The Cervical Spine

1. The Cervical Spine 방배경희한의원 M.D., O.M.D. 신정봉

2. The Cervical Spine- History - In general, a good history-taking provides information about: • The patient’s age • Symptoms • Pain • Paraesthesia • vertigo • Drugs

3. 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

4. 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.

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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

11. The Cervical Spine- History - • Vertigo • Spontanoues or postural 3. Drugs • Anticoagulants provide an absolute bar to manipulation!

12. 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

13. The Cervical Spine- CLINICAL EXAMINATION - Active Passive resistive Neck movement Active Extension Rotation Side flexions Flexion

14. The Cervical Spine- CLINICAL EXAMINATION - Active Passive resistive Pain Range Willingness Active Neck movement Pain Range End feel Passive Always (3)

15. The Cervical Spine- CLINICAL EXAMINATION - Active Resistive Aactive Shoulder Shrug Pain Range Contracture of costocoracoid fascia Scapular metastasis Pulmonary neoplasm

16. The Cervical Spine- CLINICAL EXAMINATION - Pain Weakness Active Shoulder Shrug Resistive • C2,3,4 roots • Spinal accessory N.

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

18. 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>

19. The Cervical Spine- CLINICAL EXAMINATION - D. Nerve root examination Bilateral : all resisted tests on the good side first. 1. Motor conduction 2. Sensory conduction

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

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

22. Flexion (C7) - Golf elbow Extension (C6) - Tennis elbow 1. Motor conduction(Wrist) The Cervical Spine- CLINICAL EXAMINATION -

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

24. The Cervical Spine- CLINICAL EXAMINATION - B. Shoulder shrugging 2. Sensory conduction A sensory deficit is sought in the distal part of the dermatomes

25. 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

26. The Cervical Spine- CLINICAL EXAMINATION - DTR Motor conduction Sensory condction Roots exam. Biceps Jerk C5,C6 Brachiradialis J C5 Triceps J C7

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

28. The Cervical Spine- CLINICAL EXAMINATION - Arm test Tests for neurogenic integrity and alternative causes of arm pain Active elevation Pain/limitation → Shoulder examination?

29. 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

30. The Cervical Spine- CLINICAL EXAMINATION - Arm test Wrist: • Flextion – C7 • Extension-C6 Thumb extension – C8 Little finger adduction – T1 Sensory conduction

31. The Cervical Spine- CLINICAL EXAMINATION - Arm test Reflexes • Biceps – C5 / C6 • Brachioradialis – C5 • Triceps - C7 • Planter - CNS

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

42. The Cervical Spine- Disorders - C. other disorders / differntial diagnosis 1.Differential diagnostic interpretation “ All discs are alike, but all other disorders are different.”

43. 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

44. 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)

45. The Cervical Spine- Disorders - • A full articular pattern • Elderly patient probably indicates osteoarthrosis • Ankylosing spondylitis(younger) • Metastases • Injury(fracture)

46. 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

47. 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

48. 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

49. The Cervical Spine- Disorders - 5. pressure on a nerve root • cause: ①disc protrusion ②osteophyte ③neuroma

50. 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.