EVALUATION AND MANAGEMENT OF CERVICAL SPINE DISORDERS

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Emerald McLaughlin
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CERVICAL SPINE EVALUATION AND MANAGEMENT OF CERVICAL

skull Allows movement of the head Houses the spinal

C2 Lower C spine C3-C7 UPPER C SPINE C1 Atlas C2 Axis

1 CERVICAL SPINE EVALUATION AND MANAGEMENT OF CERVICAL SPINE DISORDERS Gregory M Yoshida MD Supports the skull Allows movement of the head Houses the spinal cord CERVICAL SPINE Unique anatomy Upper C spine C1, C2 Lower C spine C3-C7 UPPER C SPINE C1 Atlas C2 Axis Very specialized Dens is the embryological body of C1 No discs 1

UPPER C SPINE LOWER C SPINE 50% of flexion/extension occurs @ occiput- C1 50% of rotation occurs

in this region PEARL CERVICAL SPINE PAIN RED FLAGS Balance/equilibrium issues Gait disturbance

2 UPPER C SPINE LOWER C SPINE 50% of flexion/extension occiput- C1 50% of rotation C1-2 Five similar structures Equally divide the remaining ROM Most degenerative disorders occur in this region PEARL CERVICAL SPINE PAIN RED FLAGS Balance/equilibrium issues Gait disturbance Fevers/chills Weakness/numbness in extremities Bowel/bladder incontinence or retention Left arm pain 2

3 PATIENT EVALUATION History PMH PE Diagnostic tests HISTORY OLD CARTS ONSET Sudden vs gradual Mechanism Head position Flexion Rotation Direction of force LOCATION Midline Paraspinous Upper trapezius Parascapular Sub-occipital Anterior 3

CHARACTERISTICS Open-ended question Sharp, dull, stabbing,

4 PEARL LOCATION Subacromial Anterior joint Bicipital tendon AC joint DURATION Total duration Time of each episode CHARACTERISTICS Open-ended question Sharp, dull, stabbing, throbbing, aching, electrical, burning, etc. Get a feel of the pt s pain 4

AGGRAVATING AND ALLEVIATING FACTORS RADIATION Position

Medications Dermatomal Sclerotomal Down the arms Left arm

alleviating factor Night pain ASSOCIATED Sx Weight loss

5 AGGRAVATING AND ALLEVIATING FACTORS RADIATION Position Flexion/extension Lateral flexion Activity Lifting Valsalva Medications Dermatomal Sclerotomal Down the arms Left arm TEMPORAL RELATIONS AM vspm Time after aggravating or alleviating factor Night pain ASSOCIATED Sx Weight loss Fever/chills Numbness/weakness Gait/balance issues Bowel/bladder problems 5

6 PAST MEDICAL Hx Previous neck surgery Malignancy Foreign travel PHYSICAL EXAM Confirm your hypothesis INSPECTION Pt posture and attitude Torticollis Pt s behavior during interview GAIT ANALYSIS Ataxia Wide based Short stride length Spasticity Drunken gait 6

flexion Gentle compression Recreate radicular pain SLR equivalent MOTOR Manual muscle test (MMT) 0 nothing 1 fasciculation 2 full

7 PHYSICAL EXAM Palpation Midline Paraspinous Trapezius Scapula Sternocleidomastoid PHYSICAL EXAM ROM Flexion/extension Rotation Lateral bend Fluidity Reversal of lordosis SPURLING S TEST NEUROLOGIC EXAM Foraminal compression Extend the patient s neck Lateral flexion Gentle compression Recreate radicular pain SLR equivalent MOTOR Manual muscle test (MMT) 0 nothing 1 fasciculation 2 full ROM, no gravity 3 full ROM, against gravity 4 between 3 and normal SENSORY Test pin prick and light touch 0 absent 1 impaired 2 - normal 7

SENSORY Lateral antecubital Thumb and index finger Long finger Ring

8 NEUROLOGIC EXAM PEARL MOTOR C5 deltoid, biceps C6 wrist extensors C7 triceps, wrist flexors C8 finger DIP T1 hand intrinsics SENSORY Lateral antecubital Thumb and index finger Long finger Ring and small fingers Medial antecubital MOTOR EXAM Free throw FREE THROW 8

9 FREE THROW PEARL SENSORY C6 Six shooter NEUROLOGIC EXAM Reflexes Biceps Brachioradialis C5,C6 Triceps C7,C8 Look for asymmetry 9

10 PEARL PE Always check shoulder abduction and internal rotation DIAGNOSTIC TESTS Patient dependent Diagnosis dependent NECK PAIN Cervical sprain/strain Cervicalgia Whiplash Mechanical neck pain Most common Dx 10

