The cervical spine
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The Cervical Spine. 방배경희한의원 M.D., O.M.D. 신정봉. 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

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The Cervical Spine

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The cervical spine

The Cervical Spine

방배경희한의원

M.D., O.M.D.

신정봉


The cervical spine

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

The Cervical Spine- History -

1. Age

  • Acute torticollis

    • Acute torticollis due to a disc protrusion – adolescents and young adults

    • Children – a afebrile otitis media

    • It 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 muscle


The cervical spine

The Cervical Spine- History -

1. Age

  • Root pain

    • Over the age of 35

    • Neuroma in young patient

  • Headache

    • The old man’s “matutinal headache”(morning headache) is an upper cervical ligarmentous lesion.


The cervical spine

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 symptoms


The cervical spine

The 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 spine

    • Neuroma: paraesthesia and pain, starting distally in the arm, spreading proximally(A neuroma is more probable than PPLP)


The cervical spine

The Cervical Spine- History -

2. Symptoms

◆ Pain

  • Recurrences

    • Duration, frequency, treatment

    • Was it always on the same side

    • How is the patient between the attacks

  • Influence of cough

    • In disc protrusion, a cough is mostly negative

    • If not the pain is felt in the scapular area

    • An arm pain on coughing suggests a neuroma


The cervical spine

The Cervical Spine- History -

  • Localization

    • Headache

      • Segmental pain or extrasegmental dural pain.

      • when

    • cervicoscapular aching ;

      • extrasegmental(dura mater) – the pain from a disc protrusion pinching the dura mater

      • segmental(facet joint). – a facet joint lesion is segmental


The cervical spine

The Cervical Spine- History -

  • Localization

    • Root pain

      • How long? Spontaneous evolution of a posterolateral disc protrusion: irreducible in the second half of the evolution

      • Dermatome: level

      • With/Without previous cervicoscapular pain: no manipulation for a PPLP


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The Cervical Spine- History -

  • Paraesthesia (=Paresthesia)

    • segmental, extrasegmental

      • segmental : nerve root

      • extrasegmental : spinal cord

      • Nerve root or spinal cord?

    • with/without pain

      • Radicular compression : first pain - with pain


The cervical spine

The Cervical Spine- History -

  • Vertigo

    • Spontanoues or postural

      3. Drugs

  • Anticoagulants provide an absolute bar to manipulation!


The cervical spine

The Cervical Spine- CLINICAL EXAMINATION -

We look for :

  • Articular signs : partial articular, full articular

  • Root signs : motor conduction, Sensory conduction, DTR

  • Cord signs : pathologic reflex, DTR, Spasticity

  • Alternative causes for the arm pain


Neck movement

The Cervical Spine- CLINICAL EXAMINATION -

Active

Passive

resistive

Neck movement

Active

Extension

Rotation

Side flexions

Flexion


Neck movement1

The Cervical Spine- CLINICAL EXAMINATION -

Active

Passive

resistive

Pain

Range

Willingness

Active

Neck movement

Pain

Range

End feel

Passive

Always (3)


Shoulder shrug

The Cervical Spine- CLINICAL EXAMINATION -

Active

Resistive

Aactive

Shoulder Shrug

Pain

Range

Contracture of

costocoracoid fascia

Scapular metastasis

Pulmonary neoplasm


Shoulder shrug1

The Cervical Spine- CLINICAL EXAMINATION -

Pain

Weakness

Active

Shoulder Shrug

Resistive

  • C2,3,4 roots

  • Spinal accessory N.


Limitation

The Cervical Spine- CLINICAL EXAMINATION -

A. bilat. arm ele.

Shoulder girdle exam

Neuropathy

Fracture

Muscle/tendon

Painful arc

Ankylosis

Limitation


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The Cervical Spine- CLINICAL EXAMINATION -

C. Active bilateral arm elevation

<Limitation>

  • Mononeuritis

    • long thoracic n.

    • spinal accessory n.

  • stress fracture

    • first rib

    • spinous process C7/T1

  • painful arc :

  • limitation at the shoulder joint

    <Shoulder Examination>


The cervical spine

The Cervical Spine- CLINICAL EXAMINATION -

D. Nerve root examination

Bilateral : all resisted tests on the good side first.

