PSIO12005 Lecture 2 Cervical Spine 2024 FINAL_Students.pdf

Lecture 2: Cervical Spine PSIO12005 Musculoskeletal Physiotherapy 2 Dr. Luke Heales – [email protected] Overview Clinical Anatomy Important Information Clinical Conditions Image by hkgoldstein0 from Pixabay Image by hkgoldstei...

Lecture 2: Cervical Spine PSIO12005 Musculoskeletal Physiotherapy 2 Dr. Luke Heales – [email protected] Overview Clinical Anatomy Important Information Clinical Conditions Image by hkgoldstein0 from Pixabay Image by hkgoldstein0 from Pixabay Clinical Anatomy Greatest ROM of the spine Inc. risk of injury Vertebral bodies: 7 Vertebrae Smaller than other vertebral sections 1st Atlas 2nd Axis C3-C7 Image by hkgoldstein0 from Pixabay  The Atlas 1st vertebrae No vertebral body No true spinous process Transverse process Transverse foramen Supports the weight of the head through the atlanto-occipital joint (C0-C1). Primary movement flexion/extension Image obtained from MindBody (2011). Basic anatomy and terminology. Available from: https://atlassubluxation.wor dpress.com/2011/06/24/basic-anatomy-and-terminology/  The Axis 2nd vertebrae Small vertebral body with superior projection (Dens) Spinous process Transverse process Transverse foramen Atlanto-axial joint Dens and atlas articulation Pivot joint Primary movement rotation of the skull Image obtained from Surange, P. N. (2010). Anatomy of the spine. Available from: https://www.slideshare.net/pankajnsurange/anatomy-of-spine Cervical vertebrae body Body Transverse process Anterior tubercle Transverse foramen Posterior tubercle Superior articular facet Vertebral foramen Pedicle Lamina Spinous process Image by OpenClipart-Vectors from Pixabay  Ligaments of the Cervical Spine Superior Crus Inferior Crus Clarkson, H. M. (2005). Joint motion and function assessment: A research-based practical guide. Philadelphia, PA: Lippincott Williams & Wilkins.  Ligaments of the Cervical Spine Clarkson, H. M. (2005). Joint motion and function assessment: A research-based practical guide. Philadelphia, PA: Lippincott Williams & Wilkins. Muscles of the Cervical Spine Brukner et al. (2017). Clinical sports medicine: Injuries Volume 1 (5th ed.). Sydney, Australia: McGraw Hill Education. Muscles of the Cervical Spine Brukner et al. (2017). Clinical sports medicine: Injuries Volume 1 (5th ed.). Sydney, Australia: McGraw Hill Education. Blood Supply of the Cervical Spine FIGURE 3-3 Anterolateral drawing of the course of the vertebral artery from C6 to C1 through the bony rings of the foramina transversaria. Note the double U-turn the artery makes from C2 to C1 and the posterior course around the lateral mass of the atlas. (Modified from Bland JH, Nakano KK: Neck pain. In Image obtained from Orthopaedics (2015). Cervical Spine. Kelley WN, et al, editors: Textbook of rheumatology, ed 1, Philadelphia, 1981, W.B. Available from: https://clinicalgate.com/cervical-spine-3/ Saunders.) Nerves of the Cervical Spine 8 Cervical Nerves 1st 7 exit above the corresponding vertebrae C8 exits below the 7th Cervical vertebrae Brachial Plexus C5 – T1 Image obtained from Repetto, V. (2017). The cervical & vagus nerve connection?! Available from: https://drvittoriarepetto.wordpress.com/2017/09/06/the-cervical- vagus-nerve-connection-a-nyc-chiropractorapplied-kinesiologistneurokinetic-therapist-explains/ Movements of the Cervical Spine Clarkson, H. M. (2005). Joint motion and function assessment: A research-based practical guide. Philadelphia, PA: Lippincott Williams & Wilkins. Possible Clinical Conditions Horses Zebras Unicorns Whiplash Syndrome Disc prolapse Fractures (hangman) Acute wry neck “Stingers” or “Burners” Vascular trauma - Stroke Spondylosis Craniovertebral Instability Retropharyngeal heamatoma Radiculopathy Fractures Vertebral Artery Insufficiency Cervicogenic Headache Concussion (MSK3) Muscle pain Myelopathy Joint pain Red Flags Major Trauma History of cancer/neoplasm