ATR 492A C-Spine Information

Cervical Pine Injury Management

HistoryGather personal Information (Name, sport, age, gender, doctor referral, diagnosis, etc)Ask simple open ended questionsProvocationQualityRegionSeverityTimingMOIHear anythingPrevious HistoryMedicationsWhat makes it better (ease factors)What makes it worse (agg. Factors)What have they done for it (self treatment / ease factors)

Observation1. Uninjured limb first/then injured2. Discoloration3. Scars4. Deformity5. Postural abnormalities6. Bleeding7. Swelling8. Torticollis

Palpation1. Uninjured limb first/then injured2. Point of tenderness3. Deformity/Crepitus4. Swelling5. Temperature Change

Boney Palpation

Cervical Vertebrae

Spinous Processes (C2-T1)Atlas/Axis - C1 (the atlas) does not have a SP; it has a posterior tubercle. To palpate the posterior tubercle of C1, palpate between the SP of C2 and the occiput, pressing anteriorly into the soft tissue.

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ATR 492A C-Spine Information

Cervical Pine Injury Management

ClavicleFirst Rib

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Soft Tissue Palpation

Ligamentum Flavum- a pair of elastic ligaments connecting the lamina of one vertebra to the lamina of the vertebra above it on the posterior margin of the vertebral canal. It limits flexion and rotation of the spineLigamentum Nuchae- the supraspinous ligament becomes this in the cervical spine. A triangular septum that serves as a broad area for muscle attachment. It restricts flexion in the cervical spine.

Articulation Palpation

Cervical Intervertebral Articulation

Qualitative ROM TestingFlexion Chin to ChestExtension Look at ceiling directly aboveLateral Bending Keep shoulders level. Laterally flex the neck to bring ear to A-C joint. Should be

approximately 45 degreesLateral Rotation

Rotate head to the right to look directly over the A-C joint. Repeat to the left.

Quantitative ROM Testing:Flexion & Extension

Fulcrum @ external auditory meatus. Norm Flx: 40-70; Norm Ext: 60-80

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Lateral Bending

Norm: 40-50 degrees Fulcrum @ patient’s sterna notch.

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Rotation

Norm: 70-90 degrees Fulcrum @ center of patient’s headWC: #4

Manual Muscle TestingAnterolateral Neck Flexors

Muslces Tested: chiefly stnernocleidomastoid and scalenes

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Posterolateral Neck Extensors

Muscles Tested: chiefly the splenius capitus and cervicis, semispinalis capitis and cervices, and cervical Erector spinae

Anterior Neck Flexors

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Note patient arm position. Anterior abdominal muscles must be strong enough to give anterior fixation of thorax to pelvis before the head can be raised by the neck flexors. If abs are weak, the examiner can give fixation by firm downward pressure on the thorax. Pressure: posterior, as shown in picture. Note: If the anterior vertebral neck flexors (L.Capitus/L.Colli, anterior scalnes) are weak, an individual cab raise the head from the table (as shown in the WRONG picture)Muscles Tested: Longus Capitus, Longus Colli, anterior scalenes

Trapezius Middle Fibers

O: Spinous Processes of T1-T5 I: Medial margin of the acromion and superior lip of spine of the scapula A: Adduction of the scapula Patient prone Patient adducts the scapula, by placing the shoulder in 90 degrees of abduction with the thumb pointed toward the ceiling Examiner stabilizes the opposite shoulder and applies pressure against the forearm in a downward direction

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Lower Trapezius

Prone. The examiner gives fixation by placing one hand below the scapula on the opposite side (not shown). Test: Adduction and depression of the scapula with lateral rotation of the inferior angle. Thumb up. Pressure: against forearm in a downward direction toward table.

