The Cervical Spine

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The Cervical Spine. M.D., O.M.D. . The Cervical Spine - History -. In general, a good history-taking provides information about: The patient s age Symptoms Pain Paraesthesia vertigo Drugs. The Cervical Spine - History -. 1. Age Acute torticollis - PowerPoint PPT Presentation

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  • The Cervical SpineM.D., O.M.D.

  • In general, a good history-taking provides information about:The patients ageSymptomsPainParaesthesiavertigoDrugsThe Cervical Spine- History -

  • 1. AgeAcute torticollisAcute torticollis due to a disc protrusion adolescents and young adultsChildren a afebrile otitis mediaIt is a pure lateral list, whereas in the other disorders, mentioned above, the head is side flexed one way and slightly ratated the opposite way by spasm of the sternocleidomastoid muscleThe Cervical Spine- History -

  • 1. AgeRoot pain Over the age of 35Neuroma in young patientHeadache The old mans matutinal headache(morning headache) is an upper cervical ligarmentous lesion.The Cervical Spine- History -

  • 2. Symptoms Pain How, When and where did it start? In the lumbar spine know what exactily brought the pain on In the cervical spine onset Is spontaneous. pt. cannot tell the caused of his symptomsThe Cervical Spine- History -

  • 2. Symptoms Pain How did it progress?A shifting pain(disc) an expanding pain(tumor)Chronology of a posterolateral disc protrusion: starting from the onset of the arm pain, the spontaneous evolution takes some 3-4months. Hence, an arm pain beyond 6 months is probably not caused by a disc protrusion.Ankylosing spondylitis: a young pt. had lumbar, thoracic and cervical spineNeuroma: paraesthesia and pain, starting distally in the arm, spreading proximally(A neuroma is more probable than PPLP)The Cervical Spine- History -

  • 2. Symptoms Pain RecurrencesDuration, frequency, treatmentWas it always on the same sideHow is the patient between the attacksInfluence of coughIn disc protrusion, a cough is mostly negativeIf not the pain is felt in the scapular areaAn arm pain on coughing suggests a neuromaThe Cervical Spine- History -

  • Localization HeadacheSegmental pain or extrasegmental dural pain. when cervicoscapular aching ; extrasegmental(dura mater) the pain from a disc protrusion pinching the dura matersegmental(facet joint). a facet joint lesion is segmental The Cervical Spine- History -

  • Localization Root pain How long? Spontaneous evolution of a posterolateral disc protrusion: irreducible in the second half of the evolutionDermatome: levelWith/Without previous cervicoscapular pain: no manipulation for a PPLPThe Cervical Spine- History -

  • Paraesthesia (=Paresthesia)

    segmental, extrasegmental segmental : nerve root extrasegmental : spinal cord Nerve root or spinal cord?

    with/without painRadicular compression : first pain - with pain The Cervical Spine- History -

  • Vertigo

    Spontanoues or postural

    3. Drugs

    Anticoagulants provide an absolute bar to manipulation! The Cervical Spine- History -

  • We look for :

    Articular signs : partial articular, full articularRoot signs : motor conduction, Sensory conduction, DTRCord signs : pathologic reflex, DTR, SpasticityAlternative causes for the arm painThe Cervical Spine- CLINICAL EXAMINATION -

  • Neck movementActive Active Passive resistive Extension Rotation Side flexions Flexion The Cervical Spine- CLINICAL EXAMINATION -

  • Neck movementThe Cervical Spine- CLINICAL EXAMINATION -Active Active Passive resistive Pain Range Willingness Pain Range End feelPassiveAlways (3)

  • Shoulder ShrugAactive Active Resistive Pain Range Contracture of costocoracoid fascia Scapular metastasis Pulmonary neoplasmThe Cervical Spine- CLINICAL EXAMINATION -

  • Shoulder ShrugActive Pain Weakness C2,3,4 roots Spinal accessory N.ResistiveThe Cervical Spine- CLINICAL EXAMINATION -

  • Limitation A. bilat. arm ele. Neuropathy Fracture Muscle/tendon Painful arc Ankylosis Shoulder girdle examThe Cervical Spine- CLINICAL EXAMINATION -

  • C. Active bilateral arm elevation

    Mononeuritislong thoracic n.spinal accessory n.

    stress fracturefirst ribspinous process C7/T1

    painful arc :

    limitation at the shoulder joint

    The Cervical Spine- CLINICAL EXAMINATION -

  • D. Nerve root examinationBilateral : all resisted tests on the good side first.

