Cervical Spine Disorders PDF

Cervical Spine Disorders By Dina Othman Shokri OBJECTIVES: By the end of this lecture, the student should be able to: Memorize the related clinical anatomy. Memorize the related clinical biomechanics. Identify the red flags of cervical spine. Recognize and understand classification...

Cervical Spine Disorders By Dina Othman Shokri OBJECTIVES: By the end of this lecture, the student should be able to: Memorize the related clinical anatomy. Memorize the related clinical biomechanics. Identify the red flags of cervical spine. Recognize and understand classification and treatment of cervical disorders  Cervical vertebrae special characteristics ❖ Transverse processes that contain a foramen (foramen transversarium), in the upper six cervical vertebrae. ❖ The typical transverse process of a cervical vertebra also has anterior and posterior tubercles for muscle attachment. ❖ The body superior surface projects upwards at the sides, while its inferior surface is correspondingly beveled. ❖ The spinous process is short & bifid except the seventh spinous process. Joints of the cervical spine Uncovertebral joint Facet joints orientation The articular facet joints of the middle and lower cervical spine (C2-C3 to C7-T1) are in the sagittal plane and incline upward, forward at approximately 45. This forward inclination allows the articular facet joints to bear weight and guides the motion of the segment. The facet joints for C1-C2 are oriented more horizontally than the middle and lower cervical spine facet joints to allow greater mobility. The C1-C2 segment allows the greatest amount of rotation (approximately 50%). Motions Available The movements of each spinal segment are limited by anatomical structures such as ligaments, intervertebral discs, and facets. Specifically, anatomical structures cause the coupling of motions of the spine, that is, movements occur simultaneously. Flexion, extension, translation, axial rotation, and lateral bending are physiologically coupled. The exact pattern of coupling depends on the regional variations of anatomical structures. In the cervical and upper thoracic spine, side bending is coupled with axial rotation in the same direction. Regarding the upper cervical spine, during cervical lateral flexion, a relative rotation occurs to the opposite side of the lateral flexion at the C1-C2 and occiput-C1 segments to allow the face to remain facing forward in a frontal plane during the lateral flexion The occiput-C1 joints are formed by a pair of convex-shaped occipital condyles and the concave-shaped superior articular surfaces of the atlas. Therefore, the occipital condyles glide in the opposite direction of the motion direction, which follows the convex/concave rule. It is logical to count C6-C7 as the last moving segment with cervical active movements, but clinically, motion is noted in the vertebral segments as caudal as T3-T4 with cervical active motion. The active and passive mobility of the upper thoracic spinal segments should be evaluated and treated with the cervical spine. LIGAMENTS  Ligaments of the upper cervical spine The transverse ligament of the atlas has its origin and insertion on the interior surface of the anterior ring of the atlas. It encloses the dens and is lined with a synovial membrane and articular cartilage to provide lubrication as the atlas rotates around the dens. The alar ligament is a winglike structure that has its origin on the lateral borders of the dens and its insertion on the occiput. It is a major portion of the stabilization system of the upper cervical spine. The configuration of the atlanto-occipital joints could allow considerable lateral flexion, which would damage the medulla oblongata. The apical ligament has its origin on the tip of the dens and inserts on the occiput. It becomes taut when traction is applied to the head. The joint capsule of the atlanto-occipital joint is reinforced with ligaments. Important consideration The ligaments of the upper cervical spine may be damaged in high- velocity accidents, weakened by rheumatoid arthritis or other types of systemic inflammatory diseases, or may be congenitally absent or malformed. Before any kind of mechanical treatment is begun, traction or manipulation of the cervical spine should be considered gravely dangerous, the integrity of the upper cervical ligament should be tested. (Sharp-Purser Test, lateral flexion alar ligament stress test. Transverse ligament stress test Vertebral artery Maximum occlusion of vertebral artery occurs with the combination of extension and rotation. Brief occlusion of the vertebral artery is not a problem in a patient who has normal carotid arteries and a normal circle of Willis; however, if there is interruption of the normal blood supply to the brain, occlusion of the vertebral artery may cause a reduction of blood flow to the brain stem and cerebellum, the symptoms of which are dizziness, nystagmus, slurring of speech, and loss of consciousness. There are many well- documented cases of coma and death secondary to vasospasm or thrombosis of the vertebral arteries caused by manipulation of the upper cervical spine. Before using traction or manipulation techniques on the upper cervical spine, the vertebral arteries should be tested carefully one at a time by placing the neck in full rotation, extension, and lateral flexion to each side and holding for approximately 1 minute. The