Upper Trapezius

Elevation of the acromial end of the clavical and scapula; posteriolateral extension of neck. Pressure: Against shoulder in direction of depression, and against the head in the direction of flexion and anteriolaterallly. WC: #2

Circulatory Check

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Carotid Pulse

Seated or supine. Using the index and middle fingers to locate the thyroid cartilage, move the fingers to either direction to find the common carotid artery between the thyroid cartilage and the SCM muscle. 60-100 bpm normal; well trained 40-60; Tachcardia >100; bradycardia < 60. WC: #4

Neurologic Exam. (M-R-S: Motor-Reflex-Sensory)

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Neurological Check

DTRs How do I grade & document deep tendon reflexes? By convention the deep tendon reflexes are graded as follows:

0 = no response; always abnormal 1+ = a slight but definitely present response; may or may not be normal 2+ = a brisk response; normal 3+ = a very brisk response; may or may not be normal 4+ = a tap elicits a repeating reflex (clonus); always abnormal

WC: #4C1 Dermatome Top of the headC1 Myotome Tested with C2C1 Reflex NoneC2 Dermatome Top of head, back of head, faceC2 Myotome Neck flexionC2 Reflex NoneC3 Dermatome Side of NeckC3 Myotome Neck Side FlexionC3 Reflex NoneC4 Dermatome Upper Trapezius AreaC4 Myotome Resisted Shoulder ShrugC4 Reflex NoneC5 Dermatome Lateral Deltoid Area (Lateral Patch)C5 Myotome Shoulder AbductionC5 Reflex Biceps Reflex: Patient sitting. Examiner stands to the side of the athlete with the forearm

cradled in one arm. The thumb is placed over the biceps tendon below the elbow. The thumb is tapped with the reflex hammer.

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ATR 492A C-Spine Information

Cervical Pine Injury Management

C6 Dermatome Lateral Forearm, thumb and index fingerC6 Myotome Elbow Flexion, Wrist extensionC6 Reflex Brachioradialis Reflex: Patient sitting. Examiner cradles the arm of the athlete. The distal

portion of the brachioradialis tendon is tapped with the reflex hammerC7 Dermatome Middle FingerC7 Myotome Elbow Extension, Wrist FlexionC7 Reflex Triceps Reflex: Patient sitting. The examiner supports the athlete’s shoulder with it abducted

to 90 degrees and the elbow flexed to 90 degrees. The distal triceps tendon is tapped with the reflex hammer

C8 Dermatome Ring and Pinky FingersC8 Myotome Ulnar DeviationC8 Reflex NoneT1 Dermatome Medial ForearmT1 Myotome Abduction and Adduction of the FingersT1 Reflex None

PostureGood

Bad

WC: #1

Special Tests

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Valsalva’s Maneuver

Patient sitting. Patient takes and holds a deep breath while bearing down similar to performing a bowel movementWC: #1

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Cervical Compress./Distract.

Patient sitting (distraction can be done supine as shown. Examiner stands behind the patient with hands interlocked over the top of the patient’s head. Examiner then presses down on the crown of the patients head. A test is positive if there is an increase in pain as the cervical structures are being compressed. For the distraction test, everything is the same, except the examiner will pull up on the head looking to relieve the symptoms

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Spurling’s Test

Examiner stands behind the patient with hands interlocked over the top of the patient’s head. Examiner then presses down on the crown of the patients head. If no pain or discomfort is felt, the patient is asked to extend the neck back and the examiner will press down on the crown of the patient’s head. If no pain or discomfort is felt, the patient is asked to then laterally flex the neck to the affected side keeping the extension. The examiner will press down on the crown of the patient’s head. Tests for nerve root impingement

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Shoulder Depression Test

Patient seated or standing Examiner stands behind the patient. One and placed on the side of the patient’s head, the other hand placed over the AC joint The cervical spine is laterally bent and the opposite shoulder depressed Pain radiating through the upper arm in a dermatomal pattern would indicate a positive test for brachial plexus injuryWC: #4

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Vertebral Artery Test

Patient supine. Examiner seated at the head of the patient with the hands placed under the occiput to stabilize the head. The examiner passively extends and laterally flexes the cervical spine. The head is then rotated toward the laterally flexed side and held for 30 seconds.

