Transcript The Cervical Spine

The Cervical Spine
방배경희한의원
M.D., O.M.D.
신정봉
The Cervical Spine
- History In general, a good history-taking provides
information about:
1.
2.
The patient’s age
Symptoms



3.
Pain
Paraesthesia
vertigo
Drugs
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
- 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
- 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
- History -
2. Symptoms
◆
Pain
 How did it progress?



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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
- History -
2. Symptoms
◆
Pain
 Recurrences


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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
- 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
- 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
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
- History 
Vertigo

Spontanoues or postural
3. Drugs

Anticoagulants provide an absolute bar to
manipulation!
The Cervical Spine
- CLINICAL EXAMINATION We look for :

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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
The Cervical Spine
- CLINICAL EXAMINATION Neck movement
Active
Passive
resistive
Active
1. Extension
2. Rotation
3. Side flexions
4. Flexion
The Cervical Spine
- CLINICAL EXAMINATION Active
Neck movement
Passive
resistive
Active
Pain
Range
Willingness
Passive
Pain
Range
Always (3)
End feel
The Cervical Spine
- CLINICAL EXAMINATION Shoulder Shrug
Active
Resistive
Aactive
Pain
Contracture
of
costocoracoid
Range
fascia
Scapular metastasis
Pulmonary neoplasm
The Cervical Spine
- CLINICAL EXAMINATION Shoulder Shrug
Pain
Weakness
Active
Resistive
C2,3,4 roots
Spinal accessory N.
The Cervical Spine
- CLINICAL EXAMINATION A. bilat. arm ele.
Limitation
Neuropathy
Fracture
Muscle/tendon
Painful arc
Ankylosis
Shoulder girdle exam
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
- CLINICAL EXAMINATION D. Nerve root examination
Bilateral : all resisted tests on the good side first.
1. Motor conduction
2. Sensory conduction
The 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 elbow

Extension (C6)
- Tennis elbow

The Cervical Spine
- CLINICAL EXAMINATION 1. Motor conduction(Thumb, Little finger)

Extension (C8)

Adduction (T1)
The Cervical Spine
- CLINICAL EXAMINATION B. Shoulder shrugging
2. Sensory conduction
A sensory deficit is sought in the
distal part of the dermatomes
The Cervical Spine
- CLINICAL EXAMINATION 
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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
The Cervical Spine
- CLINICAL EXAMINATION Roots exam.
DTR
Motor conduction
Sensory condction
Biceps Jerk C5,C6
Brachiradialis J C5
Triceps J
C7
The 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 test
Resisted movements
(tests for motor conduction):
Shoulder:


Abduction - C5
External rotation - C7
Elbow:


Flexion - C5/C6
Extenstion - C7
The Cervical Spine
- CLINICAL EXAMINATION Arm test
Wrist:
Flextion – C7

Extension-C6
Thumb extension – C8
Little finger adduction – T1

Sensory conduction
The Cervical Spine
- CLINICAL EXAMINATION -
Arm test
Reflexes
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


Biceps – C5 / C6
Brachioradialis – C5
Triceps - C7
Planter - CNS
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 endfeel of osteophytosis
The patient can have intermittent attacks of pain
with painfree episodes between the attacks
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
- 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 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
- 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(이상감
각)& 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 once
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
- 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
- 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)
The Cervical Spine
- Disorders 
A full articular pattern
Elderly patient probably indicates osteoarthrosis
 Ankylosing spondylitis(younger)
 Metastases
 Injury(fracture)

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

The Cervical Spine
- Disorders 3. Arm tests

Active bliateral arm elevation

Shoulder girdle test:




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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
- 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
- Disorders 5. pressure on a nerve root

cause:
①disc protrusion
②osteophyte
③neuroma
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
- 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
- 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.
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.
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.
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
- 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
- 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
- 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
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