Neck Conditions

CERVICAL SPINE Prepared by: Ms. Sarah A. Ligaya, PTRP

• Scanning examination

• Mobility

ANATOMY

2 divisions

•Cervicoencephalic/Cervicocranial

• upper cervical spine

•C0-C2

•Cervicobrachial for the lower cervical

spine.

• Lower cervical spine

•C3-C7

Cervicoencephalic/ Cervicocranial • upper cervical spine

• C0-C2

• Injuries in this area lead to symptoms of:

• Headache

• Fatigue

• Vertigo

• Poor concentration

• Hypertonia of sympathetic nervous system, and

• Irritability

• Cognitive dysfunction, cranial nerve dysfunction and

sympathetic system dysfunction.

LIGAMENTS • ANTERIOR ATLANTO-OCCIPITAL MEMBRANE

• is strengthened by the anterior longitudinal ligament.

• POSTERIOR ATLANTO-OCCIPITAL MEMBRANE

• replaces the ligamentum flavum between the atlas and occiput.

• TECTORIAL MEMBRANE

• is a broad band covering the dens and its ligaments

• is found within the vertebral canal

• is a continuation of the posterior longitudinal ligament.

• ALAR LIGAMENTS

• two strong rounded cords found on each side of the upper dens passing upwards and laterally to attach on the medial sides of the occipital condyles

• limit flexion and rotation

• play a major role in stabilizing C1 and C2, especially in rotation

• Lateral Flexion Alar Ligament Stress Test

• Rotational Alar Ligament Stress Test

ATLANTO-OCCIPITAL JOINTS (C0 TO C1)

• are the two uppermost joints.

• The principal motion of these two joints is:

• Flexion-extension (15° to 20°) or nodding of the

head.

• Side flexion is approximately 10°, whereas rotation

is negligible.

ATLANTO-AXIAL JOINTS (C1 TO C2)

• Pivot/trochoid joint

• Most mobile articulation of the spine

• FL-EX (10 deg.)

• Side flexion (5 deg.)

• Rotation (50 deg.)

• Ligament: transverse ligament of the atlas

• which holds the dens of the axis against the anterior arch of the atlas.

• It is this ligament that weakens or ruptures in rheumatoid arthritis.

• Transverse Ligament Stress Test.

• cruciform ligament of the atlas

The Cervicobrachial Area • Symptoms include

• neck and/or arm pain

• Headaches

• Restricted range of motion (ROM)

• Paresthesia

• Altered myotomes and dermatomes

and radicular signs.

• Sympathetic dysfunction may be.

• Injury to both areas, if severe enough,

may result in psychosocial issues.

• For C3 to C7, the main ligaments are

the:

• ALL

• PLL

• Ligamentum flavum

• Supraspinal and

• Interspinal ligaments

UNCINATE JOINTS OR JOINTS OF LUSCHKA

• C3 TO T1

• not seen until age 6 to 9 years and

• are not fully developed until 18 years

of age.

• The uncus gives a “saddle” form to the

upper aspect of the cervical vertebra,

which is more pronounced

posterolaterally; it has the effect of

limiting side flexion.

• Extending from the uncus is a “joint”

that appears to form because of a

weakness in the annulus fibrosus.

FACET ORIENTATION

• The superior facets

of the cervical

spine face:

• upward, backward,

and medially (PSM)

• The inferior facets

face:

• downward, forward,

and laterally.

• This plane facilitates flexion and extension

• C5 and C6 where greatest flexion-extension of the

facet joints occurs.

• Because of this mobility, degeneration is more likely to

be seen at these levels.

• there is almost as much movement at C4 to C5 and C6

to C7.

• Coupled movement with rotation and side flexion

• Between C0 and C2, as well as C7 and T1, the two

movements occur in opposite directions

• Between C2 and C7, they occur in the same direction.

• These joints move primarily by gliding and are classified as

synovial (diarthrodial) joints.

• Capsule: Lax

Cervical Spine

• Resting position: Midway between flexion and extension

• Close packed position: Full extension

• Capsular pattern: Side flexion and rotation equally

limited extension

IVD • make up approximately 25% of the

height of the cervical spine.

• No disc is found between the atlas and

the occiput (C0 to C1) or between the

atlas and the axis (C1 to C2).

• give the cervical spine its lordotic

shape.

• The nucleus pulposus

• functions as a buffer to axial

compression in distributing

compressive forces

• annulus fibrosus acts to withstand

tension within the disc.

NERVE ROOTS

- Eight cervical nerve roots.

- Each nerve root is named

for the vertebra below it.

- As an example, C5 nerve

root exists between the C4

and C5.

- In the rest of the spine,

each nerve root is named

for the vertebra above; the

L4 nerve root,

- for example, exists

between the L4 and L5

vertebrae

VERTEBRAL ARTERY • passes through the transverse

processes of the cervical

vertebrae

• usually starting at C6 but entering

as high as C4—supplies 20% of

the blood supply to the brain

• ICA (80%)

• The vertebral and internal

carotid arteries are

• Vertebral arteries and ICA are

stressed primarily by rotation,

extension, and traction

movements.

VERTEBRAL ARTERY • lies close to the facet joints and vertebral body where it

may be compressed by osteophyte formation or injury to

the facet joint.

• OLDER PEOPLE

• may contribute to altered blood flow in the arteries:

• atherosclerotic changes and

• other vascular risk factors (e.g., hypertension, high

fat or cholesterol levels, diabetes, smoking)

• Rotation and extension of as little as 20° have

significantly decrease vertebral artery blood flow.

