Cervical and Thoracic Spinal Conditions Chapter 11

Cervical and Thoracic Spinal Conditions Chapter 11

Anatomy Spinal column Vertebrae Cervical (7) convex anteriorly Thoracic (12) concave anteriorly Lumbar (5) convex anteriorly Sacral (5 fused) concave anteriorly Coccyx (4 fused)

Anatomy (cont.) Structure Rigid enough to support body and protect spinal cord Flexible enough to produce a variety of movements

Anatomy (cont.)

Anatomy (cont.)

Anatomy (cont.) Cervical 7 vertebrae form curve convex anteriorly Atlas 1st vertebra No body filled with odontoid process Function: support the head

Anatomy (cont.) Axis 2nd vertebra Odontoid process tooth-like Allows head to rotate Thoracic 12 vertebrae form curve concave anteriorly Extra facets for articulation with ribs

Anatomy (cont.)

Anatomy (cont.) Vertebral structure Body Vertebral arch Superior and inferior articular processes Facet joints Spinous process Transverse processes Progressive increase in vertebral size Change in angulation

Anatomy (cont.)

Anatomy (cont.) Motion segment Functional unit Any 2 adjacent vertebrae and soft tissues between them

Anatomy (cont.) Intervertebral discs Components Annulus fibrosus Thick fibrous ring Nucleus pulposus Gelatinous interior Function Shock absorption Allow spine to bend

Anatomy (cont.) Ligaments Anterior longitudinal Posterior longitudinal Ligamentum flavum Interspinous Supraspinous

Anatomy (cont.) Muscles of the neck: lateral view

Anatomy (cont.) Muscles of the neck: posterior view

Anatomy (cont.) Nerve plexus Cervical (C1 C4) Brachial (C5 T1)

Anatomy (cont.) Blood supply Common carotid Vertebral

Kinematics Movements involve a number of motion segments Flexion/extension/ hyperextension Lateral flexion Lateral rotation

Kinetics Effects of loading Primary load Cervical spine: weight of head Thoracic: weight of body above and any load in hands Effects of impact forces High speed and collision risk Cervical flexion (large bending moment) + axial compression load = danger

Kinetics (cont.)

Kinetics (cont.) Cervical spine compression deformation Angular deformation and buckling occurs as load continues and maximum compression deformation is reached Continued force results in an anterior compression fracture, subluxation, or dislocation

Anatomic Variations: Injury Potential Kyphosis Excessive curve of thoracic spine Congenital deficits in vertebral bodies Idiopathic Scheuermann s disease Secondary to osteoporosis

Anatomic Variations: Injury Potential (cont.) Scoliosis Lateral curvature of spine; C or S curve Structural Inflexible curve, persists with lateral bending Nonstructural Flexible, corrected with lateral bending Commonly idiopathic Symptoms vary with severity Mild 20 and moderate = 20 45 Treated with exercise Severe

Anatomic Variations: Injury Potential (cont.)

Prevention of Spinal Injuries Protective equipment Neck roll Rib protectors Physical conditioning Strength and flexibility Proper technique Spearing Proper lifting Posture

Cervical Spine Conditions Cervical sprain Extreme motions or violent mechanism S&S Pain, stiffness, restricted ROM Pain can persist for several days Management: standard acute; cervical collar; consult physician No return to competition until pain free and ROM is normal

Cervical Spine Conditions (cont.) Cervical strain Usually, sternocleidomastoid or upper trapezius Same mechanism as sprain; injuries often simultaneous S&S Pain, stiffness, spasm, restricted ROM pain with active contraction or passive stretch of involved muscle Management: standard acute; cervical collar; consult physician No return to competition until pain free and ROM is normal

Cervical Spine Conditions (cont.) Cervical spinal stenosis Structural Torg ratio Functional Loss of CSF around the cord cord s ability to decompress Asymptomatic until external force to head

Cervical Spine Conditions (cont.) S&S On impact, may develop immediate quadriplegia with sensory changes or motor deficits in both arms, both legs, or all 4 extremities Transient with full recovery in 10 15 minutes (or 36 48 hrs) Management: activate EMS Continued participation

Cervical Spine Conditions (cont.) Spear tackler s spine Mechanism: cervical flexion + axial loading S&S Immediate pain with sensory changes and motor deficits distal to injury site Management: activate EMS Criteria to return to play controversial

Cervical Spine Conditions (cont.) Cervical disc injuries Soft disc herniation Nucleus pulposus herniates through posterior annulus Acute mechanism: uncontrolled lateral bending of neck Hard disc disease Chronic, degenerative Diminished disc height and formation of marginal osteophytes

Cervical Spine Conditions (cont.) S&S Varying degrees of neck or arm pain, may radiate Pain exacerbated by Valsalva maneuvers and neck movement + Spurling s maneuver + Babinski s sign Severe cases potential loss of motor function below injury level Management: rest, activity modification, NSAIDs

Cervical Spine Conditions (cont.) Cervical fracture/dislocation fracture MOI axial loading with violent flexion of neck Dislocation: add rotation S&S Pain over spinous process with or without deformity Constant neck pain Muscle spasm

Cervical Spine Conditions (cont.) Signs of neural damage Muscle weakness in extremities; inability to move Abnormal sensations in extremities Absent or weak reflexes Loss of bladder or bowel control Suspect injury with violent mechanism Management: activate EMS

Cervical Spine Conditions (cont.) Red flags indicating a possible cervical spine injury: refer to Box 11.1

Brachial Plexus Injuries Mechanism Tension (stretching) Violent lateral movement of head and neck Arm forced into excessive external rotation, abduction, and extension Compression Location where plexus is most superficial (Erb s point) Forced lateral flexion, causing increased pressure between shoulder pad and superior medial scapula

Brachial Plexus Injuries (cont.)

Brachial Plexus Injuries (cont.) Classification of Burners Grade Injury Signs Prognosis I Neurapraxia injury Temporary loss of sensation or loss of motor function Recovery within days to a few weeks II Axonotmesis injury Significant motor and mild sensory deficits Deficits last at least 2 weeks Regrowth is slow, but full or normal function is usually restored III Neurotmesis injury Motor and sensory deficits persist for up to 1 year Poor prognosis Surgical intervention is often necessary

Brachial Plexus Injuries (cont.) Acute burners S&S Immediate, severe, burning pain and prickly paresthesia radiates into hand Pain transient; subsides in 5 10 minutes Weakness in abduction and external rotation Management: return to play full strength, ROM, & sensation; cryotherapy

Brachial Plexus Injuries (cont.) Chronic burner syndrome S&S Frequent acute episodes that may not produce areas of numbness Muscle weakness may develop hours or days after initial injury; dropped shoulder or visible atrophy in shoulder muscles Management: same parameters as acute; frequent re-examination

Brachial Plexus Injuries (cont.) Suprascapular nerve injury Innervates the supraspinatus, infraspinatus, and glenohumeral joint capsule Same mechanism S&S Muscles weak and atrophied Improper functioning of muscles other problems (e.g., rotator cuff tendinitis, impingement syndrome, bicipital tenosynovitis, or bursitis) Management: standard treatment; refer to physician

Thoracic Spine Conditions Sprains/strains MOI: overload; overstretch S&S Painful spasms of back muscles May develop as a sympathetic response to sprains Presence of spasms makes it difficult to determine sprain or strain Sprain dramatic improvement in 24 48 hours; severe strains 3 4 weeks to heal Management: standard acute care

Thoracic Spine Conditions (cont.) Thoracic spinal fractures and apophysitis Wedge fracture Fracture of vertebral end plates

Thoracic Spine Conditions (cont d) Mechanism Large compressive loads or landing on the buttock area Compressive stress during small, repetitive loads S&S: standard fracture; pain and muscle guarding Management: physician referral

Thoracic Spine Conditions (cont.) Scheuermann s disease Leading cause of fractures among adolescents Osteochondrosis of the spine Abnormal epiphyseal plate behavior allows herniation of disc into vertebral body After physician referral, treatment: activity modification, stretching (shoulder, neck, and back muscles), and strengthening (abdominal and spinal extensor muscles)