clinician should observe the patient for nystagmus, slurring of speech, blurring of vision, dizziness, or unconsciousness. Dizziness as a result of vertebral artery testing is fairly common and should be a warning sign to the practitioner to proceed very cautiously. Nystagmus, slurring of speech or loss of consciousness should be considered contraindications to traction and manipulation of the neck, and the practitioner should take care when treating the patient to make sure that the neck is not positioned in extension or the extremes of rotation. vertebral artery test Red flags: Features from patients subjective and objective examination which are thought to put them at higher risk of serious pathology and warrant referral for further investigation Cervical Myelopathy Neoplastic Upper Cervical Inflammatory or Vertebral Artery Conditions Ligamentous Systemic Disease Insufficiency instability Sensory disturbance Age >50 years Post trauma Temperature >37°C Drop attacks of hands RA Down Syndrome Muscle wasting of History of cancer Occipital headache Blood pressure Dizziness hand intrinsic and numbness >160/95 mm Hg muscles Unsteady gait Unexplained weight Severe limitation Resting pulse >100 Lightheadedness loss during neck AROM in bpm related to head all directions movements Hyperreflexia Constant pain; no Signs of cervical Resting respiration Dysphasia relief with bed rest myelopathy >25 bpm Bowel and bladder Night pain Fatigue nystagmus, slurring disturbances of speech, blurring of vision, unconsciousness  Classification Types Neurological or non-specific Once diagnostic triage has taken place and the individual has been cleared of serious spinal pathology neck pain is often refer simply classified as having neurological involvement or being non- specific (sometimes referred to as mechanical) neck pain. Clinical condition This is a medical model that is signs and symptoms based i.e. what condition does the individual have, such as cervicogenic headache etc. Pathoanatomical Another medical model that is structurally based i.e. which structure is dysfunctional, such as facet joint, intervertebral disc, myofascial. Response to movement (centralisation) Symptom response based i.e. how does movement change symptoms, such as with repeated movements and the centralisation phenomenon. Werneke et al suggested categorisation by changes in pain location to mechanical assessment and treatment allowed identification of patients with improved treatment outcomes and facilitated planning of conservative treatment of patients with acute spinal pain syndromes. Treatment based The system was based on the goals of treatment and the interventions used to achieve these goals, rather than an attempt to classify patients by pathology or symptom distribution. It was updated in 2008 as part of the APTA Orthopedic section ICF Guidelines with the four current classification categories including: neck pain with mobility deficits, neck pain with radiating pain (radicular), neck pain with movement coordination impairments (WAD), and neck pain with headache (cervicogenic). Therapists should be aware of the different classification systems that exist. Appropriate use of these systems can guide specific assessment and treatment selection. There has been a shift from the pathoanatomical model of diagnosis towards a more cost effective model that separates a heterogeneous population into treatment-oriented subgroups with matched treatment interventions. This type of classification is likely to be most helpful for therapists as it is based on signs and symptoms that match interventions to the subgroup of individuals most likely to benefit from them.  Treatment based classification for managing individuals with neck pain. 1-Cervical hypomobility (neck pain with mobility deficits). 2-Cervical radiculopathy(neck pain with radiating pain (radicular). 3-Clinical instability (neck pain with movement coordination impairments. 4-Acute pain (including whiplash) (neck pain with movement coordination impairments (WAD). 5-Cervicogenic headache (neck pain with headache (cervicogenic).  Cervical hypomobility When the primary dysfunction is stiffness of the cervical spine, as noted with active, passive, and passive intervertebral motion testing, patients with neck pain and the absence of arm symptoms (no symptoms beyond the shoulder) Examination finding Proposed interventions AROM exercises Restricted AROM,PROM Restricted PIVM testing cervical or Muscle energy technique upper thoracic Cervical and thoracic No UE radicular symptoms mobilization/or manipulation Sudden or gradual onset techniques Deficient in cervicosacuplothoracic strength and motor control (subacute and chronic patient)  Cervical radiculopathy Cervical radiculopathy (CR) is a disorder of the spinal nerve root The most common cause of CR (in 70% to 75% of cases) is foraminal encroachment of the spinal nerve from a combination of factors, including decreased disc height and degenerative changes of the uncovertebral joints anteriorly and zygapophysial joints posteriorly (i.e., cervical spondylosis). Herniation of the intervertebral disc is responsible for only about 25%. CR is usually present with pain in the neck and one arm, loss of motor function, or reflex changes in the distribution. Most of the time cervical radiculopathy appears unilaterally, however it is possible for bilateral symptoms to be present if severe bony spurs are present at one level, impinging/irritating the nerve root on both sides. If peripheral radiation of pain, weakness or pins and needle are present, the location of the pain will follow back to the concerned affected nerve root (dermatomal and myotomal). Clinical examination procedures Four clinical examination procedures for identification of patients with cervical radiculopathy that was confirmed and correlated with electrodiagostic testing if all four test items were positive. The four test items include 1- Positive Spurling. 