Transcript Ch 10 and 11 Cervical Thoracic and Lumbar Spinal Conditions

Cervical and Thoracic
and Lumbar Spinal
Conditions
Chapters 10 and 11
Anatomy
Spinal column
– Vertebrae
Cervical (7)
Thoracic (12)
Lumbar (5)
Sacral (5 fused)
Coccyx (4 fused)
Anatomy (cont.)
– Structure
Rigid enough to support body and protect
spinal cord
Flexible enough to produce a
variety of movements
Anatomy (cont.)
Anatomy (cont.)
Anatomy (cont.)
Cervical
– 7 vertebrae form curve forward
– Atlas
1st vertebra
– No body – filled with odontoid process
– Function: support the head
– Axis
2nd vertebra
Odontoid process – tooth-like
Allows head to rotate
Thoracic
– 12 vertebrae form curve backwards
– Extra facets for articulation with ribs
Anatomy
Lumbar spine
– Forms concave curve anteriorly
– 5 lumbar, 5 fused sacral, and 4 small,
fused coccygeal vertebrae
Sacrum articulates with ilium –
sacroiliac joint
Anatomy (cont.)
Anatomy (cont.)
Anatomy (cont.)
Vertebral structure
– Body
– Vertebral arch
– Superior and inferior articular processes
Facet joints
– Spinous process
– Transverse processes
Progressive increase in vertebral size
Change in angulation
Anatomy (cont.)
Motion segment
– Functional unit
– Any 2 adjacent
vertebrae and soft
tissues between them
Anatomy (cont.)
Intervertebral discs
– Components
Annulus fibrosus
 Thick fibrous ring
Nucleus pulposus
 Gelatinous interior
– Function
Shock absorption
Allow spine to bend
Anatomy (cont.)
Ligaments
–
–
–
–
–
Anterior longitudinal
Posterior longitudinal
Ligamentum flavum
Interspinous
Supraspinous
Anatomy (cont.)
Muscles of the neck: lateral view
Anatomy (cont.)
Muscles of the neck: posterior view
Anatomy (cont.)
Muscles of trunk
– Paired
– Unilaterally: produce lateral flexion and/or
rotation of the trunk
– Bilaterally: trunk flexion or extension
Primary movers for back extension –
erector spinae muscles
Anatomy (cont.)
• Nerve plexus
– Cervical (C1–C4)
– Brachial (C5–T1)
Anatomy (cont.)
Nerve plexus
– Lumbar (T12–L5)
– Sacral (portion of lumbar [L4–L5])
Anatomy (cont.)
• Blood supply
– Common carotid
– Vertebral
Kinematics
Movements involve a number of
motion segments
Directions of movement – Flexion/extension/ hyperextension
– Lateral flexion
– Lateral rotation
Anatomic Variations: Injury
Potential
Kyphosis
– Excessive curve of thoracic spine
– Congenital – deficits in vertebral bodies
– Idiopathic
Scheuermann’s disease
– Secondary to osteoporosis
Anatomic Variations: Injury
Potential (cont.)
Scoliosis
– Lateral curvature of spine; “C” or “S” curve
– Structural
Inflexible curve, persists with lateral bending
– Nonstructural
Flexible, corrected with lateral bending
– Commonly idiopathic
– Symptoms vary with severity
Mild 20 and moderate = 20–45
 Treated with exercise
Severe
Anatomic Variations: Injury
Potential
Lordosis
– Abnormal exaggeration of lumbar curve
– Causes include:
Congenital deformities
Weak abdominal musculature
Poor posture
Activities with excessive hyperextension
Anatomic Variations: Injury
Potential (cont.)
Sway back
– Increased lordotic curve and kyphosis
– Causes include:
Muscle weakness; compensatory muscle tightness
– Entire pelvis shifts anteriorly, causing the hips to move
into extension
– Impact on center of gravity (COG)
Anatomic Variations: Injury
Potential (cont.)
Flat back
– Decrease in lumbar lordosis (20°)
– Clinical sign: tendency to lean forward when
walking or standing
– Impact on center of gravity (COG)
Anatomic Variations: Injury
Potential (cont.)
Anatomic Variations: Injury
Potential (cont.)
Prevention of Spinal Injuries
Protective equipment
– Neck roll
– Rib protectors
Physical conditioning
– Strength and flexibility
Proper technique
– Spearing
– Proper lifting
– Posture
Cervical Spine Conditions
Cervical sprain
– Extreme motions or violent mechanism
– S&S
Pain, stiffness, restricted ROM
Pain can persist for several days
– Management: standard acute; cervical collar;
consult physician
– No return to competition until pain free and
ROM is normal
Cervical Spine Conditions (cont.)
Cervical strain
– Usually, sternocleidomastoid or upper trapezius
– Same mechanism as sprain; injuries often
simultaneous
– S&S
Pain, stiffness, spasm, restricted ROM
 pain with active contraction or passive stretch of
involved muscle
– Management: standard acute; cervical collar;
consult physician
– No return to competition until pain free and ROM is
normal
Cervical Spine Conditions (cont.)
