Cervical and Thoracic Spinal Conditions Chapter 11 Copyright

Cervical and Thoracic Spinal Conditions Chapter 11 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy • Spinal column – Vertebrae • Cervical (7) convex anteriorly • Thoracic (12) concave anteriorly • Lumbar (5) convex anteriorly • Sacral (5 fused) concave anteriorly • Coccyx (4 fused) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) – Structure • Rigid enough to support body and protect spinal cord • Flexible enough to produce a variety of movements Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Cervical – 7 vertebrae form curve – convex anteriorly – Atlas • 1 st vertebra • No body – filled with odontoid process • Function: support the head Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) – Axis • 2 nd vertebra • Odontoid process – tooth-like • Allows head to rotate • Thoracic – 12 vertebrae form curve – concave anteriorly – Extra facets for articulation with ribs Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Motion segment – Functional unit – Any 2 adjacent vertebrae and soft tissues between them Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Intervertebral discs – Components • Annulus fibrosus § Thick fibrous ring • Nucleus pulposus § Gelatinous interior – Function • Shock absorption • Allow spine to bend Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Ligaments – Anterior longitudinal – Posterior longitudinal – Ligamentum flavum – Interspinous – Supraspinous Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Muscles of the neck: lateral view Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) Muscles of the neck: posterior view Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Nerve plexus – Cervical (C 1–C 4) – Brachial (C 5–T 1) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy (cont. ) • Blood supply – Common carotid – Vertebral Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinematics • Movements involve a number of motion segments – Flexion/extension/ hyperextension – Lateral flexion – Lateral rotation Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Kinetics (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic Variations: Injury Potential • Kyphosis – Excessive curve of thoracic spine – Congenital – deficits in vertebral bodies – Idiopathic • Scheuermann’s disease – Secondary to osteoporosis Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic Variations: Injury Potential (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Prevention of Spinal Injuries • Protective equipment – Neck roll – Rib protectors • Physical conditioning – Strength and flexibility • Proper technique – Spearing – Proper lifting – Posture Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cervical Spine Conditions (cont. ) • “Red flags” indicating a possible cervical spine injury: refer to Box 11. 1 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Brachial Plexus Injuries (cont. ) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Thoracic Spine Conditions (cont. ) • Thoracic spinal fractures and apophysitis – Wedge fracture • Fracture of vertebral end plates Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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) Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Spinal Assessment—Conscious Individual (cont. ) • Observation/inspection – Postural assessment – Scan exam – Gait analysis – Inspection of injury site – Gross neuromuscular assessment Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

AROM – Cervical Spine Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

AROM – Thoracic Spine Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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° Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

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 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Stress and Functional Tests Cervical Spine Tests • Brachial plexus traction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cervical Spine Tests (cont. ) • Brachial plexus tension test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cervical Spine Tests (cont. ) • Cervical compression • Spurling’s test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cervical Spine Tests (cont. ) • Cervical distraction • Shoulder abduction Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Facet Joint Mobility • Spring Test Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nerve Root Impingement • Valsalva Test • First thoracic nerve root stretch Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests • Oppenheim • Babinski • Hoffman Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests (cont. ) – Myotomes Nerve Root Segment Action Tested C 1–C 2 neck flexion* C 3 lateral neck flexion* C 4 shoulder elevation C 5 shoulder abduction C 6 elbow flexion and wrist extension C 7 elbow extension and wrist flexion C 8 thumb extension and ulnar deviation T 1 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. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests (cont. ) – Reflexes Reflex Segmental Levels Biceps C 5, C 6 Brachioradialis C 5, C 6 Triceps C 7, C 8 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests (cont. ) • Cutaneous patterns Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Neurologic Tests (cont. ) • Referred pain Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Activity-Specific Functional Testing • Normal parameters • Pain free and unlimited movement Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Rehabilitation • Relief of Pain and Muscle Tension • Restoration of motion • Restoration of Proprioception and Balance • Muscular strength and endurance • Cardiovascular fitness Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins