CERVICAL SPINE INTRODUCTION: • Examination of the cervical spine involves determining whether the injury or pathology occurs in the cervical spine or in a portion of the upper limb. • Many conditions affecting the cervical spine can be manifested in other parts of the body. • The cervical spine is a complicated area to assess properly, and adequate time must be allowed to ensure that as many causes or problems are examined as possible. ANATOMY & BIOMECHANICS • Cervical spine is divided into two areas 1. Cervicoencephalic (upper cervical spine) 2. Cervicobrachial (lower cervical spine) • Injuries in this area lead to symptoms of: • • • • • • • headache Fatigue Vertigo poor concentration cognitive dysfunction cranial nerve dysfunction sympathetic system dysfunction OSTEOLOGY • The cervical spine contains 7 vertebral bodies (TYPICAL: C3-C6) (ATYPICAL: C1, C2, C7) • C1 (atlas) – no vertebral body, no spinous process • C2 (axis) – dens/odontoid process • C1 to C7 • have a transverse foramen – (+) vert artery, vert vain, sympathetic nerves • vertebral artery travels through transverse foramen of C1 to C6 • C2 to C6 • have bifid spinous process (2 spines) • C7 (non bifid spinous process) • despite having a transverse foramen, the vertebral artery does NOT travel through it in the majority of individuals • there is no C8 vertebral body although there is a C8 nerve root SPINAL CANAL • 17mm - Normal diameter of spinal canal • <13mm - possible cord compression Cervbelow: What is impinged in between C2 AND C3: C3 C8 SN passes in between your C7 vertebra and T1 vertebrae LIGAMENTS OF THE UPPER CERVICAL SPINE CONDITIONS OF THE CERVICAL SPINE TERMS USED • Osteophyte (bone spur): is a tiny pointed outgrowth of bone; bone spurs are usually caused by local inflammation, such as from degenerative arthritis (osteoarthritis) or tendonitis. Bone spurs may or may not cause symptoms. Bone spurs can be associated with pain, numbness, tenderness, and weakness if they are irritating adjacent tissues. • Plexopathy: is a disorder affecting a network of nerves, blood vessels, or lymph vessels. The region of nerves it affects are at the brachial or lumbosacral plexus. Symptoms include pain, loss of motor control, and sensory deficits. • Radiculopathy: is caused by compression or irritation of a nerve as it exits the spinal column. Symptoms of radiculopathy include pain, numbness, tingling, or weakness in the arms or legs. • Cervical myelopathy: results from compression of the spinal cord in the neck. Symptoms of cervical myelopathy may include problems with fine motor skills, pain or stiffness in the neck, loss of balance, and trouble walking. • Upper motor neuron: A neuron that starts in the motor cortex of the brain and terminates within the medulla (another part of the brain) or within the spinal cord. UMNL (UPPER MOTOR NEURON LESION) • Lower motor neuron: is the efferent neuron of the peripheral nervous system (PNS) that connects the central nervous system (CNS) with the muscle to be innervated. LMNL (LOWER MOTOR NEURON LESION) • Myotome: a set of muscles innervated by a specific, single spinal nerve. (TABLE SULLIVAN FOR MYOTOMES) • Dermatome: A localized area of skin that is has its sensation via a single nerve from a single nerve root of the spinal cord. BRACHIAL PLEXUS INJURY I. Erb-Duchenne Paralysis II. Klumpke (Dejerine-Klumpke) Paralysis III. Burners and Stingers Mechanisms of Injury to the Brachial Plexus A.Traction: direct blow to the shoulder with the necklaterally flexed toward the unaffected shoulder (gymnast falls on beam) B.Direct trauma: direct blow to the supraclavicular fossa over Erb’s point C.Compression: Occurs when the neck is flexed laterally toward the patient’s affected shoulder, compressing / irritating the nerves, resulting in point tenderness over involved vertebrae of affected nerve(s) (Troub, 2001) ERB-DUCHENNE PARALYSIS • Site of injury: The region of the upper trunk of the brachial plexus is called Erb's point. Injury to theupper trunk causes: Erb's Paralysis. • Causesof injury: Undue separation of the head from the shoulder, which is commonly encountered in 1)birth injury 2) fall on shoulder, and 3)during anaesthesia • Nerve roots involved: Mainly C5 and partly C6. • Muscles paralysed: Mainly biceps, deltoid, brachialis and brachioradialis. Partly supraspinatus,infraspinatus and supinator DEFORMITY • Arm: Hangs by the side, it is adductedand medially rotated (ADIR) • Forearm: Extended and pronated • Abduction impossible because of paralysisof deltoid & supraspinatus • External rotation is impossible because of paralysisof infraspinatus & teres minor • Active flexion impossible because of paralysis biceps, brachialis & brachioradialis. • Paralysis of supinator m/s causes pronation deformity of forearm. • The deformity is known as "Policeman's tip hand" or "Porter's tip hand". KLUMPKE (DEJERINE-KLUMPKE) PARALYSIS • Site of injury: Lower trunk of the brachialplexus. • Cause of injury: Undue abduction of the arm, as in clutching something withthe hand after a fall from a height, or sometimes in birth injury. • Nerve roots involved: Mainly T1 and partly C8. • Muscles paralysed: Intrinsic muscles of the hand(T1); Ulnar flexors of the wrist and fingers(C8). • Deformity: (position of the hand): claw hand due tothe unopposed action of the long flexors and extensors of the fingers. in a claw hand there is hyperextension at the metacarpophalangeal joints and flexion at the interphalangealjoints. BURNERS AND STINGERS • These are transient injuries to the brachial plexus, which may be the result of trauma combined with factors, such as stenosis or a degenerative disc (spondylosis). • Recurrent burners are not associated with more severe neck injury, but their effect on the nerve may be cumulative. • Symptoms can last from several minutes up to several weeks but they usually resolve themselves. CONDITIONS OF THE SPINE: • SPONDYLOSIS – OA (BONY SPURS/OSTEOPHYTE) OF THE SPINE • SPONDLYOLYSIS – UNILATERAL FRACTURE OF YOUR PARS INTERARTICULARIS • SPONDYLOLISTHESIS – BILATERAL FRACTURE OF THE PARS INTERARTICULARIS SLIPPAGE OF THE BONE FRAGMENT ANTERIOR SLIPPAGE • SPONDYLOLITIS – INFLAMMATION OF THE SPINE Clinical features : History : The mechanism of injury should be considered. Birth injury : Usually 5th and 6th root. Motor cycle accidents. Stab and bullet wounds. Symptoms vary depending upon the type and location of the injury to the brachial plexus. The most common symptoms of BPI include: -Weakness or numbness -Loss of sensation -Loss of movement (paralysis) -Pain Physical examination : Examination of all nerve groups controlled by the brachial plexus to identify the specific location of the nerve injury and its severity. In addition, some patients display specific signs that help determine the location of the nerve injury: A shooting nerve-like pain on taping along the affected nerves (Tinel sign) suggests an injury farther from the spinal cord. Over time, if the location of the Tinel sign moves down the arm toward the hand, it is a sign that the injury is repairing itself. During the physical examination, assess the arm and shoulder for stability and range of motion Scm = ipsilateral side flexion; contralateral rotation TORTICOLLIS TO STRETCH: Perform the opposite of the action Ex: if L SCM affected Stretch: laterally flex to the Right and rotate to the left ACTION/CLINICAL MANIFESTATION: R SCM = flexes the head to the right side and rotates the head to the left side • Derived from the Latin: tortus (twisted) + collis (neck or collar) • AKA “Wry Neck” • Torticollis refers to a symptom rather thana distinct disease process • It can be caused by a wide variety of conditions (over 80 causes have been described) which range from relatively simple self limited to life-threatening • May be congenital or acquired • Occurs more frequently in children thanin adults • The right side is affected in 75% of patients WHAT DOES IT LOOKLIKE? • Abnormal twisting of the neck. Usually, child’s head is tipped toward one side, with the chin pointing in the other direction. • Painful spasms of the neck muscles may occur. CONCLUSION • Torticollis is a clinical sign that might signify an underlying disorder. • In newborn infants with CMT, diagnostic ultrasoundis preferred and often diagnostic. • In older children CTis used to diagnose traumatic insult, neck infection and vertebral anomalies. • MRI is used to diagnose inflammatory and infectiouc spinal disorders and in cases in which CNSor neck malignancy is suspected. WHIPLASH INJURY MECHANISM OF INJURY Cervical acceleration and deceleration. Any impact or blow that causes yourhead to jerk forward or backward. The sudden force stretches and tears the muscles and tendons. CAUSES Motor vehicle accidents (most common) Head banging Falls Sports injury POSSIBLE INJURIES Disc herniation or tear Facet joint pathology Nerve root impingement Muscle tear Ligament tear Dural overstretch Dislocation Fracture Spinal cord injury Brain injury (coup-contra-coup) DIFFERENTIAL DIAGNOSIS Vertebral fracture Acute disc lesion TRANSVERSE LIGAMENT TEAR JEFFERSON FRACTURE • Bone fracture of the anterior and posterior arches of the C1 vertebra • The fracture may result from an axial load on the back of the head or hyperextension of the neck (e.g. caused by diving), causing a posterior break HANGMAN’S FRACTURE C2 - HANGMAN’S FRACTURE RADIOGRAPH CERVICAL MYELOPATHY • common degenerative condition caused by compression on the spinal cord that is characterized by clumsiness in hands and gait imbalance. • treatment is typically operative as the condition is progressive. ETIOLOGY: • Degenerative Cervical Spondylosis (CSM) • most common cause of cervical myelopathy • compression usually caused by degenerative changes (osteophytes) • Congenital stenosis • symptoms usually begin when congenital narrowing combined with spondylotic degenerative changes in older patients • Ossification of PLL or ligamentum flavum • Direct cord compression • Ischemic injury secondary to compression of anterior spinal artery • Grouped as ―spinal stenosis‖ – Central stenosis • Narrowing of the central part of the spinal canal – Foraminal stenosis • Narrowing of the foramen, resulting in pressure on the exiting nerve root – Far lateral recess stenosis • Narrowing of the lateral part of the spinal canal SPINAL STENOSIS SYMPTOMS • Neck pain and stiffness • Extremity paresthesia • Weakness and clumsiness • Gait instability SPECIAL TESTS • Romberg’s test • Lhermitte Sign