Systemic inflammatory diseases and infections Cervical myelopathy symptoms Bladder bowel dysfunction Neurological symptoms including upper or lower limb clumsiness, uncoordinated movements Previous neck surgery VBI symptoms: 5 D’s and 3 N’s Image by Annalise Batista from Pixabay Indications of Cervical Spine Trauma Known MOI – e.g. MVA, Fall, Fight Complains of consistent, severe, neck pain. Increase in pain and decrease of movement on examination. Signs of neurological injury Requires urgent MRI, CT or radiological referral Image by LillyCantabile from Pixabay  Craniovertebral Instability (Upper cervical instability) or (AAI) Excessive movement at C1-C2 vertebrae as a result of bony or ligamentous abnormality Neurological symptoms can occur when the spinal cord or adjacent nerve roots are involved. Causes Acute Trauma Degeneration Congenital conditions Down syndrome (10-20% of individuals) Figure obtained from: Clarkson, H. M. (2005) Joint motion and function assessment, A research-based practical guide. Philadelphia, PA: Lippincott Williams & Wilkins Odontoid (Dens) Fracture Anderson and D’Alonzo classification system. Image obtained from Niknejad et al. (2018). Odontoid fracture. Available from: https://radiopaedia.org/articles/odontoid-fracture Fractures of the Cervical Spine A Hangman's fracture is the colloquial name given to a fracture of both pedicles or pars interarticularis of the axis vertebra (C2). Imaged obtained from Anstead, M. (2010). Hangman's fracture that almost robbed world of the man who steered Katie Melua to success. Available from: https://www.dailymail.co.uk/health/article-1252497/Hangmans-fracture-robbed-world-man-steered-Katie-Melua-success.html Fractures of the Cervical Spine AO SPINE Classification for lower Cx fractures Type A – Compression A1. Impaction A2. Split A3. Burst Type B – Distraction B1. Posterior injury with intact vertebral body B2. Posterior fracture + Type A fracture B3. Anterior distraction – hyperextension Type C - Rotation C1. Unilateral facet fracture-dislocation C2. Unlateral facet dislocation C3. Separation fracture of articular mass + type A + type B Ono et al. (2015). Subaxial cervical fracture: Application and correlation of AO and SLIC. Coluna/Columna, 14(3), 218-222. https://dx.doi.org/10.1590/S1808-185120151403114135 Craniovertebral Instability Presentation Neck pain Wry neck posture Headache Myelopathy Cord compromise signs and symptoms: Difficulty walking & clumsiness with hands Lack of coordination Bowel & bladder dysfunction Positive Babinski & ankle clonus Hyperreflexia Spasticity Vascular symptoms Feeling of instability (something isn’t right?) Craniovertebral Instability Diagnosis Severe signs and symptoms and acute trauma require urgent referral for diagnostic imaging! Alar ligament tests. Damage to alar ligaments can increase rotation by up to 30% - frank instability Sharp Purser Test Neurological examination Imaging (Radiography, CT, MRI). C-Spine Rule State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014.  Vascular Conditions Cervical arterial dissection (CAD) aka, vertebral arterial dissection Vertebrobasilar Insufficiency (VBI) FIGURE 3-3 Anterolateral drawing of the course of the vertebral artery from C6 to C1 through the bony rings of the foramina transversaria. Note the double U-turn the artery makes from C2 to C1 and the posterior course around the lateral mass of the atlas. (Modified from Bland JH, Nakano KK: Neck pain. In Kelley WN, et al, editors: Textbook of rheumatology, ed 1, Philadelphia, 1981, W.B. Image obtained from Orthopaedics (2015). Cervical Spine. Saunders.) Available from: https://clinicalgate.com/cervical-spine-3/ Cervical arterial dissection (CAD) What is CAD? – A tear in the wall of the vertebral artery (or less commonly the internal carotid artery) which may result in a cerebrovascular accident (i.e. stroke) Relatively rare but it is the most serious