Cervical Spine Pathologies and Special Tests

1. Cervical Spine Pathologies and Special Tests Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. Pathologies • Brachial Plexus Pathology: • Brachial Plexus Neuropraxia: • Common name: “Burner” or “Stinger” • Definition: • “Transient brachial plexopathy involving the upper trunk” • “Temporary episode of unilateral upper extremity burning dysethesia with or without motor weakness” • “Stinger” → tingling that occurs in upper extremity after injury

3. Brachial Plexus Pathology: Epidemiology: (specific studies) 50% of a Division I FB team had 1 or more burners/season (Robertson et al.) 65% of DIII FB players (201) during careers / 57% > 1 burner (Sallis et al.) 70% reported additional burners that they did NOT report ↑ occurrence with defensive players (DB’s) Pathologies

4. Brachial Plexus: C5 – T1 7 cervical vertebrae 8 cervical nerves: 1st 7: exit above the corresponding vertebrae C8: exits below the 7th cervical vertebrae Pathologies

5. Pathologies • Brachial Plexus Pathology: • Mechanism of Injury: • Stretch of the brachial plexus: • Head forced laterally while opposite shoulder is depressed (common MOI – tackling) • C5 and C6 (most commonly affected) • Nerve root compression: • Combination of neck hyperextension and ipsilateral lateral flexion • Nerve roots impinged between vertebrae • Spinal stenosis - ↑ risk • Compression of brachial plexus: • Direct blow to Erb’s point (shoulder pads compress plexus)

6. Pathologies

7. (A) Traction to the brachial plexus (ipsilateral shoulder depression and contralateral lateral neck flexion) (B) Direct blow to the supraclavicular fossa (Erb's point) (C) Compression of the cervical roots or brachial plexus (ipsilateral lateral flexion and hyperextension)

8. Pathologies

9. Pathologies • Brachial Plexus Pathology: • Signs and symptoms: • Numbness and burning of the entire arm, hands, fingers • Sensation loss over dermatomes • Complete transient paralysis of affected nerves • Tenderness over the brachial plexus • Grading: • Grade 1 (Neuropraxia): transient signs/sx. last from a few minutes → 2 weeks • Grade 2 (Axonotmesis): significant sensory/motor deficits > 2 weeks and less than < 6 months • Grade 3 (Neurotmesis): symptoms 6 months → 1 year

10. Pathologies • Brachial Plexus Pathology: Evaluation • Inspection: • Athlete shakes arm/hand in attempt to regain feeling • Inspect cervical spine for abnormality (fracture/dislocation) • Palpation: • Cervical spine • Clavicle, humerus, scapula, sternum, ribs • SC, AC, GH joints • Shoulder musculature

11. Pathologies • Brachial Plexus Pathology: Evaluation • Functional Testing: • Active and passive ROM (all neck and shoulder movements) • RROM – can be performed in conjunction with myotome check • Key muscles tested: deltoid, external rotators, biceps brachii • Neurological Screening: • Upper quarter sensory/motor testing • Special Tests: • Brachial plexus stretch test • Cervical compression and distraction • Spurling test

13. Clinical Evaluation

14. Pathologies • Brachial Plexus Pathology: • Return to Play Criteria: • Full, pain-free active and passive ROM in the cervical spine • Full, pain-free neck strength against resistance • Full strength of all shoulder and arm movements • Normal sensation in all dermatomes • Check shoulder pads/helmet to ensure proper fit • Recheck in 3-5 minutes

15. Protective Equipment: A: Neck Roll B: Lifter C: Cowboy Collar

16. Research Article #1: Effects of Football Collars on Cervical Hyperextension and Lateral Flexion Objective: Evaluate the effectiveness of 3 football collars in ↓ cervical ROM Why: MOI for stingers Do the collars ↓ movement? PREVENTION Pathologies

17. Pathologies • Effects of FB Collars on Cervical Hyperextension and Lateral Flexion: • Methods: • Subjects: 15 D1 football players • Force applied (hand-held dynamometer) • Motion: 2-dimensional video analysis • Movement: • AROM and PROM • Hyperextension • Lateral flexion

19. Hyperextension Findings: Can be limited by all 3 collars: (rankings) 1. Cowboy collar 2. A-Force 3. Neck roll Note: Passive overloading still resulted in additional 190 of hyperextension Lateral Flexion Findings: No collar ↓ passive lateral flexion better than the shoulder pads alone Standard neck roll ↓ active ROM

20. Pathologies • Research Article #2: • Biomechanical Analysis of Football Neck Collars: • Objective: Perform a biomechanical analysis of neck collars through dynamic testing • Why: • MOI for head and neck injuries • Do the collars ↓ force transmission (upon impact)?

