Cervical Spine Orthopedics DX 611

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Cervical Spine Orthopedics DX 611 Cervical Spine Anatomy University of

Spine Chief Complaint Interview Involves the taking of a history, performance

1 Cervical Spine Orthopedics DX 611 Cervical Spine Anatomy University of Bridgeport College of Chiropractic Orthopedic Examination of the Cervical Spine Chief Complaint Interview Involves the taking of a history, performance of physical examination procedures and laboratory evaluation, which may include imaging studies. The O, P, Q, R, S, T process is suggested for all patients presenting with neuromusculoskeletal conditions. History Taking Process History Taking Process The history should precede all physical exam procedures but include observation. Establishing rapport Listening and questioning Observation Integration 1

Obstacles to History Taking 1. Fear 2. Antagonism 3.

Rambling and talkativeness History Taking Process Chief complaint

occupational history Systems review (SHEENT)CR, GI, GU, MS, NS, VD,

Memory History Taking and Observation Rust s sign Dejerine s sign

edu/neurologicexam/html/me ntalstatus_normal.

2 Obstacles to History Taking 1. Fear 2. Antagonism 3. Mental cloudiness 4. Incoherence 5. Language barriers 6. Rambling and talkativeness History Taking Process Chief complaint History of present illness (OPQRST) Past, family, social, and occupational history Systems review (SHEENT)CR, GI, GU, MS, NS, VD, and OB Mental Status Appearance Alert Cooperative Oriented x3 / Memory History Taking and Observation Rust s sign Dejerine s sign Lhermitte s sign Barre-Lieou sign ntalstatus_normal.html Vital Signs Height Weight Blood pressure Pulse rate Respiration rate Temperature Patient Preparation Why should the patient be gowned prior to evaluation? 2

3 Prepare Patient Inspection Environment Gowned Explain procedures General inspection is a series of accurate and meaningful observations Inspection Involves Five Special Senses Allegory of Five Senses Theodore Rombouts Sight Hearing Touch Taste Smell Inspection Posture Body movements Gait Speech Surface scars and wounds Inspection Palpation Nutrition Stature Body temperature Breath odors Static palpation Flat palpation Superficial Deep 3

Motion Palpation Palpation Technique evaluation

Deep tissues Joint play Palpation Objectives

Detect and assess movements Detect and evaluate

reflex instrument Spinous processes Interspinous

flexion to 90 degrees Record 3 readings with each

accurate mensuration of spinal or joint motion

4 Motion Palpation Palpation Technique evaluation includes motion palpation Superficial tissues Deep tissues Joint play Palpation Objectives Detect abnormal tissue textures Evaluate symmetry Detect and assess movements Detect and evaluate changes in findings Percussion Stroking with the reflex instrument Spinous processes Interspinous ligaments Paravertebral muscles Dynamometer Elbow flexion to 90 degrees Record 3 readings with each hand Record dominant hand Inclinometer Most accurate mensuration of spinal or joint motion Record 3 readings Impairment ratings and independent medical exams 4

5 Goniometer Reflex Hammer Babinski Easiest to utilize for most joint range of motion examinations Buck Reflex Hammer Taylor Reflex Hammer Patient position Doctor position Relaxed patient and doctor Stroke tendon for rebound DTR Testing Diagnostic Instruments Tuning Forks Identify the grade of reflex being tested C128 and C 256 are utilized with orthopedic examinations 5

$Safety Pin Test for osseous fracture pain$ and perception of vibration Sterile Large

discrimination but not for pain Half Time

6 Diagnostic Instruments Tuning Forks Safety Pin Test for osseous fracture pain and perception of vibration Sterile Large enough Test for sharp and dull Cotton Balls Paper Clips Test for light touch Superficial reflexes Test for two-point discrimination but not for pain Half Time Cervical Range of Motion Testing Who is going to win? 6

Range of Motion Evaluation Symmetrical motion Free of restriction or aberrant Pain free or provocative Passive,

canal patency Spinal canal patency Ligamentous Muscle Tendon Cervical Spine Assessment Protocol History Observation

removal of cervical collar May use hand to lift head when rising from supine position Rust s Sign Shoulder Abduction

7 Range of Motion Evaluation Symmetrical motion Free of restriction or aberrant Pain free or provocative Passive, active, and restricted isometric movements Orthopedic Maneuvers Anatomical structure tests Dural tension Foraminal canal patency Spinal canal patency Ligamentous Muscle Tendon Cervical Spine Assessment Protocol History Observation Physical examination Inspection Palpation Range of motion Orthopedic maneuvers Rust s Sign May grab head upon removal of cervical collar May use hand to lift head when rising from supine position Rust s Sign Shoulder Abduction Test Suspect upper cervical spine instability History of roll-over MVA or blow to head Bakody s sign for nerve root irritation 7