    1. Motor conduction

    2. Sensory conductionThe Cervical Spine- CLINICAL EXAMINATION -

  • 1. Motor conduction(Shoulder)Abduction (C5)Lateral rotation (C5)The Cervical Spine- CLINICAL EXAMINATION -

  • 1. Motor conduction(Elbow)Flexion (C5-C6)Extension (C7)The Cervical Spine- CLINICAL EXAMINATION -

  • 1. Motor conduction(Wrist)Flexion (C7) - Golf elbowExtension (C6) - Tennis elbowThe Cervical Spine- CLINICAL EXAMINATION -

  • Extension (C8)Adduction (T1)The Cervical Spine- CLINICAL EXAMINATION -1. Motor conduction(Thumb, Little finger)

  • B. Shoulder shrugging

    2. Sensory conduction A sensory deficit is sought in the distal part of the dermatomesThe Cervical Spine- CLINICAL EXAMINATION -

  • C5: outer part of the forearmC6: thumb and index fingerC7: dorsum of index, middle and ring fingerC8: ring and little finger, ulnar part of the handT1: inner side of the fore armT2: inner side of the armThe Cervical Spine- CLINICAL EXAMINATION -

  • Roots exam. DTR Motor conduction Sensory condction Biceps Jerk C5,C6 Brachiradialis J C5 Triceps J C7The Cervical Spine- CLINICAL EXAMINATION -

  • Cord sign Pathologic Reflex DTR Spasticity Babinski sign Ankle clonus Hoffman sign The Cervical Spine- CLINICAL EXAMINATION -

  • Arm test

    Tests for neurogenic integrity and alternative causes of arm pain

    Active elevation

    Pain/limitation Shoulder examination?

    The Cervical Spine- CLINICAL EXAMINATION -

  • Arm testResisted movements(tests for motor conduction):Shoulder:Abduction - C5External rotation - C7Elbow:Flexion - C5/C6Extenstion - C7The Cervical Spine- CLINICAL EXAMINATION -

  • Arm testWrist:Flextion C7Extension-C6Thumb extension C8Little finger adduction T1

    Sensory conductionThe Cervical Spine- CLINICAL EXAMINATION -

  • Arm test

    ReflexesBiceps C5 / C6Brachioradialis C5Triceps - C7Planter - CNSThe Cervical Spine- CLINICAL EXAMINATION -

  • A. IntroductionNot tally with the clinical findings: The pain can be unilateralThe neck movements can be painful in one direction and not in another directionThe end-feel is much softer than the hard end-feel of osteophytosisThe patient can have intermittent attacks of pain with painfree episodes between the attacksThe Cervical Spine- CLINICAL EXAMINATION -

  • B. Disc protrusionDura mater Disc protruding in posterior direction can exert pressure on Dura mater -> pain & tenderness protrusion near midline-> interfere with articular mobility. dural pain &articular signs posterolateral protrusion-> root pain with or without root sign, but better articular sign The Cervical Spine- Disorders -

  • Articular signs pain maybe limitation, on some, but not all, active movements: more pain on P test no pain on R test partial articular pattern of internal derangement particular end-feel ( "crisp" ) is expected The Cervical Spine- Disorders -

  • Root sign motor deficit, sensory deficit, sluggish or absent jerk differance to Lumbar spine-> neurological decifit from Disc protrusion is monoradicular The Cervical Spine- Disorders -

  • Alarm( probably no protrusion) a number of particularity, most of them based on empirical findingswe should discard the idea of a disc protrusion in case of : Ti-palsy C1- or C2- palsy motor deficit C4 (shoulder shrug) sensory deficit C5 The Cervical Spine- Disorders -

  • Clinical patterns 1. Acute torticollis Young patients( 15~30y) Attack with spontaneous recovery in 7-10 day. extreme partial articular pattern: head is tilted sideways, one rotation & one side flexion are completely blocked: the other movement are less limited but all painful The Cervical Spine- Disorders -

  • 2. Unilateral cervicoscapular aching usually over 25 ache is intermittent ( a few weeks) with painfree episodes between the attack: maybe not always the same side is affected partial articular pattern ( but less marked than in previous case) over 50, the pain may become constant. The Cervical Spine- Disorders -

  • 3. Unilateral root pain certainly over 35 attack began with pressure on dura metar first, then protrusion reched the nerve root; severe root pain, possibly paraesthesia()& neurological deficit. strict chronology with spontaneous recovery in 3-4 months The Cervical Spine- Disorders -

  • 4. Acroparaesthesia paraesthesia in both hand and both feet in patient over 60. The cause is small bilateral protrusion, which is mostly irreducible The Cervical Spine- Disorders -

  • 5.Bilateral scapular aching Over the age of 60 Central protrusion(need special manipulative)

    6.Extrasegmental paraesthesia Pressure on the spinal cord from a central protrusion When no contraindication exists, a disc protrusion should be reduced at onceThe Cervical Spine- Disorders -

  • C. other disorders / differntial diagnosis

    1.Differential diagnostic interpretation

    All discs are alike, but all other disorders are different.The Cervical Spine- Disorders -

  • 1. Neck movements

    A muscular pattern One or more resistance tests hurt more than the active or the passive testsSome possibilities: a muscle lesion, a fractured first rib, metastases grandular fever, or psychogenic symptomsThe Cervical Spine- Disorders -

  • A particular partial articular pattern

    The pattern, in which side flexion away from the painful side is the only painfully limited movement, suggests an extra-artic