2- Neck distraction test. 3- Upper limb neurodynamic test 1 (ULNT 1). 4- Limited ipsilateral neck rotation range of motion (less than 60 degrees). Positive Spurling’s A test:The Spurling's test (also known as Maximal Cervical Compression Test and Foraminal Compression Test) is used during a musculoskeletal assessment of the cervical spine when looking for cervical nerve root compression causing. There are different ways described in the literature to perform the Spurling's test. The version that provoked arm symptoms the best was with the neck in extension, lateral flexion and axial compression  Positive neck Positive ULNT 1 distraction test  Neck rotation range of motion By goinometer By CROM By inclinometers Clinical Presentation Typical symptoms of cervical radiculopathy are: neck pain, irradiating arm pain and parasthesia, corresponding to a dermatomal pattern. muscle weakness in a myotomal pattern, reflex impairment/loss, headaches, scapular pain. Symptoms are generally amplified with side flexion towards the side of pain and when an extension or rotation of the neck takes place because these movements reduce the space available for the nerve root to exit the foramen causing impingement.. This often causes the patient to present with a stiff neck and a decrease in cervical spine ROM as movement may activate their symptoms. This may result in secondary musculoskeletal problems which can manifest as a decrease in muscle length of the cervical spine musculature (Upper fibers of trapezius, scaleni, levator scapulae), weakness, joint stiffness and postural defects which can go Proposed interventions Cervical traction (manual/mechanical) Upper-extremity neurodynamic (gliding and sliding/tensioning). Cervical range of motion (active and passive motion). Active ROM exercises such as contralateral rotation and side flexion are amongst the simplest forms of exercises which are effective against signs and symptoms. Stretching for shorted muscles via muscle energy techniques. Deep neck flexor strengthening exercises and scapular strengthening exercises. Non-thrust cervical mobilizations (PA glides/Lateral Glides). Thrust manipulation techniques of the cervical or thoracic spine Education on proper posture and postural exercises  Clinical instability Clinical instability is defined as the inability of the spine under physiological loads to maintain its pattern of displacement, may result in the spinal cord or nerve roots becoming damaged or irritated, deformity or pain can develop. Clinical instability is believed to be a result of increase in the size of the neutral zone and reduction in the passive resistance to motion created in the elastic zone. The total range of motion of a spinal segment may be divided into the neutral zone and the elastic zone. Motion that occurs in and around the neutral mid position of the spine is produced against minimal passive resistance (i.e., neutral zone). Motion that occurs near the end range of spinal motion is produced against increased passive resistance (i.E.,Elastic zone). Clinical spinal instability occurs when the neutral zone increases relative to the total range of motion, the stabilizing subsystems are unable to compensate for this increase, and the quality of motion in the neutral zone becomes poor and uncontrolled. Degeneration and mechanical injury of the spinal stabilization components are the primary causes of increases in neutral zone size. Factors that contribute to degeneration or mechanical injury of the stabilizing components are poor posture, repetitive occupational trauma, acute trauma, and weakness of the cervical musculature. Poor quality of motion is a key aspect of clinical instability, the presence of aberrant motions during active movement has been suggested by several authors to be a cardinal sign of clinical instability. Aberrant motions are described as either sudden accelerations or decelerations of movement that occur outside the intended plane of movement. General tenderness of the cervical region, referred pain in the shoulder and parascapular area, cervical radiculopathy, cervical myelopathy, occipital and frontal/retroorbital headaches, paraspinal muscle spasm, decreased cervical lordosis, and pain with sustained postures. Head feels heavy, Neck gets locks with movement, Better in unloaded position such as lying down. Catching, clicking, clunking, and popping sensation. Physical examination The following tests can be used to measure cervical instability Sharp-Purser test Transverse Ligament Stress Test Neck Flexor Muscle Endurance Test Craniocervical flexion test Sharp-Purser test: Assesses the integrity of the Atlanto-Axial joint and more notably the stabilizers of the dens on the Atlas. This test specifically assesses the integrity of the Transverse Ligament. If the transverse ligament that maintains the position of the odontoid process relative to C1 is torn, C1 will