• Dutton reports that the most common mechanism for non-

penetrating injury to the vertebral artery is neck

extension, with or without side flexion or rotation.

VERTEBRAL ARTERY • The greatest stresses are placed on the vertebral arteries in

four places:

• where it enters the transverse process of C6

• within the bony canals of the vertebral transverse processes

• between C1 and C2

• and between C1 and the entry of the arteries into the skull

• Given the type of injury possible, symptoms may be delayed.

• Symptoms related to the vertebral artery include:

• Vertigo

• Nausea

• Tinnitus

• “drop attacks” (falling without fainting)

• visual disturbances, or,

• in rare cases, stroke or death.

Signs and Symptoms of Vertebrobasilar Artery Insufficiency* • • Dizziness

• • Giddiness

• • Drop attacks

• • Syncope (loss of consciousness)

• • Stroke

• • Diplopia, blurred vision

• • Visual hallucination

• • Tinnitus (ringing in the ears)

• • Flushing

• • Sweating

• • Lacrimation (tearing)

• • Rhinorrhea (runny nose)

• • Scotomata (visual defect in

defined area of eye[s])

• • Hiccups

• • Myotonic jerks

• • Tremor and rigidity

• • Disorientation

• • Vertigo

• • Photophobia (sensitivity to light)

• • Numbness and tingling

• • Quadriparesis (weakness in all

four limbs)

• • Dysphagia (difficulty swallowing)

• • Dysarthria (difficulty articulating)

• • Photopsia (sensation of flashing

lights)

• • Visual anosognosia (unawareness

of visual defect)

• • Nystagmus

• • Ataxia (lack of voluntary muscle

coordination)

OBSERVATION

Head and Neck Posture.

Shoulder Levels.

• Normally

• With injury?

• Poking chin will cause shoulders to be?...

Muscle Spasm or Any Asymmetry.

• Is there any atrophy of the deltoid muscle

(_______nerve palsy)

- Torticollis?

Facial Expression.

• Such observation should give the examiner an idea of how much the

patient is subjectively suffering.

Bony and Soft-Tissue Contours. • If the cervical spine is injured, the head tends to be tilted

and rotated away from the pain, and the face is tilted

upward.

• If the patient is hysterical, the head tends to be tilted and

rotated toward the pain, and the face is tilted down.

Evidence of Ischemia in Either Upper Limb. • The examiner should note any altered coloration of the skin, ulcers, or

vein distention as evidence of upper limb ischemia.

Normal Sitting Posture.

• The nose should be in line with the manubrium and xiphoid

process of the sternum.

• From the side, the ear lobe should be in line with the

acromion process and the high point on the iliac crest for

proper postural alignment.

• The normal curve of the cervical spine is a lordotic type of

curve.

• Referred pain from conditions, such as spondylosis, tends

to occur in the shoulder and arm rather than the neck.

SCANNING EXAMINATION

ACTIVE MOVEMENTS

PASSIVE MOVEMENTS

RESISTED ISOMETRIC MOVEMENTS

Active Movements of the Cervical Spine • Flexion

• Extension

• Side flexion left and right

• Rotation left and right

• Combined movements (if necessary)

• Repetitive movements (if necessary)

• Sustained positions (if necessary)

• Passive overpressure - differentiating between physiological

(active) end range and anatomical (passive) end range.

Flexion • palpate

• the relative movement between the mastoid and

transverse process of C1

• posterior arch of C1 and the lamina of C2

Posterior bulging of SP of C2 – Forward

subluxation of atlas

Sharp Purser test

• MAX ROM is normally found when the chin is able to

reach the chest with the mouth closed;

• however, up to two finger widths between chin and

chest is considered normal.

• SCM compensation

• IV foramen: 20-30% larger inflexion than in extension

Extension • The examiner can lift the occiput at the same time.

• 70 deg

• No anatomic block to stop the movement

• Atlas tilts upward – posterior compression between the

atlas and occiput

Side, or lateral, flexion • 20 to 45 deg

• palpate adjacent transverse

processes on the convex side

Rotation

• 70° to 90

NORMAL ROM VALUES

Repetitive Movements Or Sustained Postures

Passive Movements of the Cervical Spine • If pt does not have full ROM

• If PT does not apply overpressure to determine end-feel

• Greater in supine > sitting

• End feels: Tissue stretch

A. FLEXION

B. EXTENSION

C. SIDE FLEXION

D. ROTATION

A. FLEXION

• palpates between the mastoid process and the transverse

process for movement between C0 and C1

• between the arch of C1 and spinous process of C2

• The rest, palpate between SP

B. SIDE FLEXION C. ROTATION

palpating the adjacent transverse

processes on each side while doing the

movement

the TP on the side to which the head is

rotated will seem to disappear (bottom

one) while the other side (top one)

seems to be accentuated in the normal

case.

If (-) disappearance/accentuation: there is

restriction of movement between C0 and

C1 on that side.

Resisted Isometric Movements of the Cervical Spine

• “Don’t let me move you,”

A. FLEXION

B. EXTENSION

C. SIDE FLEXION

D. ROTATION

Peripheral Joint Scan Temporomandibular Joints.

• Open mouth

• Close mouth

Shoulder Girdle.

• Abduction

• Flexion

• Scaption

• Apley’s scratch test (right and

left)

• Rotation in 90° abduction

Elbow joints

• Flexion

• Extension

• Supination

• Pronation

Wrist and hand joints

• Flexion

• Extension

• Abduction

• Adduction

• Opposition of thumb

and little finger

Myotomes

Resisted isometric contractions with joint at or near resting position (5 sec.)