C STRAIN Antecedent event MVA, lifting, slip and fall, etc.

pathology can be mistaken for neck pain Impingement Rotator

shoulder exam TREATMENT Initial Medrol dose pack X-rays One

11 C STRAIN Antecedent event MVA, lifting, slip and fall, etc. Isolated neck pain No red flags PEARL C STRAIN Shoulder pathology can be mistaken for neck pain Impingement Rotator cuff tear Pain aggravated with overhead activities Brief shoulder exam TREATMENT Initial Medrol dose pack X-rays One week F/U NSAID PT +/- antispasmodics One month F/U 40% improved Not improved PT Meds 11

TREATMENT HERNIATED DISC (HNP) Three month F/U

radiating down UE in a dermatomal distribution

Increased pain with valsalva HNP PE Pain with

relieved with arm abduction +/- neuro deficits

12 TREATMENT HERNIATED DISC (HNP) Three month F/U 75% improved Not improved MRI Refer Pain radiating down UE in a dermatomal distribution Flexion and rotation Flexion more comfortable Increased pain with valsalva HNP PE Pain with extension and lateral bend + Spurling test Pain relieved with arm abduction +/- neuro deficits HNP Affects the exiting nerve root C5-6 gets C6 C4-5 gets C5 12

PEARL HNP 76% will resolve on their own within 3-4 mo TREATMENT Without a deficit Medrol Soft collar If improved Rx like a strain PT If not improved ESI With a

13 PEARL HNP 76% will resolve on their own within 3-4 mo TREATMENT Without a deficit Medrol Soft collar If improved Rx like a strain PT If not improved ESI With a deficit Medrol Soft collar MRI Follow previous algorithm SURGICAL REFERAL Patients failing conservative treatment Increasing neurological deficit Myelopathy 13

PEARL RADICULOPATHY Carpal tunnel syndrome can mimic a C6,7

sensory deficit Motor findings will differentiate between

Narrowing of the spinal canal from degeneration Myelopathy

14 PEARL RADICULOPATHY Carpal tunnel syndrome can mimic a C6,7 sensory deficit Cubital tunnel syndrome can mimic a C8 sensory deficit Motor findings will differentiate between cervical and peripheral compression STENOSIS STENOSIS Narrowing of the spinal canal from degeneration Myelopathy Ataxia Hyperreflexia Quadraparesis Painless +/-radiculopathy Extension worse 14

of the sternal head Head tipped up and away from affected side TORTICOLLIS

15 STENOSIS Differentiate from central disorder Cranial nerve function MRI Refer TORTICOLLIS Contraction of the SCM Intrauterine compartment syndrome of the sternal head Head tipped up and away from affected side TORTICOLLIS Treatment Gentle stretching Reverse deformity If unresponsive refer PEARL 15

TORTICOLLIS In older children torticollis can be the presentation of a

Rheumatoid arthritis Down s syndrome Incompetence of the transverse ligament C1-2

fingers and toes with downward gaze C1-2 INSTABILITY PE Limited flexion +/-

16 TORTICOLLIS In older children torticollis can be the presentation of a retropharyngeal abscess INSTABILITY C1-2 instability Atlanto-axial instability Rheumatoid arthritis Down s syndrome Incompetence of the transverse ligament C1-2 INSTABILITY High suspicion Sub-occipital pain L hermitte s sign Tingling of fingers and toes with downward gaze C1-2 INSTABILITY PE Limited flexion +/- myelopathy X-rays Lateral flexion and extension views Patient controls motion Atlanto-dens interval > 2.5 mm 16

17 C1-2 INSTABILITY Surgical referral DEGENERATIVE DISC DISEASE Dx of exclusion Spondylosis Discogenic pain Facet syndrome DEGENERATIVE DISC DISEASE THE FUTURE Conservative care PT NSAIDs Pain management Surgery is 65% successful at best Disc regeneration therapy Improve minimally invasive surgery Robotics 17

18 CONCLUSION THANK YOU Neck pain is common The majority of pts can be treated successfully conservatively Differentiate from extremity problems Some pts require early referral 18

Low back pain is a symptom EVALUATION AND MANAGEMENT LOW BACK PAIN 9/28/2011 CONGRATULATIONS CAPA ON 35 YEARS

Low back pain is a symptom EVALUATION AND MANAGEMENT LOW BACK PAIN 9/28/2011 CONGRATULATIONS CAPA ON 35 YEARS CONGRATULATIONS CAPA ON 35 YEARS EVALUATION AND MANAGEMENT OF LOW BACK PAIN Gregory M Yoshida MD 35 years ago I was graduating from middle school and my biggest concern was what color leisure suit to wear.