Cervical disc injuries
– Soft disc herniation
Nucleus pulposus herniates through posterior annulus
Acute mechanism: uncontrolled lateral bending of neck
– Hard disc disease
Chronic, degenerative
Diminished disc height and formation of marginal
osteophytes
Cervical Spine Conditions (cont.)
– S&S
Varying degrees of neck or arm pain, may
radiate
Pain exacerbated by Valsalva maneuvers and
neck movement
Severe cases—potential loss of motor function
below injury level
– Management: rest, activity modification,
NSAIDs
Cervical Spine Conditions (cont.)
Cervical
fracture/dislocation
fracture
– MOI—axial loading with
violent flexion of neck
– Dislocation: add
rotation
– S&S
Pain over spinous
process with or without
deformity
Constant neck pain
Muscle spasm
Cervical Spine Conditions (cont.)
Signs of neural damage




Muscle weakness in extremities; inability to move
Abnormal sensations in extremities
Absent or weak reflexes
Loss of bladder or bowel control
Suspect injury with violent mechanism
– Management: activate EMS
Brachial Plexus Injuries
Mechanism
– Tension (stretching)
Violent lateral movement of head and neck
Arm forced into excessive external rotation, abduction, and
extension
– Compression
Location where plexus is most superficial (Erb’s point)
– Forced lateral flexion, causing increased pressure between
shoulder pad and superior medial scapula
Brachial Plexus Injuries (cont.)
Brachial Plexus Injuries (cont.)
Acute burners
– S&S
Immediate, severe, burning pain and prickly paresthesia
radiates into hand
Pain transient; subsides in 5–10 minutes
Weakness in abduction and external rotation
– Management: return to play—full strength, ROM, &
sensation; cryotherapy
Brachial Plexus Injuries (cont.)
Chronic burners
– S&S
Frequent acute episodes that may not produce
areas of numbness
Muscle weakness may develop hours or days
after initial injury; dropped shoulder or visible
atrophy in shoulder muscles
– Management: same parameters as acute;
frequent re-examination
Thoracic Spine Conditions
Sprains/strains
– MOI: overload; overstretch
– S&S
Painful spasms of back muscles
 May develop as a sympathetic response to sprains
 Presence of spasms makes it difficult to determine
sprain or strain
Sprain—dramatic improvement in 24–48 hours;
severe strains—3–4 weeks to heal
– Management: standard acute care
Lumbar Spine Injuries
Contusions, strains, and sprains
– Estimated 80% of population has low back pain
(LBP) at some time
– Nearly 97% stems from mechanical injury to
muscles, ligaments, or connective tissue
– Chronic LBP: associated with LBP, reduced spinal
flexibility, repeated stress, and activities that
require maximal extension of the lumbar spine
Lumbar Spine Injuries (cont.)
– LBP
Pain and discomfort can range (local or diffuse)
No radiating pain
No signs of neural involvement
– Management: standard acute; stretching
Lumbar Spine Injuries (cont.)
LBP in runners
– Associated with tightness in hip flexors and/or hamstrings
– S&S
Localized pain, ↑ with active and resisted back extension
No radiating pain
No signs of neural involvement
Possible anterior pelvic tilt and hyperlordosis
– Management
Ice, NSAIDs, muscle relaxants, TENS, and EMS
Avoiding excessive flexion activities and a sedentary posture
– Decrease incidence—use progressive training techniques
Anatomic Variations: Injury
Potential (cont.)
Pars interarticularis
– Area between superior and inferior facets
Weakest part of the vertebrae
– Spondylolysis—fracture
Congenital or mechanical stress
 Repeated weight loading in flexion, hyperextension, and rotation
Occurs at an early age (8 years); asymptomatic until ages
10–15 years
Anatomic Variations: Injury
Potential (cont.)
– Spondylolisthesis—bilateral separation
Anterior displacement of a vertebra
Common site—lumbosacral joint
Ages 10–15 years
Anatomic Variations: Injury Potential
(cont.)
Anatomic Variations: Injury
Potential (cont.)
Spondylolisthesis
– MRI demonstrates anterior shift of L5
Lumbar Spine Injuries (cont.)
Lumbar disc conditions
– Protruded disc (A)
Eccentric accumulation of nucleus with slight deformity of
annulus
– Prolapsed disc (B)
Eccentric nucleus produces a definite deformity as it works its
way through fibers of annulus fibrosus
– Extruded disc (C)
Nuclear material bulges into spinal canal and runs risk of
impinging adjacent nerve roots
– Sequestrated disc (D)
Nuclear material from intervertebral disc is separated from disc
itself and potentially migrates
Lumbar Spine Injuries (cont.)
Lumbar Spine Injuries (cont.)
– S&S
Sharp pain and spasm at site of herniation;
pain shoots down extremity
Walk in slightly crouched position, leaning
away from side of lesion
Compression on spinal nerve
– Sensory and motor deficits
– Alteration in tendon reflex
Lumbar Spine Injuries (cont.)