adverse event associated with manipulative therapy. Early presenting features – Acute onset neck pain and/or headache (clinical symptoms similar to MSK presentation) Risk factors – Minor trauma – Infection – Genetic factors – Migraine (but less likely) Thomas, L, Shirley, D & Rivett, D (2017) Clinical Guide to Safe Manual Therapy Practice in the Cervical Spine, www.physiotherapy.asn.au/cervicalspine  Cervical arterial dissection (CAD) What to look out for – Younger 65 year but might present in younger populations as CAD Occurs more commonly in association with chronic neck pain and stiffness Often related to movement and positions of the neck Potential causes – Atherosclerosis – Spondylosis (Osteophyte formation) – Trauma – Occlusion may occur during sudden or sustain movements of the http://www.massagetoday.com/mpacms/mt/article.php?id=14035 head or neck Thomas, L, Shirley, D & Rivett, D (2017) Clinical Guide to Safe Manual Therapy Practice in the Cervical Spine, www.physiotherapy.asn.au/cervicalspine  VBI Questioning In EVERY patient presenting with upper quadrant dysfunction, questioning is specifically directed to elicit the presence of symptoms related to VBI. This is completed prior to assessment and treatment of the cervical spine. The 5 D’s and 3 N’s – Dizziness – Diplopia (Double vision) – Dysarthria (Talking) – Dysphagia (Swallowing) – Drop attacks (collapse without loss of consciousness) – Nausea (vomiting), Numbness (Perioral) [around mouth/noes], Nystagmus (spontaneous)  VBI Testing “The VBI positional tests should be used if the symptoms are unclear and the clinician is exploring the possibility of VBI in differentiating the source of any dizziness, light headedness or unsteadiness.” “The VBI positional test are not indicated when the patient has clear symptoms of VBI” Refer to hospital (ED if emergency or specialist) “Cease testing if symptoms not settling within seconds and/or getting worse” Refer to hospital (ED if emergency or specialist) Thomas, L, Shirley, D & Rivett, D (2017) Clinical Guide to Safe Manual Therapy Practice in the Cervical Spine, www.physiotherapy.asn.au/cervicalspine VBI Testing Minimum test include – Sustained end range rotation L) and R) (ERRT) (10 seconds unless symptoms provoked sooner) – Therapist watches for nystagmus and questions about symptom reproduction – Wait 10 secs in neutral between sides (latency) Other Tests (if pt history indicates) – The position or movement which provokes symptoms – Cervical Extension with or without combined rotation – Simulated manipulation position – Rapid movements through the available range (patient dependant) Positive test – Dizziness, Nystagmus (does not settle within a few secs), pre-syncope, feeling “unwell”, 5 D’s NOTE: This is done prior to ERRT or HVT (Manipulation) VBI Testing If symptoms are provoked with rotation, either during sustained or repetitive motion, these test are explored in the standing position in order to differentiate dizziness arising from vestibular system or VBI. Head held still, sustained trunk rotation to left and right (min 10 seconds) Head held still, repetitive trunk rotation to the left and right Differentiate between VBI and vestibular system http://www.jaocr.org/articles/vertebrobasilar-insufficiency-and-stroke-a-review-of-posterior-circulation-diagnostic-imaging-and-endovascular-treatment-options Vertebral Artery Trauma 46% report neck pain 67% report occipital headaches Abrupt onset May be associated with fractures May have nerve root symptoms Posterior-lateral location If you believe your patient has vertebral artery trauma refer to Emergency Department immediately.  