• “Don’t let me move you,”

Cervical Myotomes

• Neck flexion: C1 to C2

• Neck side flexion: C3 and cranial nerve XI

• Shoulder elevation: C4 and cranial nerve XI

• Shoulder abduction/shoulder lateral rotation: C5

• Elbow flexion and/or wrist extension: C6

• Elbow extension and/or wrist flexion: C7

• Thumb extension and/or ulnar deviation: C8

• Abduction and/or adduction of hand intrinsics: T1

Sensory Scanning Examination

• Accomplished by running relaxed hands over all aspects

of the arm.

• (+) difference = use pinwheel, pin, cotton batting, or brush

(or a combination of these) to map out the exact area of

sensory difference

• May include:

• deep tendon reflexes

• Pathological reflexes

• Neurodynamic tests

Reflexes

Common Reflexes Checked in Cervical

Spine Assessment

• Biceps (C5, C6)

• Brachioradialis (C5-C6)

• Triceps (C7, C8)

• Hoffmann sign (if upper motor neuron lesion

suspected)

• Jaw Jerk (CNV)

DEEP TENDON REFLEXES

Pathologic Reflexes

Hoffman (Digital) Reflex

ELICITATION:

“Flicking” of terminal phalanx of index, middle, or ring

finger

POSITIVE RESPONSES:

Reflex flexion of distal phalanx of thumb and of distal

phalanx of index or middle finger (whichever one was not

“flicked”), interphalangeal joint of the thumb of the same

hand flexes/adducts.

PATHOLOGY:

Increased irritability of sensory nerves in tetany

Pyramidal tract lesion

Sensory Distribution Of The Peripheral Nerves

Dermatome Pattern Of The Various Nerve Roots

Brachial Plexus - Dermatomes • All based upon anatomical position

• C5 – lateral arm

• C6 – lateral forearm, thumb, index finger

• C7 – posterior forearm, middle finger

• C8 – medial forearm, ring and little fingers

• T1 – medial arm

Referral of symptoms from the cervical spine to areas of the spine, head, shoulder girdle, and upper limb.

Muscles and their referred

pain patterns

Muscles

and their

referred

pain

patterns

Referred pain patterns suggested with pathology of the apophyseal joints.

Signs of Headaches Having a Cervical Origin

• • Occipital or suboccipital component to headache

• • Neck movement alters headache

• • Painful limitation of neck movements

• • Abnormal head or neck posture

• • Suboccipital or nuchal tenderness

• • Abnormal mobility at C0–C1

• • Sensory abnormalities in the occipital and suboccipital areas

Bakody’s sign

• The patient may state that the pain and referred symptoms are

decreased or relieved by placing the hand or arm of the

affected side on top of the head

• it is usually indicative of problems in the C4 or C5 area.

Bilateral tingling symptoms

• usually indicate either systemic disorders (e.g., diabetes,

alcohol abuse) that are causing neuropathies or central space–

occupying lesions.

DIZZINESS?

• Semicircular canal problems

• vertebral artery problems.

• Falling with no provocation while remaining conscious is

sometimes called a drop attack.

• Has

• the patient experienced any Disturbances

• such

VISUAL DISTURBANCES? • diplopia (double vision),

• Nystagmus (“dancing eyes”)

• scotomas (depressed visual field)

• loss of acuity

• may indicate severity of injury, neurological injury, and

sometimes increased intracranial pressure

Pain on swallowing

• may indicate soft- tissue swelling in the throat

• vertebral subluxation

• osteophyte projection

• or disc protrusion into the esophagus or pharynx.

In addition, swallowing becomes more difficult and the voice

becomes weaker as the neck is extended.

FUNCTIONAL ASSESSMENT

• Breathing

• Swallowing

• Looking up at the Ceiling

• 40° to 50° of neck extension is usually

necessary for everyday activities

• Looking down at Belt Buckle or Shoe Laces

• At least 60° to 70° of neck flexion is

necessary.

• Shoulder Check • At least 60° to 70° of cervical rotation is necessary.

• Tuck Chin IN

• Poke Chin OUT

• Neck Strength

• Paresthesia

FUNCTIONAL ASSESSMENT

Special Tests For cervical muscle (deep neck flexors) strength:

• Craniocervical flexion test (CCF)

• Deep neck flexor endurance test

For neurological symptoms:

• Brachial plexus lesions

• Brachial plexus tension test

• Shoulder depression test

• Tinel Sign for Brachial Plexus lesions

• Distraction test (if symptoms are severe)

• Foraminal compression/Spurling’s test (three stages) (if symptoms are absent or mild)

• Maximum cervical compression test

• Upper limb neurodynamic (tension) tests

• Shoulder Abduction or Relief Test

• Radicular symptoms at C4 –C5 nerve roots

For myelopathy:

• Romberg test

• Lhermitte’s

• 10 Second Step Test

Special Tests For cervical instability

• Anterior shear stress test

• Lateral flexion alar ligament stress test

• Lateral shear test

• Rotational alar ligament stress test

• Transverse ligament stress test

For cervical spine mobility:

• Cervical flexion rotation test

• Pettman’s Distraction Test.

For first rib mobility:

• First rib mobility

For vascular signs:

• Hold planned mobilization/manipulation position for at least 30

seconds watching for vertebral-basilar artery signs

For Vertigo and Dizziness:

• Dizziness Test

• Hallpike-Dix Test

• Temperature/Caloric Test

Outcome Measures

• Whiplash Disability Questionnaire (WDQ) (Figure 3-30)

to assess the impact of whiplash associated disorders

including social and emotional problems.

• Page 181

• Neck Disability Index (NDI) (Figure 3-31), which is a

modification of the Oswestry low back pain index.

• Page 183

CERVICAL SPINE CONDITIONS

Tzietze’s Syndrome

• Aka Costal chondritis

• Painful inflammation of the costochondral junction

TORTICOLLIS

Is the head tilted or

rotated to

one side or the other

d/t

muscle spasm,

tightness, or

prominence of the

sternocleidomastoid

muscle)

TORTICOLLIS MECHANISM OF INJURY:

CONGENITAL/ MUSCULAR:

- ABN position of head in utero

- prenatal injury

- fibroma in the muscle

- rupture of SCM fibers during birth with hematoma and scar formation

ACUIRED:

• Acute Traumatic or Inflammatory

• Chronic Infectious or Neoplastic

• Arthritic

• Circatricial

• Paralytic

• Hysterical Spasmodic

ACUIRED MECHANISMS OF INURY OF TORTICOLLIS

Acute Traumatic or Inflammatory

Cervical Injures

Atlanto-axial rotatory subluxation

Mm inflammations

Cervical lymph nodes inflammation

Chronic Infectious or Neoplastic Osteomyelitis

TB

Tumors of spine or SC

Arthritic

RA

Ankylosing spondylitis

OA

Circatricial

Contracture or scar tissue after burn

Paralytic

Asymmetrical flaccid or spastic

paralysis of the neck muscles

Hysterical Psychogenic inability of patients to

control neck muscles

Spasmodic

CNS or cervical nerve root lesion

resulting to involuntary contraction of

the neck muscles

TORTICOLLIS DISTINGUISHING SIGNS AND SYMPTOMS

• Chin is rotated AWAY from the side of shortened

muscle and head is displaced and tilted toward the

side of shortening

• Shoulder elevation on affected size

• LOM: Restricted rotation and lateral bending of the

neck BUT N FL-EX ROM

• Cervicodorsal Scoliosis

• Flattening and shortening of the face on the side to

which the neck is tilted

• C/L Occipital flattening

• Orbital asymmetry

TORTICOLLIS ASSESSMENT

• History: Painless deformity since birth

• (-) X-RAY findings of C-spine

MANAGEMENT

• Passive stretching of the shortened muscle into overcorrected position

• Direct gaze: I/L superior direction

• Use of skull shaping orthotics

• Positioning: head during sleep

• Active exercises

• Modalities:

• Hot applications

• Gentle massage

• Horizontal and vertical traction

• Cervical Orthosis

• Functional strengthening of C/L neck muscles

• Lateral AND Ant head righting reactions

• Surgery: Successful resectioning of fibrotic SCM

Klippel-Feil syndrome

- congenital fusion of some

cervical vertebra, from C2-

C7; usually C3 to C5 (MC

radiographic findings)

MOST COMMON CLINICAL

FINDINGS:

- Short neck

- Low posterior headline

- LOM on neck motions

ASSOCIATED FINDINGS

- Deafness

- Scoliosis (Alone or with

kyphosis

POKING CHIN

• result in adaptive

shortening of the

occipital muscles.

• It also causes the

cervical spine to

change alignment

resulting in

increased stress

of the facet joints

and posterior

discs and other

posterior elements

FLAT NECK

• Exaggerated military posture

• Increase in flexion of AO joint

• Decrease in cervical lordosis, <20 DEGREES

• Mandible protrusion

FORWARD HEAD

• Increased extension of AO joint and upper cervical vertebrae

• Increased flexion of lower cervical and upper thoracic

• Retrusion of mandible

UPPER CROSSED SYNDROME

MYOFASCIAL PAIN SYNDROMES • Demonstrate generalized aching and

• at least three trigger points,

• which have lasted for at least 3 months

• with no history of trauma.

Cervical Spondylosis

Pain: Unilateral

Distribution of pain: Into affected dermatomes

Pain on extension Increases

Pain on flexion Decreases

Pain relieved by rest No

Age group affected 60% of those older than 45 years

85% of those older than 65 years

Instability Possible

Levels commonly affected C5–C6, C6–C7

Onset Slow

Diagnostic imaging Diagnostic

Cervical Disc Herniation

Pain: May be unilateral (most common) or bilateral

Distribution of pain: Into affected dermatomes

Pain on extension May increase (most common)

Pain on flexion May increase or decrease (most common)

Pain relieved by rest No

Age group affected 17 to 60 years

Instability No

Levels commonly affected C5–C6

Onset Sudden

Diagnostic imaging Diagnostic (be sure clinical

signs support)

Cervical Disc Herniation

• commonly cause severe neck pain that may

radiate into the shoulder, scapula and/or arm,

• limit ROM, and

• an increase in pain on coughing, sneezing, jarring,

or straining

Cervical radiculopathy

• injury to the nerve roots in the cervical spine

• presents primarily with:

• Unilateral motor and sensory symptoms into the upper limb,

• with muscle weakness (myotome),

• sensory alteration (dermatome),

• reflex hypoactivity, and

• Acute radiculopathies are commonly associated with disc

herniations, whereas chronic types are more related to

spondylosis.

