compression injury, symptoms noted in direction of lateral flexion  Cervical Distraction/Compression Tests Distraction – Patient supine, clinician stabilizes head – Passive traction force applied to cervical spine – Positive test if neuro symptoms and/or pain reduced with traction force Compression – Patient sitting, clinician pushes down on top of patient’s head – Positive test if pain and/or neuro symptoms reproduced in cervical spine and/or upper extremity Cervical Compression Test  Spurling Test Same positioning as cervical compression test Instead of linear axial load through top of head, clinician extends and laterally rotates neck with compression to impinge on nerve root/s Positive if pain and/or neuro symptoms reproduced in cervical spine and/or upper extremity Spurling Test compression with extension with or without rotation  Upper Motor Neuron Lesions Symptoms of catastrophic head and/or spinal cord injury associated with trauma Babinski test – Blunt device stroked along plantar aspect of foot from calcaneus to 1st metatarsal head – Positive test if great toe extends and other toes splay Oppenheim test – Fingernail ran along medial tibial border/crest – Positive test if great toe extends and other toes splay Babinski Test in spine the most provocative test is increase in compression within the vertebrae Vertebral Artery Test any change in the orientation in the cervical vertebrae may cause compression of the vertebral artery Assesses patency of vertebral artery Patient placed supine on table Clinician supports head at occiput Patients neck passively extended, laterally flexed and then rotate toward laterally flexed side for ~30 seconds Positive test if dizziness, confusion, nystagmus, unilateral pupil changes and/or nausea present if bending to right, im testing left side artery flow Cervical Spine Pathologies to differentiate between strains and sprains we simply look at ROM if active and passive both are painful - sprain if only active is painful - strain  Cervical Spine Injuries Acute injuries typically trauma induced and involve excessive movement/s of the spine and injury to related structures Chronic conditions result from poor posture, muscle imbalances, decreased flexibility and/or repetitive movement related to activity  Cervical Spine Injuries brachial plexus can be stretched and compressed - those who play basketball/volleyball, when they are throwing a ball, someone pushes them down or jumps over them, so injury happens Brachial plexus injuries (stinger/burner) they feel stinging or burning sensation starting from above – Compression or distraction the clavicle going down to the upper extremity but it is provoked around the erbs point - specific point where the trunk of brachial plexus is very much superficial Cervical nerve root impingement – Degenerative disc changes – Acute disc injury Sprain/strain syndrome – Difficult to differentiate Vertebral artery impingement  Cervical Injuries Brachial Plexus (C5-TI) “burners or stingers” – MOI: stretch or compression – S/S: burning or stinging neck/arm/hand, muscle burning or stinging sensation from above weakness, supraclavicular tenderness (Erb’s 2-3 cms from the the clavicle and going clavicle down the upper extremity Point), neck pain chronic: numbness ,tingling, and weakness lasts longer mild case that cant continuously heal when neural system is injured, it is not replaced by neural cells, it is usually replaced by glial cells. so its a form of cells that sit like fibrous tissue but basically form neural tissue only so repeated injury to same site - prognosis is not good because we remove more than 1 tissue in that location upper extremity effected - goes into weakness and tenderness  Brachial Plexus Pathology TESTS: Neurological findings!! Brachial Plexus Traction Test Tinel’s Sign Spurling’s Test Cervical Distraction Burning, achy pain Muscle weakness Point tenderness Mechanism of Injury  Brachial Plexus Injury Compression force – nerve roots pinched between adjacent vertebrae – Increased risk if spinal stenosis (narrowing of intervertebral foramen exists) Distraction force – tension or “stretch” force on nerve roots – Most common at C5/C6 levels but may involve any cervical nerve root – Erb’s point – 2-3 cm above clavicle anterior to C6 transverse process, most superficial passage of brachial plexus  it is tender Erb’s Point used for electrical stimulation in erbs palsy trunk of brachial plexus  Brachial Plexus Injury Signs and symptoms – Immediate and significant pain paraesthesia – “Burning” or radiating pain in upper extremity – Dropped shoulder on affected sidebecause of the weakness – Myotome and dermatome deficiencies at affected nerve root levels depend on extent of injury Generally, symptoms minimize or resolve quickly If recurrent, takes less trauma to induce symptoms and longer for symptoms to diminish longer time to heal  Cervical Nerve Root Impingement between facet joints, there are neural canals where nerve roots come out. for it to be compressed, it can be from a narrowing base, from degenerative conditions, from osteophytes. signs and symptoms are more or less same but mechanism of treatment is different treatment of spondylosis would be different than the Disc related conditions one for cervical disc herniation there may be overlapping of exercises but the sequence of the treatment would be different – Degenerative disc changes – Disc herniations – most at C5/C6 or C6/C7 levels – Often presents with head in position of least compression on affected nerve root/s – Similar neuro symptoms to brachial plexus injuries at involved level/s Narrowing of intervertebral foramen – Exostosis (bone spur) – Facet degeneration  Cervical Nerve Root Impingement Causes: – Spinal stenosis compresses the main cord – Disc herniations (C5-6 or C6-7) are most common – Chronic Muscular Tension/Facet Joint Syndrome Pain characteristics: – Radiating pain into upper extremity Upper quarter screening reveals: – Sensory deficits and/or muscle weakness  Sprain/Strain Syndrome Since unable to directly palpate facet joints, difficult to differentiate pain/spasm associated with sprain of joint capsule from strain of musculature Inflammation from sprain/strain may irritate nerve roots in close anatomical orientation to affected area and produce neuro symptoms Severe sprains (dislocations) will present with postural change due to joint disassociation  Cervical Strains and Sprains S/S: – limited AROM/RROM/PROM, – diffuse tenderness, – no peripheral pain or paresthesia, – normal neurological To Board or Not to Board – That is the question? **Criteria for return to play – Full pain free ROM and strength, physician’s approval  Vertebral Artery Impingment Due to anatomic location, may be compromised with same mechanism of injury as brachial plexus/cervical nerve root impingement injuries Signs and symptoms – Dizziness – Confusion – Nystagmus Cervical Disk, Nerve Impingement, or Fracture/Dislocation S/S: – Abnormal neurological – Peripheral pain or parasthesia, – specific tenderness BOARD them and call emergency **Criteria for return to play – Full pain free ROM and strength, Dr. approval  can be involved as a source of pain Cervical Facet Joint Syndrome cervical lesion, sometimes people take one position more than the other- while driving looking at one side all the time the rotatory movt of one facet joint over the next will make it locked S/S: - results in localized pain and with time, it becomes intermittent. In the beginning, it was inflammation, with time it turns mechanical. relieved by positional change example, people who crack their necks – limited AROM/RROM/PROM, sometime with severe pain, they crack their neck and the pain still exists - because they already misalign the facet joints, so whatever they do they cannot get it back – Achy and intermittent pain – relieved by where exactly is it? position changes, thumbs on the transverse processes, then move between two transverse processes and press - if one side painful than other then facet joint on that side is inflammed. – peripheral pain or paresthesia is unlikely, – normal neurological unless chronic and symptoms have developed – **Criteria for return to play - Full pain free ROM and strength, Physician approval (for players) to board or not board - means to keep him on field or get him out happens because of compression or tension Neck Contusion Contusions to Neck – MOI: Clothes lining – Voice box injury, Tracheal injury – Loss of voice, Raspy voice – Inability to swallow ecchymosis around anterior throat area because excessive pulling cause: head stuck in shirt and cant get out and the pt keeps pulling to a point they overstretch the soft tissues results in neck contusion pain with swallowing - if its so much need to go to physician. Thank You