Valsalva Maneuver Valsalva maneuver for IVD syndrome or tumor (space occupying

myospasm Positive test relieves pain Negative test increases pain Soto-Hall

neck with sternum stabilized Contraindicated with severe injury Swallowing

Spurling s Maximums cervical rotary compression Extension/Flexion Common

8 Valsalva Maneuver Valsalva maneuver for IVD syndrome or tumor (space occupying lesion) Cervical Distraction Test Distraction test for nerve root, facet, or myospasm Positive test relieves pain Negative test increases pain Soto-Hall Test Non-specific test for cervical spine injury or lesion Passive flexion of neck with sternum stabilized Contraindicated with severe injury Swallowing Test Difficulty swallowing might be related to a space occupying lesion anterior to the cervical spine. Cervical Compression Tests Maximal foraminal compression (active) Jackson s Spurling s Maximums cervical rotary compression Extension/Flexion Common Cervical Provocative Tests All of them test for dural sheath, nerve root, or spinal nerve involvement Positive findings all indicate radicular pain 8

Cervical Orthopedic Tests Don t memorize the tests Practice them with comprehension Discuss the tests and practice Marinate, practice

Most benign Dysesthesia, paresthesia Brachial plexopathy or neuropraxia Motor or reflex changes Atrophy or denervation Severe

Pathological Neurological Responses Hemiparesis or neurotmesis Transient quadriparesis Neuropraxia This is the physiological

9 Cervical Orthopedic Tests Don t memorize the tests Practice them with comprehension Discuss the tests and practice Marinate, practice and discuss the relevance of the tests and signs Nerve Injuries Neuropraxia Axonotmesis Neurotmesis Pathological Neurological Responses Most benign Dysesthesia, paresthesia Brachial plexopathy or neuropraxia Motor or reflex changes Atrophy or denervation Severe Pathological Neurological Responses Axonotmesis Cervical cord neuropraxia Cervical stenosis Cervical myelopathy Most Severe Pathological Neurological Responses Hemiparesis or neurotmesis Transient quadriparesis Neuropraxia This is the physiological interruption of an anatomically intact nerve. In this condition there is minimal damage. The axons are intact but conduction is lost because of segmental demyelination. 9

Therefore, it is imperative that the mechanism of compression be identified to insure optimal recovery. Neuropraxia may be caused by a ligamentous structure, extended pressure, or repetitive motion.

10 Neuropraxia Neuropraxia "Identify Cause" This is a transient lesion and recovery is spontaneous after a few days or weeks. In neuropraxic insult, the offending compressive agent, must be eliminated to protect the nerve from further damage. Neuropraxia Neuropraxia Otherwise, Wallerian Degeneration would likely result. Therefore, it is imperative that the mechanism of compression be identified to insure optimal recovery. Neuropraxia may be caused by a ligamentous structure, extended pressure, or repetitive motion. Axonotmesis Axonotmesis is characterized by axonal and myelin sheath damage that results in loss of continuity with the cell body and its end organ. There is preservation of the endoneurium, perineurium, and epineurium. Axonotmesis A complete absence of sensory modalities can be expected. The prognosis for recovery is good,. However, occasionally, the possible loss of some cell bodies inhibits complete recovery. This is due to retrograde neuronal degeneration. 10

Symptoms often develop insidiously and are characterized by neck stiffness, arm pain, numbness in the hands, and weakness of the hands and legs.

11 Myelopathy Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in older persons. The aging process results in degenerative changes in the cervical spine that, in advanced stages, can cause compression of the spinal cord. Symptoms often develop insidiously and are characterized by neck stiffness, arm pain, numbness in the hands, and weakness of the hands and legs. Myelopathy The differential diagnosis includes any condition that can result in myelopathy, such as multiple sclerosis, amyotrophic lateral sclerosis and masses (such as metastatic tumors) that press on the spinal cord. The diagnosis is confirmed by magnetic resonance imaging that shows narrowing of the spinal canal caused by osteophytes, herniated discs and ligamentum flavum hypertrophy. (Am Fam Physician 2000;62: ,1073.) Neurotmesis Neurotmesis Implies complete disruption of all the axon and supporting connective tissue structures. Without surgical repair, this injury has a very poor prognosis. End of Cervical Orthopedic Tests Thank you for your attention and enjoy the day 11

Evaluation and Management of Spinal Cord Emergency and Cervical Spondylotic Myelopathy

Evaluation and Management of Spinal Cord Emergency and Cervical Spondylotic Myelopathy James J. Lehman, DC, MBA, FACO Associate Professor of Clinical Sciences University of Bridgeport College of Chiropractic