Cervical radiculopathy

• Arm pain in dermatome distribution

• Pain increased by extension and rotation or side flexion

• Pain may be relieved by putting hand on head (C5, C6)

• Sensation (dermatome)

• Affected gait not affected

• Altered hand function

• Bowel and bladder not affected

• Weakness in myotome but no spasticity

• DTR hypoactive

• Negative pathological reflex

• Negative superficial reflex

• Atrophy (late sign), hard to detect early

WHIPLASH-TYPE (ACCELERATION) INJURY OR WHIPLASH ASSOCIATED DISORDER (WAD)

• WHIPLASH INURY

• MC cause of cervical ligament sprain and mm strain

• Caused by: Trauma

• MOI: ACCELERATION-DECCELERATION

• d/t rear end MVA

• 30-50 year old females

• MC affected ligament?

• ASSESSMENT:

• ST: (+) reverse Spurling’s sign

• (-) NEUROLOGIC FINDINGS

WHIPLASH-TYPE (ACCELERATION) INJURY OR WHIPLASH ASSOCIATED DISORDER (WAD)

• lead to hypertonia of the sympathetic nervous system.

• Some of the sympathetic signs and symptoms the examiner may

elicit are:

• “ringing” in the ears (tinnitus),

• dizziness,

• Blurred vision,

• photophobia,

• rhinorrhea,

• sweating,

• lacrimation,

• and loss of strength.

CHRONIC POST WHIPLASH SYNDROME • Can lead to anxiety, pain catastrophizing (negative or

heightened orientation toward pain), and other adverse

psychosocial factors over time, and it can play a major role in

the symptoms felt by the patient.

BRACHIAL PLEXUS INJURIES OF THE CERVICAL SPINE

INJURIES TO CERVICAL NERVE ROOTS AND BRACHIAL PLEXUS

PATHOLOGY (a) neuropraxia (Sunderland I), or a stretch injury that results in

a temporary nerve conduction block;

(b) axonotmesis (Sunderland I I-IV), or varying degrees of

rupture of the neural axon in which tile neural sheath remains

intact but internal elements are disrupted;

(c) neurotmesis (Sunderland V), or complete rupture of the axon

and the encapsulating connective tissue;

(d) avulsion, in which tile nerve roots tear away from the spinal

cord.

DX: • Currently, neurophysiological studies appear to underestimate

the severity of the injury and falsely provide optimism about

recovery.

PROGNOSIS

• Preganglionic or Postganglionic lesions?

• Preganglionic lesions are avulsions from tile cord tl1at

do not spontaneously recover

- Better prognosis if Axonotmesis: axon regrowth (1

mm/day)

- Poor prognosis – C5-C7

• Recovery : 4-6 months – upper arm; 6-9 months – lower

arm

• Recovery continue until 2 years – upper arm; until 4

years – lower arm

PROGNOSIS

• Infants who recover partial antigravity upper trunk muscle

strength during the first 2 months of life should show full

recovery over the first 1 to 2 years of life.

• Microsurgical reconstruction of the brachial plexus is

indicated for infants who do not recover antigravity

strength by 5 to 6 months of age, because successful

surgery results in a better outcome than natural history

alone.

• Infants who have partial recovery of CS-C6-C7

antigravity strength at 3 to 6 months of age have

permanent, progressive limitations of motion and strength.

Erb-Duchenne Paralysis.

• UPPER NERVE ROOT INJURY

(C5,C6)

• Cause:

• Compression

• Stretching

• Most common impairments:

• paralysis of the rhomboid,

• levator scapulae,

• serratus anterior,

• subscapularis,

• deltoid,

• supraspinatus,

• infraspinatus,

• teres minor,

• biceps brachialis,

• brachioradialis, and

• supinator muscles.

Erb-Duchenne Paralysis.

• Therefore the shoulder usually is

held in extension,

• medial rotation, and adduction with

elbow extension and forearm

pronation.

• Although grasp function is intact,

sensory loss usually is present

• sensation over the radial surfaces

of the forearm and hand and the

deltoid area are affected.

Dejerine-Klumpke Paralysis. • Lower BPI (C8-T1)

• Atrophy and weakness are evident in the muscles of the

forearm and hand as well as in the triceps. The obvious

changes are in the distal aspects of the upper limb.

• The resultant injury is a functionless hand. Sensory loss

occurs primarily on the ulnar side of the forearm and

hand.

• paralysis of tile wrist flexors and extensors and the

intrinsic muscles of the wrist and hand.

• Clinically, hand grasp is poor, although more proximal

muscles are intact.

Brachial Plexus Birth Palsy. • These injuries to the brachial plexus occur in 0.1% to 0.4% of

births with the majority showing full recovery within 2 months.

• Those infants who have not recovered within 3 months are at

considerable risk to decreased strength and range of motion in

the upper limb.

“Burners” or “stingers”

• These are transient injuries to the brachial plexus typically occur from a blow

to part of the brachial plexus or from stretching or compression of the

brachial plexus.

• combined with factors, such as stenosis or a degenerative disc spondylosis).

Erb’s Point

1st MOI

2nd MOI

3rd MOI

INJURIES TO THE CERVICAL NERVE ROOTS AND BRACHIAL PLEXUS ETIOLOGY

• The peak incidences of brachial plexus injuries are:

• at birth

• 20 to 40 years of age, as a result of motor vehicle accidents or knife

or bullet wounds.

• Surgery

• median sternotomy for open heart surgery

• shoulder reconstruction

• axillary arteriography

• venous cannulation

• administration of regional anesthetic blocks

• Positioning during surgical procedures

• Neoplastic Disease

• Pancoast tumor/ superior sulcus tumors

• Breast tumors

• Athletic injuries

• Defensive players

INJURIES TO THE CERVICAL NERVE ROOTS AND BRACHIAL PLEXUS CLINICAL PRESENTATION

• Transient weakness of the shoulder musculature accompanied by upper

extremity paresthesia.