Myelopathy Injury to the spinal cord typically due to severe compression from either: – Trauma – Stenosis (congenital or degenerative) Signs and Symptoms – Bilateral neurological symptoms – Bilateral weakness or altered muscle performance – Bladder and bowel dysfunction – Saddle anaesthesia Depending on signs and symptoms you should refer on to emergency department or specialist for thorough investigation (diagnostic imaging). NB: Don’t confuse with radiculopathy (nerve root compression)  Regional Disorders of the Cervical Spine Upper cervical spine – frequently cause of cervicogenic headaches Mid cervical spine – commonly involve zygapophyseal joint dysfunction Lower cervical spine – most frequent region for discogenic disorders and spinal nerve/nerve root compromise http://www.spiritscienceandmetaphysics.com/studies-find-body-pain-correlates-with-spiritual-emotional-pain/  Possible Clinical Conditions Horses Zebras Unicorns Whiplash Syndrome Disc prolapse Fractures (hangman) Acute wry neck “Stingers” or “Burners” Vascular trauma - Stroke Retropharyngeal Spondylosis Craniovertebral Instability heamatoma Radiculopathy Fractures Vertebral Artery Insufficiency Cervicogenic Headache Week 2 Concussion MSK3 Muscle pain Myelopathy Joint pain “Whiplash Syndrome” Acceleration/Deceleration Injury “an acceleration-deceleration mechanism of energy transfer to the neck. It may result from rear-end or side-impact motor vehicle collisions, but can also occur from with diving or other mishaps. The impact may result in bony or soft tissue injuries (whiplash injury), which in turn may lead to a variety of clinical manifestations (Whiplash Associtated Disorders [WAD]).” (Spitzer et al., 1995, as cited in Brukner and Khan, 2017) Image from: State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. MOI: Whiplash Syndrome Acceleration - deceleration injuries of the cervical spine Rapid hyperextension to hyperflexion movement +/- shear forces Can also involve rotational and lateral shear forces depending on impact Speed of impact and force of impact exceed capacity of tissue to cope which leads to failure of the tissues. Clinical Presentation Dependent on patient presentation Note: Neck Pain Delay in the onset of symptoms Headache Not to be missed: Fracture Decreased neck mobility and/or vascular injury +/- thoracic, shoulder pain Chronicity Arm pain Depression, anxiety, dependence, psychosocial 5 D’s problems 3 N’s Liability issues – Legal matters – Dizziness, tinnitus, blurred vision etc. Self-reported severity of the crash (if MVA) Clinical Diagnosis History Taking Physical Exam All of your normal information Observation – Age, sex, occupation etc etc. Palpation Prior history of WAD ROM (Active and Passive) Prior history of long term disability Neurological Assessment MOI of injury in detail Assessment of any other OUTCOME MEASURES injuries (e.g. shoulder) – NDI – General Health Questionnaire Grades of WAD State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. Guidelines for Management of WAD State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. Guidelines for Management of WAD State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. Recommended Treatment of WAD Thorough Patient History Reassure and stay active (Normal ADL’s) Exercise – ROM, low load isometrics, postural endurance, strengthening Pharmacology – Simple analgesics – NSAIDs Refer to pharmacist – Opioid analgesics Manual Therapy (may be effective) Manipulation (Thoracic Spine) – No evidence for efficacy of C spine manipulation in the treatment of acute WAD  Prognosis Things that can impact on prognosis: Symptom severity (>5/10 VAS; >15/50 NDI) More concerted Rx or refer earlier. High pain at initial is associated with persistent pain and disability Diagnostic Imaging (Changes on Images are NOT associated with ongoing pain and disability) Psychological factors – Do you think you will get better soon? (Initial assessment) If negative response than refer to clinician with expertise in WAD – Posttraumatic stress (PTS) symptoms using the Impact of Events Scale (IES) (3-6 weeks post injury) Score >25 should be referred to Psychologist with expertise in PTS Socio-demographic