Lumbar fractures and dislocations
– Transverse or spinous process fracture
Due to:
 Extreme tension from attached muscles
 Direct blow
Additional injury to surrounding soft tissues
– Compression fracture
Hyperflexion crushes anterior aspect of vertebral body
Primary danger—possibility of bony fragments moving
into spinal canal, damaging cord or spinal nerves
Lumbar Spine Injuries (cont.)
– Dislocations
Occur only when a fracture is present
Rare in sports
– S&S
Localized, palpable pain may radiate down
the nerve root if a bony fragment compresses
a spinal nerve
Lumbar Spine Injuries (cont.)
– Spinal cord ends—L1 or L2 level
Fracture below not a serious threat, but handle with
care to minimize potential damage to cauda equina
– Management
Fracture or dislocation: activate EMS
Conservative treatment: initial bed rest, cryotherapy,
and minimizing mechanical loads
Sacrum and Coccyx Conditions
Sacroiliac joint sprain
– Mechanisms
Single traumatic episode involving bending and/or
twisting
Repetitive stress from lifting
Fall on buttocks
Excessive side-to-side or up-and-down motion during
running
Running on uneven terrain
Suddenly slipping or stumbling forward
Wearing new shoes or orthoses
Sacrum and Coccyx Conditions
(cont.)
– S&S
Unilateral, dull pain that extends into buttock and posterior
thigh
ASIS or PSIS may appear asymmetric bilaterally
Leg length discrepancy
↑ pain with standing on one leg and stair climbing
Forward bending reveals block to normal movement with
the PSIS on injured side moving sooner than uninjured side
↑ pain with lateral flexion toward injured side
↑ pain with straight leg raises beyond 45°
– Management: standard acute; gentle stretching
Assessment of Spinal Conditions
Traumatic episode
– When in doubt, always assume a severe
spinal injury and activate emergency care
plan
– Do not move head, neck, or spine (or
helmet)
Assessment of Spinal Conditions
(cont.)
“Red flags”—warrant immobilization and
immediate referral
– Severe pain, point tenderness, or deformity along
vertebral column
– Loss or change in sensation anywhere in the body
– Paralysis or inability to move a body part
– Diminished or absent reflexes
– Muscle weakness in a myotome
– Pain radiating into the extremities
– Trunk or abdominal pain referred from visceral
organs
– Any injury involving uncertainty about severity or
nature
Spinal Assessment—Conscious
Individual
History
– Important to ask questions about:
Pain
 Location (i.e., localized or radiating)
 Type (i.e., dull, aching, sharp, burning)
Sensory changes (i.e., numbness, tingling, or absence of
sensation)
Muscle weakness or paralysis
– Neck injury
– Determine both long- and short-term memory loss that
may indicate an associated brain injury
Spinal Assessment—Conscious
Individual (cont.)
Observation/inspection
–
–
–
–
–
Postural assessment
Scan exam
Gait analysis
Inspection of injury site
Gross neuromuscular assessment
Spinal Assessment—Conscious
Individual (cont.)
Palpation
– Seated, standing, supine, or prone position
– Relax the neck and spinal muscles—lying position
– Posterior cervical structures
Patient supine
– Thoracic and/or Lumbar region
Patient prone
Pillow under the hip region to tilt the pelvis back and
relax the lumbar curvature
Spinal Assessment—Conscious
Individual (cont.)
Physical examination testing
– If, at anytime, movement leads to increased
acute pain or change in sensation or the
individual resists moving the spine, a
significant injury should be assumed and
EMS activated
Range of Motion (ROM)
Active range of motion (AROM)
–
–
–
–
–
–
–
–
Cervical flexion
Cervical extension
Lateral cervical flexion (left and right)
Cervical rotation (left and right)
Forward trunk flexion
Trunk extension
Lateral trunk flexion (left and right)
Trunk rotation
AROM – Cervical Spine
AROM – Thoracic Spine
AROM – Lumbar Spine
ROM (cont.)
Passive ROM
– Cervical spine
Do not perform if motor and sensory deficits
are present
Normal end feel—tissue stretch
– Thoracic is seldom performed
ROM (cont.)
Resisted ROM
– Cervical spine
Stabilize the hip and trunk to avoid muscle
substitution
Patient seated; one hand stabilizes the shoulder or
thorax while other hand applies manual
overpressure
– Thoracic region
Weight of the trunk will stabilize the hips
Stress and Functional Tests
Brachial plexus
traction
Cervical compression
Stress and Functional Tests
(cont.)
 Straight leg raise test – for
sciatic
 Well straight leg raise test
– for disc injury
 Bowstring test – for sciatic
Stress and Functional Tests
(cont.)
 Valsalva’s – for disc injury
 Milgram test – for disc
injury
Stress and Functional Tests
(cont.)
 Single leg stance – for fracture
 Quadrant test – for
neuropathy
Stress and Functional Tests
(cont.)
 Hoover test – for
malingering
Stress and Functional Tests
(cont.)
 Sacroiliac
compression and
distraction test – for
SI sprain
 Approximation test –
for SI sprain/fracture
Stress and Functional Tests
(cont.)
 FABER (Patrick) test – for SI joint pathology
Neurologic Tests
Babinski – for spinal neuropathy
Oppenheim – for spinal neuropathy