• sensation is a lightning-like, burning pain into the shoulder and arm,

followed by a period of heaviness or loss of function in the arm

• Immediately after injury, weakness can be found in the biceps, deltoid,

supraspinatus, and infraspinatus muscles.

• DTR of biceps may also be diminished

• Acute syndrome symptoms usually last several seconds to a few minutes

and are followed by complete recovery.

• Neck pain may or may not be present

• Symptoms often ca n be reproduced by cervical extension and side

flexion toward the involved extremity or lateral flexion away from the

extremity

• Any restriction of cervical movement or spinal pain should alert the

examiner to the possibility of cervical spine injury.

• Restriction of shoulder range of motion should alert the clinician to the

possibility of a clavicular fracture or acromioclavicular separation .

IMPAIRMENTS • Weak AB-ER

• Common contractures of the upper extremity include:

• scapular protraction

• Shoulder extension, and

• wrist and finger flexion.

• Medial rotation and Add contracture

• absent or abnormal sensation may lead to neglect, and injuries to the skin often

go unnoticed

• The primary functional limitations involve:

• reaching and grasping,

• manipulation of objects, and

• bilateral hand use;

• Resultant delayed motor activities may include:

• getting into and out of positions over the involved side,

• protective extension using the involved side, and

• delayed balance reactions.

• Creeping may be delayed or replaced by scooting,

• Significant functional limitations in hand to head, hand to mouth, and

overhead activities

INJURIES TO THE CERVICAL NERVE ROOTS AND BRACHIAL PLEXUS ACUTE MANAGEMENT

• Resting the extremity

• Ice

• Transcutaneous electrical nerve stimulation (TENS)

• Ultrasound

• Anti-inflammatory medications if pain and tenderness of the

cervical spine and shoulder persist.

• Neck and shoulder strengthening exercises

• Padded neck rolls and shock-absorbing shoulder pads that

should restrict cervical extension and side bending

Rehabilitation Management: Evaluation, Intervention, and Clinical Implications • Reflexes

• Developmental milestones

• MMT

• Sensory Test

• Motor function of UE

• AROM/PROM

PT: Acute -> preventive (first few months)

Goals over first few years:

• Achieving and maintaining full range of motion,

• muscle extensibility,

• normal motor control,

• strength,

• functional bilateral activities, and

• developmental skills

Rehabilitation Management: Evaluation, Intervention, and Clinical Implications

• 2 years of age, goals should include:

• achievement of age-appropriate self-care skills (e.g., dressing and grooming using

either extremity) and

• active participation in age-appropriate movement activities and preschool

program.

Family education:

• passive ROM exercises,

• goals of the home program,

• risk of contractures,

• importance of joint integrity,

• precautions to prevent overstretching and joint dislocation,

• precautions with regard to sensory loss, and

• how to position the infant in all activities to maintain range of motion and regain

muscle strength


• Facilitation of fill1ctional development through therapeutic play activities,

such as:

• hand to mouth;

• reaching,

• grasping, and

• manipulating objects;

• propping on the elbows;

• hands to midline;

• rolling to each side; and

• Bilateral hand activities.

• Facilitation of a normal scapulothoracic and glenohumeral relationship should

be emphasized.

• A variety of play activities should be used to promote strengthening of

weakened muscles.

• To develop motor control throughout the range of motion, the clinician should

control time to fatigue, allowing the child to be successful by initially

challenging the involved extremity in a gravity neutral position.


• Activities should involve toys of different sizes, shapes, and textures and should

incorporate:

• hand to mouth,

• transferring items from one hand to the other,

• weight shifting in prone position,

• quadruped or sitting,

• creeping, and

• reaching for toys at various angles and distances.

• Constraining the opposite extremity for brief periods or occupying the opposite

hand with another object can be extremely helpful in focusing and encouraging the

child to use the involved extremity.

• Transitional movements over the involved extremity,

• Pulling to stand using bilateral hands,

• Challenging balance reactions while sitting on a lap or therapy ball, and

• Performing bilateral upper extremity activities (e.g., catching a large ball, clapping

to music, or opening a jar)

• Weight-bearing activities such a s wheelbarrow walking, bear crawling, crab

walking and wall push-ups are important for the development of shoulder girdle

strength and stability as well as to improve proprioception and body awareness.

Potential Cause: Fracture

Clinical Characteristics

• Clinically relevant trauma in adolescent or adult

• Minor trauma in elderly patient

• Ankylosing spondylitis

Potential Cause: Neoplasm


• Pain worse at night

• Unexplained weight loss

• History of neoplasm

• Age of more than 50 or less than 20 years

• Previous history of cancer

• Constant pain, no relief with bed rest

Potential Cause: Infection


• Fever, chills, night sweats

• Unexplained weight loss

• History of recent systemic infection

• Recent invasive procedure

• Immunosuppression

• Intravenous drug use

Potential Cause: Neurologic injury


• Progressive neurologic deficit

• Upper and lower extremity symptoms

• Bowel or bladder dysfunction

Potential Cause: Cervical myelopathy


• Sensory disturbance of the hands

• Muscle wasting of hand intrinsic muscles

• Unsteady gait

• Hoffman reflex

• Hyperreflexia

• Bowel and bladder disturbances

• Multisegmental weakness and/or sensory changes

Cervical Myelopathy • Motor Changes

Initial Symptoms (Predominantly Lower Limbs)