21. Pathologies • Biomechanical Analysis of FB Neck Collars: • Methods: • Collars (3) evaluated: • Cowboy collar (McDavid) • Bullock collar • Kerr collar • Crash-test dummy: • Shoulder pads (raised and unraised), helmet, collar • Accelerometers / load cells / angular rate sensors • Impacts: • Pneumatic linear impactor • 5 m/s and 7 m/s

23. Pathologies • Biomechanical Analysis of FB Neck Collars: • Results: • Top of Head Impact: • Most protection: Kerr collar (Bullock – 2nd) • Why? Kerr collar contacts the base of the helmet during impact → redirects some load to shoulders • Front Impact: • Most protection: Kerr collar (all provided ↑ protection) • ↓ head and neck movement ** • Side Impact: • Kerr – minimal protection • Cowboy and Bullock – no protection

24. Peak Values for Front Impact: Normal Shoulder Pad Configuration

25. Cervical Nerve Root Impingement: History: Onset: Acute of chronic Pain: Radiating symptoms into trapezius, scapula, shoulder, arm, wrist, and hand MOI: Compression or irritation of nerve Predisposing conditions: Disc pathology, narrowing of intervertebral foramina, facet degeneration Pathologies

26. Pathologies • Cervical Nerve Root Impingement: • Inspection: • Posture of head • Palpation: • Point tenderness • Functional Tests: • Pain with extension, lateral bending toward same side, and rotation • AROM, PROM, RROM • Neurological Tests: • Upper quarter screen: • Muscle weakness, paresthesia, diminished reflexes • Special Tests: • Cervical compression test (↑ symptoms) • Cervical distraction test (↓ symptoms) • Spurling test / Vertebral artery test / Abduction test

28. Special Tests • Brachial Plexus Traction Test: • Patient position: • Seated • ATC position: • Standing behind the patient • Procedure: • One hand placed on side of the patient’s head; other hand over the AC joint (same side) • Cervical spine is laterally bent and opposite shoulder depressed • Positive test: • Radiating pain on the side opposite the lateral bending • Stretching of brachial plexus • Radiating pain on the side toward the lateral bending • Compression of cervical nerve roots between 2 vertebrae

29. MOI is duplicated in attempt to replicate the athlete’s symptoms. Radiating pain down left shoulder – traction injury / Radiating pain down right shoulder – compression injury. Perform bilaterally and do NOT perform with suspected cervical spine fracture and/or dislocation.

30. Special Tests: • Cervical Compression Test: • Patient position: • Sitting • ATC position: • Standing behind the athlete with hands interlocked over the top of the patient’s head • Procedure: • Press down on the crown of patient’s head • Positive test: • Pain in upper cervical spine and/or upper extremity • Implication; • Compression of the facet joints and narrowing of the intervertebral foramen

31. Special Tests Cervical Compression Test:Attempts to duplicate patient’s symptoms by ↑ pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out.

32. Special Tests • Spurling Test (Foraminal Compression): • Patient position: • Seated • ATC position: • Standing behind the athlete with hands interlocked over crown of patient’s head • Procedure: • Patient laterally flexes the head while a compressive force is placed along patient’s cervical spine • Positive test: • Radiating pain down patient’s arm • Implication: • Nerve root impingement

33. Special Tests Spurling’s Test: Attempts to compress a cervical nerve root. Do NOT perform until a cervical fracture, dislocation, or instability has been ruled out.

34. Special Tests • Cervical Distraction Test: • Patient position: • Supine (relaxes the muscles acting on the cervical spine) • ATC position: • At head of patient with one hand under the occiput and the other on top of the forehead (stabilizing head) • Procedure: • Apply traction on patient’s head, causing distraction of cervical spine • Positive test: • Relief or reduction in symptoms • Implications: • Compression of the cervical facet joints and/or stenosis of neural foramina

35. Cervical Distraction Test: Attempts to relieve patient’s symptoms by ↓ pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out.

36. Special Tests • Vertebral Artery Test: • Patient position: • Supine • ATC position: • Seated at head of the patient with hands placed under the occiput to stabilize the head • Procedure: • Passively extend and laterally flex the cervical spine (1) • Head is rotated toward the laterally flexed side and held for 30 seconds (2) • Positive test: • Dizziness, confusion, nystagmus, unilateral pupil changes, nausea • Implication: • Occlusion of the cervical vertebral arteries

37. Vertebral Artery Test: Used to assure the competency of the vertebral artery prior to initiating treatment or rehabilitation techniques that may compromise a partially occluded artery. Do NOT perform until the presence of a cervical fracture, dislocation, or instability has been ruled out. Positive Test: Refer to physician