Tinel’s Sign

Examiner is to tap at Erb’s point, located 2 to 3 cm above the clavicle in front of the transverse process of the sixth cervical vertebraWC: #3

Injuries and Conditions to KnowCervical Dislocation

Definition: Displacement of 1+ vertebrae

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ATR 492A C-Spine Information

Cervical Pine Injury Management

MOI: blunt trauma Cervical Subluxation

Definition: Mildly displaced vertebra

MOI: blunt traumaCervical Sprain Definition: Over lengthening to inert tissue in the neck e.g. joint capsule of facet joint

MOI: forced ROM beyond normal Cervical Strain Definition: Over lengthening of contractile tissue in the neck e.g. upper trap.

MOI: external force, asynchronous firing during neck motion Neck Contusion Definition: muscle damage + bleed

MOI: blunt trauma Neck Burner Definition: Compression or traction injury to the nerve supply of the upper arm occurring

either at the neck or shoulder, brachial plexus.MOI: often in collision sports if head is forcefully laterally flexed and flexed, over stretching / pinching the nerves

Neck Muscle Atrophy

Definition: Shrinking of neck muscle

MOI: nerve root or peripheral neuropathy, postural, lack of use e.g. with prolonged usage of cervical brace

Vertebral Fracture

Definition: Fracture of a vertebra

MOI: likely a ‘crush’ type mechanism e.g. an axial load through column (body fracture) or blunt trauma (transverse or spinous process fracture), or hyper extension mechanism (pars interarticularis fracture).

Faulty Head and Neck Posture

Definition: abnormal posture of head and or neck e.g. forward head posture.

MOI: likely postural, could have neuro. etiology Disc Herniation Definition: herniated nucleus pulposus

MOI: acute episode Nerve Root Compression

Definition: abnormal pressure on a spinal nerve root

MOI: can be from intervertebral stenosis or an HNP Spinal Cord Ischemia

Definition: Reduced blood flow to the spinal cord which is supplied by the anterior spinal artery and the paired posterior spinal arteries.MOI: arteriosclerosis, trauma, emboli, diseases of the aorta, and other disorders. Prolonged ischemia may lead to infarction of spinal cord tissue.

Torticollis Definition: abnormal rotation of the cervical vertebrae; wry neck.MOI: May be congenital or may develop as a result of neurological or muscular damage. Visable shortening of the neck muscles and the head will tilt toward to affected side while the chin points to the opposite side. Treatment of congenital torticollis involves stretching the shortened neck muscles, the sternocleidomastoid, surgery heat, massage, anticholinergic drugs. On athletic performance this can have greater biomechanical implications, headache, visual problems, compression of nerve roots.

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ATR 492A C-Spine Information

Cervical Pine Injury Management

Brachial Plexus Neuropathy

Definition: pathology of brachial plexus

MOI: compression, stretch, nerve root compression Vertebral Artery Occlusion

Definition: closing off of vertebral artery

MOI: ?

Other Cool StuffRED FLAGS! (may need to zoom into word doc. to see text in image)

WC: #4Mnemonic: Randy Travis Drinks Cold Beer

Roots > Trunks > Divisons > Cords > Branches

Works CitedWC: #1 Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. Upper

Saddle River, NJ: Prentice-Hall.

WC: #2 Kendall, P. F., McCreary, K. E., Provance, G. P. (1993). Muscles Testing and Function, Ed. 4. Philadelphia, PA: Lippincott Williams & Wilkins.

WC: #3 Konin, G. J., Wiksten, L. D., Isear, A. J., Brader, H. (2006). Special Tests for Orthopedic Examination, Ed. 3. Thorofare, NJ: SLACK Incorporated.

WC: #4 Starkey, C., Brown, D. S., & Ryan, J. (2010). Examination of Orthopedic and Athletic Injuries, Ed. 3. Philadelphia, PA: F.A. Davis Company.

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