translate forwards on C2 in flexion. Transverse Ligament Stress Test: Test for hypermobility of the atlantoaxial articulation The patient is placed in a supine position with the therapist supporting the patient's. The therapist then places the index fingers between the occiput and spinous process of C2, so the index fingers are over the neural arch of the C1 vertebra. The therapist then lifts the patient's head and C1 vertebra anteriorly, without allowing flexion or extension. The position should be held for 10-20 seconds. A positive test : Abnormal pupil response Nystagmus Soft end-feel Dizziness Nausea Paresthesia of the lip face or limb Lump sensation in the throat The Sharp-Purser test should be performed before the Transverse Ligament Stress Test, because the Sharp-Purser test works to reduce symptoms, while the Transverse Ligament Stress Test works to reproduce symptoms. Neck Flexor Muscle Endurance Test: To assess the endurance of the deep neck flexors, ability to lift the head and neck against gravity for an extended period Performing the Test: The patient is positioned in supine, in hook lying. The chin is maximally retracted and maintained isometrically while the patient lifts the head and neck until the head is approximately 2.5cm (1 in) above the plinth while keep the head retracted to the chest. The therapist focuses on the skin folds along the patient’s neck and places a hand on the table just below the occipital bone of the patient’s head. The therapist gives verbal commands such as “tuck your chin” or “hold your head up” whenever the skin folds begin to separate or the patient’s occiput touches the therapist’s hand. The test is terminated if the skin fold(s) is/are separated due to loss of chin tuck or the patient’s head touches the clinician’s hand for more than 1 second. The examiner looks for substitution of the platysma or SCM Normal Values: Men: 38.9 seconds, Women: 29.4 seconds (“The Deep Neck Flexor Endurance Test: normative data scores in healthy adults”). Patients with neck pain due to clinical instability show a delay in DNF activation and display deficits in the postural endurance of these muscles and is associated with an increased activity in superficial flexor muscles leading to altered neuro-motor control strategy during craniocervical flexion. This alteration potentially compromises the cervical spine's control which may leave it vulnerable to further strain. Craniocervical flexion test (CCFT) :2 stages ( strength and endurance) Calculation and Interpretation for Craniocervical flexion test Activation score is indicates the activation of the deep cervical flexor musculature. The performance index is a term used to understand the isometric endurance of these muscles. Activation score = The highest pressure level the subject can achieve and hold for a duration of 10 seconds Performance index = The number of times the subject can maintain the pressure level achieved in the activation, out of a maximum of 10 repetitions.  Subjective feature of clinical cervical Objective feature of clinical cervical instability instability Past history of neck dysfunction or Poor coordination /neuromuscular control trauma. frequent episodes of acute attacks”; and “sharp pain, possibly with sudden movements. Intolerance to prolonged static posture Aberrant movement Symptoms relieved with non–weight- Hypermobility with loose end feel of mid bearing postures cervical segments Fatigue and inability to hold the head up Poor strength (2/5) of deep cervical spine muscles Symptoms decrease with external support Greater cervical active range of motion in supine (non–weight-bearing) position than in standing (weight bearing) position Frequent need of self manipulation Motion that is not smooth throughout ROM Feeling of instability, shaking or lack of Hypomobility of the upper thoracic spine control  Physical Therapy Management Proper posture reduces the loads placed on spinal segments at end-ranges and returns the spine to a biomechanically efficient position. Spinal manipulation can be performed on hypomobile segments below the level of instability. Strength to deep flexor muscles. Strengthening the stabilizing muscles of the cervical spine enables these muscles to improve the quality and control of movement that occurs within the neutral zone. Proprioception exercises. One of the main goals of the non-surgical treatment is to improve the quality of controlled motion. Ergonomic corrections When cervical spine instability is seen with severe neurological involvement, surgery is the primary treatment intervention. The anterior cervical fusion is the most common surgical intervention. Postsurgical rehabilitation involves a similar approach as treatment of instability with progression of low level strengthening exercises for the anterior cervical and parascapular and postural muscles. The exercises mainly focused on the neutral postural alignment. The patient is not required to wear a brace. After 6 weeks it is not encouraged to do any lifting more than 4kg as also overhead work. No cervical dynamic strengthening or ranges of motion exercises are encouraged in the first 6 months.  