Thoracic Spine Conditions (cont.) Apophysitis Repeated flexion extension of thoracic spine Progressive condition characterized by local pain and tenderness After physician referral, treatment: eliminate flexion extension stress; strengthening of abdominal and other trunk muscles

Assessment of Spinal Conditions Traumatic episode When in doubt, always assume a severe spinal injury and activate emergency care plan Do not move head, neck, or spine (or helmet)

Assessment of Spinal Conditions (cont.) Red flags warrant immobilization and immediate referral Severe pain, point tenderness, or deformity along vertebral column Loss or change in sensation anywhere in the body Paralysis or inability to move a body part Diminished or absent reflexes Muscle weakness in a myotome Pain radiating into the extremities Trunk or abdominal pain referred from visceral organs Any injury involving uncertainty about severity or nature

Spinal Assessment Conscious Individual History Important to ask questions about: Pain Location (i.e., localized or radiating) Type (i.e., dull, aching, sharp, burning) Sensory changes (i.e., numbness, tingling, or absence of sensation) Muscle weakness or paralysis Neck injury Determine both long- and short-term memory loss that may indicate an associated brain injury

Spinal Assessment Conscious Individual (cont.) Observation/inspection Postural assessment Scan exam Gait analysis Inspection of injury site Gross neuromuscular assessment

Spinal Assessment Conscious Individual (cont.) Palpation Seated, standing, supine, or prone position Relax the neck and spinal muscles lying position Posterior neck structures Patient supine Thoracic region Patient prone Pillow under the hip region to tilt the pelvis back and relax the lumbar curvature

Spinal Assessment Conscious Individual (cont.) Physical examination testing If, at anytime, movement leads to increased acute pain or change in sensation or the individual resists moving the spine, a significant injury should be assumed and EMS activated

Range of Motion (ROM) Active range of motion (AROM) Cervical flexion Cervical extension Lateral cervical flexion (left and right) Cervical rotation (left and right) Forward trunk flexion Trunk extension Lateral trunk flexion (left and right) Trunk rotation

AROM Cervical Spine

AROM Thoracic Spine

ROM (cont.) Normal ranges Cervical flexion 80 90 Cervical extension 70 Lateral cervical flexion (left and right) 20 45 Cervical rotation (left and right) 70 90 Forward trunk flexion 40 60 Trunk extension 20 35 Lateral trunk flexion (left and right) 15 20 Trunk rotation 35 50

ROM (cont.) Passive ROM Cervical spine Do not perform if motor and sensory deficits are present Normal end feel tissue stretch Thoracic is seldom performed

ROM (cont.) Resisted ROM Cervical spine Stabilize the hip and trunk to avoid muscle substitution Patient seated; one hand stabilizes the shoulder or thorax while other hand applies manual overpressure Thoracic region Weight of the trunk will stabilize the hips

Stress and Functional Tests Cervical Spine Tests Brachial plexus traction

Cervical Spine Tests (cont.) Brachial plexus tension test

Cervical Spine Tests (cont.) Cervical compression Spurling s test

Cervical Spine Tests (cont.) Cervical distraction Shoulder abduction

Facet Joint Mobility Spring Test

Nerve Root Impingement Valsalva Test First thoracic nerve root stretch

Neurologic Tests Oppenheim Babinski Hoffman

Neurologic Tests (cont.) Myotomes Nerve Root Segment C1 C2 C3 C4 C5 C6 C7 C8 T1 Action Tested neck flexion* lateral neck flexion* shoulder elevation shoulder abduction elbow flexion and wrist extension elbow extension and wrist flexion thumb extension and ulnar deviation intrinsic muscles of the hand (finger & adduction) *These myotomes should not be performed in an individual with a suspected cervical fracture or dislocation, as they may cause serious damage or death.

Neurologic Tests (cont.) Reflexes Reflex Segmental Levels Biceps C5, C6 Brachioradialis C5, C6 Triceps C7, C8

Neurologic Tests (cont.) Cutaneous patterns

Neurologic Tests (cont.) Referred pain

Activity-Specific Functional Testing Normal parameters Pain free and unlimited movement

Rehabilitation Relief of Pain and Muscle Tension Restoration of motion Restoration of Proprioception and Balance Muscular strength and endurance Cardiovascular fitness