1. Motor conduction

2. Sensory conduction


1 motor conduction shoulder

Abduction (C5)

Lateral rotation (C5)

1. Motor conduction(Shoulder)

The Cervical Spine- CLINICAL EXAMINATION -


1 motor conduction elbow

Flexion (C5-C6)

Extension (C7)

1. Motor conduction(Elbow)

The Cervical Spine- CLINICAL EXAMINATION -


1 motor conduction wrist

Flexion (C7)

- Golf elbow

Extension (C6)

- Tennis elbow

1. Motor conduction(Wrist)

The Cervical Spine- CLINICAL EXAMINATION -


The cervical spine

Extension (C8)

Adduction (T1)

The Cervical Spine- CLINICAL EXAMINATION -

1. Motor conduction(Thumb, Little finger)


The cervical spine

The Cervical Spine- CLINICAL EXAMINATION -

B. Shoulder shrugging

2. Sensory conduction

A sensory deficit is sought in the distal part of the dermatomes


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The Cervical Spine- CLINICAL EXAMINATION -

  • C5: outer part of the forearm

  • C6: thumb and index finger

  • C7: dorsum of index, middle and ring finger

  • C8: ring and little finger, ulnar part of the hand

  • T1: inner side of the fore arm

  • T2: inner side of the arm


Roots exam

The Cervical Spine- CLINICAL EXAMINATION -

DTR

Motor conduction

Sensory condction

Roots exam.

Biceps Jerk C5,C6

Brachiradialis J C5

Triceps J C7


Cord sign

The Cervical Spine- CLINICAL EXAMINATION -

  • Pathologic Reflex

  • DTR

  • Spasticity

Cord sign

Babinski sign

Ankle clonus

Hoffman sign


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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

The Cervical Spine- CLINICAL EXAMINATION -

Arm test

Resisted movements

(tests for motor conduction):

Shoulder:

  • Abduction - C5

  • External rotation - C7

    Elbow:

  • Flexion - C5/C6

  • Extenstion - C7


The cervical spine

The Cervical Spine- CLINICAL EXAMINATION -

Arm test

Wrist:

  • Flextion – C7

  • Extension-C6

    Thumb extension – C8

    Little finger adduction – T1

    Sensory conduction


The cervical spine

The Cervical Spine- CLINICAL EXAMINATION -

Arm test

Reflexes

  • Biceps – C5 / C6

  • Brachioradialis – C5

  • Triceps - C7

  • Planter - CNS


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The Cervical Spine- CLINICAL EXAMINATION -

A. Introduction

Not tally with the clinical findings:

  • The pain can be unilateral

  • The neck movements can be painful in one direction and not in another direction

  • The end-feel is much softer than the hard end-feel of osteophytosis

  • The patient can have intermittent attacks of pain with painfree episodes between the attacks


The cervical spine

The Cervical Spine- Disorders -

B. Disc protrusion

  • Dura 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

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


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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


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The Cervical Spine- Disorders -

  • Alarm( probably no protrusion)

    • a number of particularity, most of them based on empirical findings

    • we should discard the idea of a disc protrusion in case of :

      ①Ti-palsy

      ②C1- or C2- palsy

      ③motor deficit C4 (shoulder shrug)

      ④sensory deficit C5


The cervical spine

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


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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

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(이상감각)& neurological deficit.

  • strict chronology with spontaneous recovery in 3-4 months


The cervical spine

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


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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 once


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The 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

The Cervical Spine- Disorders -

1. Neck movements

  • A muscular pattern

    • One or more resistance tests hurt more than the active or the passive tests

    • Some possibilities: a muscle lesion, a fractured first rib, metastases grandular fever, or psychogenic symptoms


The cervical spine

The 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-articular(visceral) lesion: pulmonary neoplasm(pancoast)


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The Cervical Spine- Disorders -

  • A full articular pattern

    • Elderly patient probably indicates osteoarthrosis

    • Ankylosing spondylitis(younger)

    • Metastases

    • Injury(fracture)


The cervical spine

The Cervical Spine- Disorders -

2. Shoulder shrugging

  • limitaion = alarm-bell

    • Contracture of the costocoracoid fasicia

    • Metastases in the scapula

  • Pain without limitation

    • Thoracic disc protrusion

    • Subclavius muscle or a sternoclavicular arthritis


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The Cervical Spine- Disorders -

3. Arm tests

  • Active bliateral arm elevation

    • Shoulder girdle test:

      • Long thoracic or spinal accessory neuritis,

      • clay shoveller's fracture

      • Painful arc

      • supraspinatus, inpraspinatus, subscapularis tendinitis, chronic subdeltoid bursitis

  • nerve root tests

    • Excessive, bilateral or pluriradicular palsy

    • T1-palsy also is extremely unlikely to be caused by a disc protrusion


The cervical spine

The Cervical Spine- Disorders -

4. Neuralgic amyotrophy

  • An uncommon disorder with a spontaneous cure in less than a year: sudden severe neck pain without limitation: after a few days bilateral, then unilateral, arm pain; rather severe pain for about two months, gradually easing in the next two months. Extreme muscle weakness, the muscles do not belong to the same root

  • Osteophyte => gradual evoution

    no sever pain

    usually Cs weakness


The cervical spine

The Cervical Spine- Disorders -

5. pressure on a nerve root

  • cause:

    ①disc protrusion

    ②osteophyte

    ③neuroma


The cervical spine

The Cervical Spine- Disorders -

2. post-concussion headache

①Our first problem is to find out whether the headache is organic or alleged.

②The immobility, imposed by the concussion, can also lead to upper cervical ligamentous adhesions, which should be ruptured by manipulation.

③A muscular lesion, at its occipital insertion, is treated by deep friction.


The cervical spine

The Cervical Spine- Disorders -

3. The facet joints

  • The dura mater is the only structure in the locomotor system, which causes extrasegmental reference of pain. Hense, we expect a diffuse cervicoscapular ache when a disc protrusion compresses the dura mater, whereas the ache from a facet joint lesion would felt in one dermatome only.

    Moreover, a disc protrusion is more probable than a facet joint lesion if ;

    ①the pain is felt on the midline

    ②there is a shifting pain

    ③the attacks of unilateral aching are not always felt on the same side

    ④if a cough hurts


The cervical spine

The Cervical Spine- Disorders -

Dr. Troisier describes two clinical patterns in case of a facet joint lesion:

  • convergence, i.e. "closing" of the facets

    e.g. left sided pain on extension, rotation and side flexion to the left

  • divergence, i.e. "opening" of the facets

    e.g. left sided pain on flexion, rotation and side flexion to the right.


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The Cervical Spine- Disorders -

  • Osteoarthrosis(C2~C3, C3~C4)

    • three possible treatments :

      • ①capsular stretching("slow stretch"),

      • ②DF

      • ③an i.a. injection of triamcinolone.

  • Rheumatoid arthritis

    • The treatment : an i.a. injection of triamcinolone.


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The Cervical Spine- Disorders -

4. Migraine

  • At the very beginning, an attack of migraine can sometimes be stopped by strong traction. It is performed manually and should last about 30 seconds.


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The Cervical Spine- Disorders -

5. Headache

Headache of cervical origin can either be segmental or extrasegmental.

  • Segmental(C1~C2)

    • Post-traumatic capsuloligamentous adhesions.

    • Capsular contracture in upper cervical osteoarthrosis ; possibly there is only referred headache without local pain. capsular

    • The old man's matutinal headache.

  • Extrasegmental

    • Compression of the dura mater by a disc protrusion.


The cervical spine

The Cervical Spine- Disorders -

8. Thoracic pain

  • Upper thoracic pain : extrasegmental reference from the cervical dura mater

  • Pectoral pain : dural origin

  • Interscapular pain : central cervical disc protrusion


The cervical spine

The Cervical Spine- Disorders -

  • extrasegmental tenderness from dura mater 의 존재가 진단을 어렵게 할 경우 평가되어야 할 점

    • neck flexion - has a cervical and a thoracic meaning

    • other neck movements painful - cervical lesion

    • pain on scapular tests or on taking a deep breath - thoracic lesion


The cervical spine

The Cervical Spine- Disorders -

9. Misleading tenderness

  • During palpaion, a tender spot within the painful scapular area can be identified by the paitient

  • extrasegmental reference from the cervical dura mater


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The Cervical Spine- Disorders -

10.Congenital torticollis

11. Acute torticollis children

12. Acute torticollis in adult and adolescents

13. Spasmodic torticollis

14. Spastic torticollis

15. Hysterical torticollis

16. Inspection of the scapular area

① position of the scapula

② isolated wasting of the infraspinatus muscle


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