Tutorial Case #7
Cervical Spine Case Presentation - Part I
History: Bruce Wayne is a 75 year-old, retired math teacher. Three days ago while stopped at a red light
waiting for the signal to change Bruce was rear-ended. He was wearing his seat belt. The car he was
driving sustained moderate damage from the impact of an estimated 35mph. Bruce was transported to
the ER secondary to complaints of light-headedness and dizziness. The attending ER doctor who saw
him requested x-rays. The x-rays demonstrated a loss of the cervical lordosis, degenerative disc disease
at multiple levels, bony spurring at C5-6 and C6-7. He was diagnosed with a cervical sprain/strain and
mild concussion. Bruce was given Vicodan, Flexoril, and Naprosyn as well as a soft cervical collar. He
was advised to rest for a few days before beginning Physical Therapy. His chief complaints are
sub-occipital headaches, nausea, and pain with all cervical movements. Bruce states he has been unable
to concentrate, and has problems remembering recent events. In addition to his neck pain and
immobility he has complaints of bilateral paraesthesia of forearms and hands in a stocking glove
distribution.
Behavior:
 Aggravating Factors: All cervical movements increased neck and upper back pain to “10”. It settles
after 3-4 hours to “3’; unable to sleep lying down, awakes with severe pain, RTS 2-3 hours.
 Easing Factors: sleep sitting up; cervical collar; Vicodan and Flexoril
24 Hours:



AM: slightly improved if sleeps for more than 3 hours
Day: worse by end of day, tires easily
Night: awakes 2-3 times/night; RTS with meds
Special Questions:
GH:

WL:

Meds: Vicodan, Flexoril, Naprosyn, and Soma
for sleep;
Cord: +ve
VA:
+ve
Steroids:

Anticoagulants: 
Cough/sneeze: 
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7
Tutorial Case #7
Diagnostics: DDD C5-6 and C6-7, reversal of cervical lordosis, osteophytes at C5-6, and C6-7
anterior vertebral bodies.
Social History: 75 year old retired math teacher, married and in otherwise good health.
Recreational interest is aviation. Still maintains a pilot’s license.
Current History: Bruce Wayne is a 75-year old retired math teacher. Three days ago while
stopped at a red light waiting for the signal to change he was rear-ended. He was wearing his seat
belt. The car he was driving sustained moderate damage from the impact of an estimated 35mph.
He was transported to the ER secondary to complaints of light-headedness and dizziness. The
attending ER Doctor who requested x-rays saw him. The x-rays demonstrated a loss of the
cervical lordosis, degenerative disc disease at multiple levels, bony spurring at C5-6 and C6-7.
He was diagnosed with a cervical sprain/strain and mild concussion. He was given Vicodan,
Flexoril, and Naproxyn as well as a soft cervical collar. He was advised to rest for a few days
before beginning Physical Therapy. Ms chief complaints are sub-occipital headaches, nausea,
and pain with all cervical movements. He states he has been unable to concentrate, and has
problems remembering recent events. In addition to his neck pain and immobility he has
complaints of bilateral paraesthesia of forearms and hands in a stocking glove distribution.
Past History: Unremarkable for neck pain, headaches or previous trauma. Denies previous
history of numbness and tingling in arms. Has consistently passed medical exams for flying.
Does remember being diagnosed with Scheurmann’s Disease as a child.
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7
Tutorial Case #7
Learning Objectives for Cervical Spine Case Study: Part I
The learning objectives for this case presentation are laid out below. By the end of this case
presentation the student should be able to:
1. Define all unknown terms;
2. List the Signs and Symptoms associated with post-traumatic headache syndrome;
3. Describe the pathomechanics and pathophysiology of a sudden acceleration and deceleration
injury;
4. Describe the spondylitic changes which can occur in the vertebral motion segment (disc,
facet, vertebral body);
5. Describe the course of the vertebral artery and the clinical test for patency;
6. Identify the ligaments which stabilize the C2 dens and the clinical tests used to assess
stability in the upper cervical spine as well as understand which x-ray view rules out trauma
at this level;
7. Rationalize the prognosis, typical medical treatment and rehabilitation course most
appropriate for a patient who has sustained a "whiplash" injury.
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7
Tutorial Case #7
Plan the Objective Examination
Use the following outline to plan your evaluation and produce a diagnosis for this patient.
1.
Name as the possible source of any part of the patient’s symptoms every
structure which must be examined:
Joints under the
area of symptoms
Joints referring
into the area of
symptoms
Contractile
structures
underlying the
area of symptoms
1.1.
What is the most probable source(s) of the symptoms.
1.2.
Will you do a neurological examination? Yes / No
Other structures to
be examined
1.2.1. Segmental / peripheral / central (circle)
1.2.2. Why? ________________________________________________________________
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7
Tutorial Case #7
2.
Influence of the Symptoms of the Examination
2.1.
Are the symptoms: minimal / moderate / severe?
2.2.
Does the subjective examination suggest an easily irritable disorder?
Local:
Yes / No
Referred:
Yes / No
Give
an
example:
_____________________________________________________________________
Local:
Activity causing symptoms
____________________________________________
Severity of symptoms
____________________________________________
Duration before symptoms subside
____________________________________________
Referred:
Activity causing symptoms
____________________________________________
Severity of symptoms
____________________________________________
Duration before symptoms subside
____________________________________________
2.3.
Does the nature of the symptoms indicate caution?
Yes / No
Specify _________________________________________________________________
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Tutorial Case #7
2.4
Does the nature of the symptoms require specific testing?
Yes / No
Specify _________________________________________________________________
2.5
Does any other aspect of the subjective examination indicate caution, e.g. severity,
irritability, stage?
Yes / No
Specify _________________________________________________________________
2.6
Are there any contraindications to any part of your examination?
Yes / No
Specify _________________________________________________________________
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Tutorial Case #7
3.0 The Kind of Examination
3.1.
Do you think you will need to be gentle or moderately vigorous with your examination?
_________________________
Local Pain
Pain or point of
increase
3.2.
Referred Pain
Paraesthesia /
Anesthesia
Dizziness or Other
Symptoms
Short of pain
Short of symptoms
Short of symptoms
Pain or point of
increase
Pain or point of
increase
Pain or point of
increase
Active limit of
movement
Active limit of
movement
Partial reproduction
of symptoms
Partial reproduction
of symptoms
Active limit plus
overpressure
Active limit plus
overpressure
_______________
_______________
Sustained
Repeated
Combined
Sustained
Repeated
Combined
_______________
______________
At which point will you limit your objective examination?
_________________________
3.3.
Do you expect a comparable sign to be easy/hard to find?
_________________________
3.3.
Do you expect to be treating pain, resistance, or spasm?
_________________________
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7
Tutorial Case #7
4.0
4.1.
Associated Examination
Which associated factors must be examined?
_________________________
4.1.1. Suggest reasons why the joint, muscle, or other structure has become symptomatic
Specify _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
4.1.2. Suggest reasons why the disorder may occur
Specify _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
PT720/PT721 - Orthopedic Tutorial Case Presentations # 7