factors (e.g. age, gender, education, etc) – NOT predictive of ongoing pain State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. Prognosis (Crash related factors) State Insurance Regulatory Authority: Guidelines for the management of acute whiplash-associated disorders – for health professionals. Sydney: third edition 2014. Acute Wry Neck Sudden onset of sharp neck pain with protective deformity and limitation of movement. Typically caused after a sudden quick movement or on waking from sleep. Two hypothesised common types of Acute Wry Neck – Zygapophyseal wry neck – Diskogenic wry neck Atlantoaxial Rotatory Fixation/Subluxation (AARS) – A fixed rotatory subluxation of C1 on C2 (more in younger children covered in MSK3) Image by Anna Mikkelgaard from Pixabay Brukner et al. (2017). Clinical sports medicine: Injuries Volume 1 (5th ed.). Sydney, Australia: McGraw Hill Education. Zygapophyseal Wry Neck Presentation Most common in children and young adults Most common at upper Cx (e.g. C2-C3 level) Associated with sudden movement resulting sharp pain Locking of C0-C1 or C1-C2 may result from some form of trauma Posture away from pain (lateral flexion and slight flexion) Limited ROM http://www.ultimatephysionq.com/789-2/ Zygapophyseal Wry Neck Treatment Soft tissue techniques Joint mobilisations/manipulation AROM/PROM (if permitted) Traction EPAs (Heat) Reassure, Advice and Education Home Exercise – ROM exercises – Motor control exercises – Posture – Advice about cervical support during sleep http://www.ultimatephysionq.com/789-2/ Diskogenic Wry Neck Presentation More gradual onset compared to Z-joint wry neck Most common after waking from long sleep Most common in older group (e.g. middle aged adults) Typically lower cervical or upper thoracic Posture away from pain (lateral flexion, rotation and slight flexion) +/- referred to scapular region http://www.ultimatephysionq.com/789-2/ Diskogenic Wry Neck Treatment Important to differentiate between Z-joint and Diskogenic as manipulation may result in provocation of symptoms in individuals with discogenic pain Gentle traction Soft tissue techniques Gentle mobilisations EPAs (Heat) Reassure, Advice and Education Temporary soft collar Motor control exercises as tolerated Postural retraining as tolerated – Advice about cervical support during sleep http://www.ultimatephysionq.com/789-2/ Non-Specific Cervical Spine Pain (NSCSP) There are many structures in the cervical spine capable of causing non-specific pain: – Muscle/ligament Non-specific – lack of clinical tests that enable – Z joint differentiation of the source of symptoms with accuracy – can use signs and symptoms with – Disc clinical reasoning. – Ligament – Bony Potential for specific pathology/diagnosis (e.g., UCI, VBI, – Vascular CAD, #, Radiculopathy etc) – Neural Image from: Makkar, G. Cervical spondylosis neck pain homeopathic treatment, available from: https://www.askdrmakkar.com/cervical_spondylosis_neck_pain__homeopathic_treatment.aspx Spondylosis - NSCSP Refers to degeneration of the spine, typically associated with the aging process. Degeneration of the disc – prolapse/breakdown Joint space narrowing Osteophyte formation Spinal stenosis Foramen stenosis Normal Degenerative Image from: Makkar, G. Cervical spondylosis neck pain homeopathic treatment, available from: https://www.askdrmakkar.com/cervical_spondylosis_neck_pain__homeopathic_treatment.aspx Spondylosis Clinical Presentation Most people don’t have significant symptoms Neck and/or arm pain Stiff neck Headaches Radiculopathy-nerve root compression Neurological symptoms (unilateral) Myelopathy-spinal cord compression Neurological symptoms (bilateral) Diagnosis Normal Degenerative Patient history Imaging (CT, MRI, X-ray) Image from: Makkar, G. Cervical spondylosis neck pain homeopathic treatment, available from: https://www.askdrmakkar.com/cervical_spondylosis_neck_pain__homeopathic_treatment.aspx