• Spastic paraparesis

• Stiffness and heaviness, scuffing of the toe, difficulty climbing stairs

• Weakness, spasms, cramps, easy fatigability

• Decreased power, especially of flexors (dorsiflexors of ankles and toes;

flexors of hips)

• Hyperreflexia of knee and ankle jerks, with clonus

• Positive Babinski sign, extensor hypertonia

• Decreased or absent superficial abdominal and cremasteric reflexes

• Drop foot, crural monoplegia

Later Symptoms (In Order of Occurrence)

• Various combinations of upper and lower limb involvement

• Mixed picture of upper and lower motoneuron dysfunction

• Atrophy, weakness, hypotonia, hyper-reflexia to hyporeflexia, and absent

deep tendon reflexes

Cervical Myelopathy Sensory Changes

• Headache and head pain

• Neck, eye, ear, throat, or sinus pain

• Sensory symptoms in the pharynx and larynx

• Paroxysmal hoarseness and aphonia

• Rotary vertigo

• Tinnitus synchronous with pulse or continuous whistling noises

• Deafness

• Oculovisual changes (e.g., blurring, photophobia, scintillating scotomata,

diplopia, homonymous hemianopsia, and nystagmus)

• Autonomic disturbance (e.g., sweating, flushing, rhinorrhea, salivation,

lacrimation, nausea, and vomiting)

• Weakness in one or both legs, drop attacks with or without loss of consciousness

• Numbness on one or both sides of the body

• Dysphagia or dysarthria

• Myoclonic jerks

• Hiccups

• Respiratory changes (e.g., Cheyne-Stokes respiration, Biot respiration, or ataxic

respiration)

Cervical Myelopathy • (+) pathological reflexes (e.g.

Babinski, Hoffman)

• Hyperreflexia of DTRs

• Clonus

• (+) lhermitte’s sign

• sharp, electric shock-like pain down

the spine and into the upper or

lower limbs

• INDICATION: dural or meningeal

irritation in the spine or possible

cervical myelopathy.

• Romberg test = (+) UMNL

• Ten Second Step Test: Ave:19-20 steps

Potential Cause: Upper cervical ligamentous instability


• Occipital headache and numbness

• Severe limitation during neck active

• ROM in all directions

• Signs of cervical myelopathy

Potential Cause: Vertebral artery insufficiency


• Drop attacks

• Dizziness or lightheadedness related

• to neck movement

• Dysphasia

• Dysarthria

• Diplopia

• Positive cranial nerve signs

Potential Cause: Inflammatory or systemic disease


• Temperature more than 37° C

• Blood pressure more than

• 160/95 mm Hg

• Resting pulse more than 100 bpm

• Resting respiration more than 25 bpm

• Fatigue

Cervical Spine Injuries

• Cervical Sprains

• Cervical Strains

• Cervical Spinal Stenosis

• Cervical Fractures and Dislocations

Cervical Spinal Stenosis

Pain: Unilateral or bilateral

Distribution of pain: Usually several dermatomes

affected

Pain on extension Increases

Pain on flexion Decreases

Pain relieved by rest Yes

Age group affected 11 to 70 years

Most common: 30 to 60 years

Instability No

Levels commonly affected Varies

Onset Slow (may be combined with

spondylosis or disc herniation)

Diagnostic imaging Diagnostic

SPINAL STENOSIS

• Narrowing of spinal canal

• N diameter: 17 mm – Spinal canal

• 10 mm – Spinal cord

RELATIVE STENOSIS: 12 mm

ABSOLUTE STENOSIS: 10 mm

ETIOLOGY:

Facet joint hypertrophy

Ligamentum flavum hypertrophy

Disc protrusion4Spur formation

Position:

Avoid: Extension

Ideal: Flexion

CERVICAL STRAIN AND SPRAINS

• CERVICAL STRAIN Musculotendinous injury produced by an overload injury resulting from forces imposed on the cervical spine

• CERVICAL SPRAIN Overstretching or tearing injuries of the spinal ligaments

• EPIDEMIOLOGY

• Muscular strains > ligamental sprains

• MC type of injuries to MVA

• MC cause of pain after noncatastrophic sports injures

• MC in women ages 30-50 years old


PATHOPHYSIOLOGY

• ALL tears

• Traumatic blows

• Repetitive motions

• Thoracic kyphosis, cervical lordosis and extension -> levscap, SCM, scalene and suboccipital mm strain

• Acceleration-decceleration injuries

• 100 ms after rear end impact – S-shaped curvature excursion of spine

• 90-120 ms – activation of posterior neck muscles

• 200 – 250 ms – head initiates forward flexion of neck

• Neck eccentrically contract to decelerate head


DIAGNOSIS

- Headache: Sharp/ dull localized to cervical/ shoulder

girdle mm

- History of MVA

- Neck Fatigue and stiffness – aggravated by

PROM/AROM

- Dec. ROM

- MC invovled areas: SCM, Trapz

- (-) Neuro signs

- Give way weakness


TREATMENT

Initial Care:

- Control Pain and Inflammaition

- NSAIDS and acetaminophen

PT Modalities

- Massage

- Superficial and deep heat

- Soft cervical collar

Gradual return to activities (2-4 weeks after inury)

Postural reeducation program

Proper movement patterns

Proprioceptive, balance and postural conditioning

Mobilization and stretching exercises

CERVICAL RADICULOPATHY AND RADICULAR PAIN

CERVICAL RADICULOPATHY

- Pathologic process involving neurophysiologic dysfunction of the

nerve root

- Reflex and strength deficits marking a hypofunctional nerve root as

a result of pathologic changes

CERVICAL RADICULAR PAIN

- Hyperexcitable state of the afferent nerve root

EPIDEMIOLOGY:

Decreasing frequency of involvement:

C7 C6 C8 C5


PATHOPHYSIOLOGY

- Cervical nerve root injury most commonly caused by cervical IVD

herniation

- Next MC cause: Cervical spondylosis

- CERVICAL SPONDYLOSIS

- Degenerative OA changes

- Manifested by:

- ligamentous hypertrophy

- Hyperostosis

- Disk generation

- Z joint arthopathy

- Hypertrophy of Zygapophyseal joints and uncovertebral joints IV

foramina stenosis and nerve root impingement

- Vertebral body osteophytes and dsik material can form a “disk” that can

also compress adjacent nerve root

CERVICAL RADICULOPATHY AND RADICULAR PAIN DIAGNOSIS

- History and PE

- Hx of cervical pain that is followed by an expulsive onset of

upper limb pain

- Spondylitic radicular pain presents more gradually

- Cervical radicular pain can masquerade as deep dull ache or

lancinating pain

- Exacerbating factors:

- Coughing, sneezing, valsalva

- Cervical extension: significant stenosis is present

- (+) Bakody sign


DIAGNOSIS

- Atrophy – severe or longstanding lesions

- Mm testing has greater specificity

- Altered sensation to pinprick, light touch and vibration

- Long tract signs – Hoffman’s and Babinski signs : SC involvement

- Spurling’s maneuver – highly specific but not sensitive

- Root tension – more sensitive, less specific

- Lhermitte’s sign – SC involvement, tumor, spondylosis or MS

- Imaging studies

- Plain cervical radiography

- CT Myelography

- MRI – Cervical radicuolpathy

- Contrast enhanced CT Scan – disk pathology


TREATMENT

Primary Objectives:

- Pain resolution

- Improve myotome weakness

- Avoid SC complications

- Prevent recurrence

SURGICAL APPROACH – Progressive neuro fdeficit

Pt educ, activity modiification, pain relief

Avoid repetitive heavy lifting

Modalities

TENS

COLD,

Superficial heat but Avoid deep heat!

CERVICAL RADICULOPATHY AND RADICULAR PAIN TREATMENT

Cervical Orthosis (1-2 weeks)

Cervical Traction

distract midcervical segment – 25 lb weight applied for 25

minutes at 24 degree angle of pull

Cerviothoracic stabilization

- restore biomechanics, limit pain, max function, prevent

recurrence and progression

Cervical strengthening

Medications

NSAIDs

Mm relaxants

Low dose tricyclic antidepressants

Opiate

CERVICAL JOINT PAIN EPIDEMIOLOGY

- 30-60% prevalence

- MC in C2-C3; then C5-C6 & C6-C7

- Cervical Z joints are common source in chronic post traumatic neck pain

- Associated with symptomatic IVD at the same level

- Traumatically induced lower cervical pain attributable to a Z joint MC

involves C5-C6

DIAGNOSIS

- Unilateral occipital headaches

- Unilateral paramidline neck pain with or without periscapular symptoms,

that is more painful than any associated headache

- Localized spot of maximal pain

- Focal tenderness to palpation

- Painful C1-C2 = Increase suboccipital pain that is exacerbated with 45

degrees of cervical flexion and sequential axial rotation

CERVICAL JOINT PAIN IMAGING STUDIES

Plain Radiography = Joint subluxation

CT Scan = Fracture

TREATMENT

Acute Phase

NSAIDS

Superficial cryotherapy (20 mins initially 3-4x a day)

ST mobilization and massage

Soft cervical collar worn up to 72hours after initial injury

Pt education on proper positioning

CERVICAL INTERNAL DISK DISRUPTION IVD has lost its N internal architecture but remains a preserved

external contour in the absence of nerve root compression

EPIDEMIOLOGY

- 20% of traumatically induced neck pain

- 41% CIDD + concomitant Z joint injury

DIAGNOSIS

SYMPTOM COMPLEX

- Posterior neck pain

- Interscapular and periscapular pain

- Upper trapezial pain

- Occipital and subociipital pain

- Nonradicular arm pain

- Vertigo, tinnitus, ocular dysfunction

- Dysphasia, facial pain

- Anterior chest wall pain

CERVICAL INTERNAL DISK DISRUPTION

DIAGNOSIS

- Hx of trauma with acute onset

- With absence of precipitating event, symptoms of CIDD can start spontaneously or

gradually, or explosively

- If (+) referred pain: axial pain associated with nondescript upper limb symptoms

- Exacerbating factors: prolonged sitting, coughing, sneezing or lifting

- Alleviating factors: lying supine with head support

- Subtle ROM restrictions

- If (+) cervical spondylosis – cervical extension and side bending more restricted than

flexion and axial rotation

- (+) pain on palpation over cervical SP of involved level.

IMAGING

- MRI

- Plain films – hyperostosis and disk space collapse but frequently do not correlate with

pain symptoms

- MARKERS OF DISK DEGENERATION:

- Disk dessication

- Loss of disk height

- Annular fissure

- Osteophytosis

- Reactive end plate changes

CERVICAL INTERNAL DISK DISRUPTION TREATMENT

- SIMILAR WITH CERVICAL RADICULOPATHY

- NSAIDS

- Modalities

- Traction should be used cautiously

- Cervical collars help comfortable positioning

Active stretching and flexibility program with transition

conditioning and stabilization

Neck Conditions

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