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? 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 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 : 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 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 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: 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