Acute pain and whiplash associated disorders Whiplash is an injury which results from sudden acceleration- deceleration forces on the neck. The term encompasses a variety issues affecting muscles, joints, bones, ligaments, discs and nerves. Whiplash- associated disorders, is a complex condition with varied disturbances in motor, sensorimotor, and sensory functions and psychological distress. Quebec task force classification for whiplash-associated disorders (WAD) Physical examination A key feature regarding motor impairments of patients with WAD, is muscle imbalance between superficial and deep neck muscles. It can be evaluated with the craniocervical flexion test (CCFT). The CCFT is indicative of impairment of the deep cervical flexors. The test assesses precision and control to determine whether a patient can use the deep neck muscles and hold a contraction. Clinical Presentation Recent history of trauma High pain and disability score (Neck pain that is constant or motion-induced). Referred symptoms into upper quarter Poor tolerance to examination and most intervention Decrease in cervical motion and stiffness, Headaches Low back pain Pain or numbness in the arm and/or hand Dizziness, irritability, sleep disturbances, fatigue Difficulty concentrating or remembering There may be up to 48 hrs delay of symptom onset from the initial injury Physical therapy Early physical activity (Gentle AROM within patient tolerance) Gentle manual therapy and exercises, but avoidance of pain-inducing manual therapy techniques or exercises Different types of exercise can be considered for WAD, including ROM exercises, postural exercises, and training the deep neck flexors can assist in motor retaining, postural correction, and pain inhibition. More vigorous manipulation techniques can be used to the thoracic spine to inhibit neck pain and restore thoracic mobility. Intermittent use of a cervical collar may be beneficial to provide relative rest through the day. Activity modification to control pain Gradual progression of an aerobic exercise program that is enjoyable for the patient, such as walking or biking within the patient’s pain tolerance, can also assist in pain management Craniocervical flexion training program with airbag pressure biofeedback device. An equally effective means to strengthen the anterior cervical flexor muscles is to have the patient maintain craniocervical neutral in the supine position as the patient lifts the head off the folded towel (or pillow) and repeat for up to three sets of 10-12 repetitions holding 10 sec.  Cervicogenic headaches Cervicogenic headaches are believed to originate from musculoskeletal dysfunction of the cervical spine. The incidence of cervicogenic headache is estimated to be 14% to 18% of all chronic headaches. Physical examination The cranio cervical flexion test (CCFT) is a clinical test of neuromotor control of the deep flexors of the cervical spine (rectus capitis anterior, rectus capitis lateralis, longus colli, longus capitis). An impaired and delayed activation of the deep cervical flexor muscles causes headaches. The Cervical Flexion-Rotation test (CFRT) is a useful clinical measure in cervical movement impairment and can assist in the differential diagnosis of Cervicogenic Headache. the Cervical Flexion-Rotation test was positive when the estimated range was reduced by more than 10° from the anticipated normal range (44). The inverse relationship between headache severity of CGH and ROM towards the most restricted side. Amount of rotation in the upper cervical spine, can be used as a diagnostic test to assess whether cervicogenic headache (CGH) is due to upper cervical dysfunction versus dysfunction at other levels of the cervical spine CFRT: Assess dysfunction at the C1-C2 motion segment. Clinical presentation Patients with cervicogenic headache present with a similar set of impairments as do patients with cervical spine instability or hypomobility, but their primary complaint is headache. Pain localized in the neck and occiput, which can spread to other areas in the head, such as forehead, orbital region, vertex, or ears, usually unilateral. Restricted upper cervical segment mobility Pain is aggravated by specific neck movements or sustained postures. Headache pain elicited by pressure on posterior neck, especially at 1 of 3 upper cervical joints  Cervicogenic headache patients tend to have increased tightness, trigger points and increased activity in upper trapezius, levator scapulae, sternocleidomastoid, scalenes, pectoralis major and minor and short sub-occipital extensors (rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis superior, and obliquus capitis inferior ). Weakness in the deep neck flexors. Those with bilateral headache or symptoms that typify migraine headaches. Cervicogenic headache patients are differentiated from migraine by Less cervical range of motion flexion/extension A significantly higher incidence of upper three cervical joint dysfunctions (facet joint hypomobility and tenderness) Muscle length limitations (tightness of upper trapezius, levator scapula, scalenes, and suboccipital extensor muscles).  Physical therapy Cervical spine manipulation or mobilization, Thoracic spine thrust manipulation & exercise. Strengthening exercises including deep neck flexors and upper quarter muscles (exercise regimen included training the muscles of the scapula, particularly the lower trapezius and serratus anterior muscles to hold scapular adduction and retraction postural positions. C1-C2 SNAG, Self-sustained Natural Apophyseal Glide shown to be effective for reducing cervicogenic headache symptoms. Myofascial release and subocciptal release for overactive muscle. THANK YOU