Spondylosis Clinical Treatment Advice & Education Reassurance Soft tissue Muscle strengthening Traction Stretching ROM exercises Medication Normal Degenerative Alternative therapies Dry needling Heat Surgery Potential to refer for surgery depending on severity and duration of symptoms Image from: Makkar, G. Cervical spondylosis neck pain homeopathic treatment, available from: https://www.askdrmakkar.com/cervical_spondylosis_neck_pain__homeopathic_treatment.aspx Disc Prolapse Acute – trauma (e.g., fall, MVA) Insidious – degeneration 3rd – 5th decade of life (highest 51-60 years old) Females > males C5/6 and C6/7 most common Symptoms Neck pain (± referred shoulder pain) Impaired/painful AROM Impaired/painful PROM (PPIVMs and PAIVMs) ± Arm symptoms (progress to radiculopathy) Sharrak, S. & Khalili, Y. A. (2023). Cervical disc herniation. StatPearls [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546618/ Cervical Radiculopathy A compression of the nerve root as it exists the vertebral column of the cervical spine. Trauma – fall, MVA Disc injury – younger population – Disc prolapse cause Spondylosis/degeneration – older population – Stenosis cause Image from: Makkar, G. Cervical spondylosis neck pain homeopathic treatment, available from: https://www.askdrmakkar.com/cervical_spondylosis_neck_pain__homeopathic_treatment.aspx Cervical Radiculopathy Clinical Presentation +/- neck pain +/- arm pain Neurological Symptoms (dermatome) – P+N, Tingling, Numbness Weakness - myotome Reflex changes Diagnosis Patient history Neurological Examination Spurling’s test – provocative Diagnostic Imaging Eubanks, J. D. (2011). Cervical radiculopathy: Non-operative management of neck pain and radicular symptoms. American Family Physician 81(1), 33-40. Cervical Radiculopathy Treatment Traction Immobilisation Pharmacotherapy Soft tissue Manual therapy – (manipulation not recommended) EPA’s (limited evidence) As pain improves – ROM – Strength training Steroid injection Referral Eubanks, J. D. (2011). Cervical radiculopathy: Non-operative management of neck pain and radicular symptoms. American Family Physician 81(1), 33-40.  Stinger and Burner Syndrome Transient brachial plexopathy - brachial plexus traction injury Common  rugby league, rugby union, AFL, NFL (contact sports) 30-40% of players at least 1 in their career Symptoms typically resolve in 24 hours Image from: https://musculoskeletalkey.com/stingers-and-burners/ Prolonged = more severe injury Signs and symptoms – Radicular type burning, shooting, stinging pain down the arm – Numbness and weakness (radicular pattern) Be mindful of #clavical, ACJ injury Ensure perfusion to the upper limb and brain/head (5Ds, 3Ns, HA etc). Tosti, R., Rossy, W., Sanchez, A., & Lee, S. G. (2016). Burners, stingers, and other brachial plexus injuries in the contact athlete. Operative Techniques in Sports Medicine, 24(4), p273-277. https://doi.org/10.1053/j.otsm.2016.09.006.  Stinger and Burner Syndrome Diagnosis Neuro examination, AROM/PROM, MMT Treatment Image from: https://musculoskeletalkey.com/stingers-and-burners/ Advice and education (injury and prognosis) Rx the deficits – AROM/PROM in the first instance – Stretching exercises (gentle without pain) – Postural retraining – Progressive strength training (recovery) – Sport specific training and game simulation – Refer on if not improving 85% of players did not miss a game Mild residual weakness can last up to six weeks Tosti, R., Rossy, W., Sanchez, A., & Lee, S. G. (2016). Burners, stingers, and other brachial plexus injuries in the contact athlete. Operative Techniques in Sports Medicine, 24(4), p273-277. https://doi.org/10.1053/j.otsm.2016.09.006. Summary Learn the anatomy – The best physio’s have an impeccable understanding of anatomy. Remember the red flags and important information (UCI, CAD, & VBI) Revise clinical conditions Practical: Physical Assessment of the cervical spine