Cervical Spine Orthopedics DX 611

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Cervical Spine Orthopedics DX 611

• James J. Lehman, DC, MBA, DABCO
• University of Bridgeport College of Chiropractic

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Cervical Spine Anatomy
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Orthopedic Examination of the Cervical Spine

• Involves the taking of a history, performance of
  physical examination procedures and laboratory
  evaluation, which may include imaging studies.

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Chief Complaint Interview

• The O, P, Q, R, S, T process is suggested for all
  patients presenting with neuromusculoskeletal
  conditions.

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History Taking Process

• The history should precede all physical exam
  procedures but include observation.

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History Taking Process

• Establishing rapport
• Listening and questioning
• Observation
• Integration

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Obstacles to History Taking

• Fear
• Antagonism
• Mental cloudiness
• Incoherence
• Language barriers
• Rambling and talkativeness

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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

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Mental Status

• Appearance
• Alert
• Cooperative
• Oriented x3 / Memory
• http//library.med.utah.edu/neurologicexam/html/me
  ntalstatus_normal.html

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History Taking and Observation

• Rusts sign
• Dejerines sign
• Lhermittes sign
• Barre-Lieou sign

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Vital Signs

• Height
• Weight
• Blood pressure
• Pulse rate
• Respiration rate
• Temperature

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Patient Preparation

• Why should the patient be gowned prior to
  evaluation?

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Prepare Patient

• Environment
• Gowned
• Explain procedures

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Inspection

• General inspection is a series of accurate and
  meaningful observations

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Inspection Involves Five Special SensesAllegory
of Five SensesTheodore Rombouts

• Sight
• Hearing
• Touch
• Taste
• Smell

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Inspection

• Posture
• Body movements
• Gait
• Speech
• Surface scars and wounds

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Inspection

• Nutrition
• Stature
• Body temperature
• Breath odors

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Palpation

• Static palpation
• Flat palpation
• Superficial
• Deep

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Motion Palpation

• Technique evaluation includes motion palpation

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Palpation

• Superficial tissues
• Deep tissues
• Joint play

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Palpation Objectives

• Detect abnormal tissue textures
• Evaluate symmetry
• Detect and assess movements
• Detect and evaluate changes in findings

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Percussion

• Stroking with the reflex instrument
• Spinous processes
• Interspinous ligaments
• Paravertebral muscles

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InstrumentationDynamometer

• Elbow flexion to 90 degrees
• Record 3 readings with each hand
• Record dominant hand

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InstrumentationInclinometer

• Most accurate mensuration of spinal or joint
  motion
• Record 3 readings
• Impairment ratings and independent medical exams

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InstrumentationGoniometer

• Easiest to utilize for most joint range of motion
  examinations

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InstrumentationReflex Hammer Babinski
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InstrumentationBuck Reflex Hammer
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InstrumentationTaylor Reflex Hammer

• Patient position
• Doctor position
• Relaxed patient and doctor
• Stroke tendon for rebound

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DTR Testing

• Identify the grade of reflex being tested

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Diagnostic InstrumentsTuning Forks

• C128 and C 256 are utilized with orthopedic
  examinations

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Diagnostic InstrumentsTuning Forks

• Test for osseous fracture pain and perception of
  vibration

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Safety Pin

• Sterile
• Large enough
• Test for sharp and dull

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InstrumentationCotton Balls

• Test for light touch
• Superficial reflexes

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InstrumentationPaper Clips

• Test for two-point discrimination but not for pain

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Half Time

• Who is going to win?

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Cervical Range of Motion Testing
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Range of Motion Evaluation

• Symmetrical motion
• Free of restriction or aberrant
• Pain free or provocative
• Passive, active, and restricted isometric
  movements

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Orthopedic Maneuvers

• Anatomical structure tests
• Dural tension
• Foraminal canal patency
• Spinal canal patency
• Ligamentous
• Muscle
• Tendon

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Cervical Spine Assessment Protocol

• History
• Observation
• Physical examination
• Inspection
• Palpation
• Range of motion
• Orthopedic maneuvers

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Rusts Sign

• May grab head upon removal of cervical collar
• May use hand to lift head when rising from supine
  position

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Rusts Sign

• Suspect upper cervical spine instability
• History of roll-over MVA or blow to head

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Shoulder Abduction Test

• Bakodys sign for nerve root irritation

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Valsalva Maneuver

• Valsalva maneuver for IVD syndrome or tumor
  (space occupying lesion)

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Cervical Distraction Test

• Distraction test for nerve root, facet, or
  myospasm
• Positive test relieves pain
• Negative test increases pain

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Soto-Hall Test

• Non-specific test for cervical spine injury or
  lesion
• Passive flexion of neck with sternum stabilized
• Contraindicated with severe injury

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Swallowing Test

• Difficulty swallowing might be related to a space
  occupying lesion anterior to the cervical spine.

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Cervical Compression Tests

• Maximal foraminal compression (active)
• Jacksons
• Spurlings
• Maximums cervical rotary compression
• Extension/Flexion

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Common Cervical Provocative Tests

• All of them test for dural sheath, nerve root, or
  spinal nerve involvement
• Positive findings all indicate radicular pain

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Cervical Orthopedic Tests

• Dont memorize the tests
• Practice them with comprehension
• Discuss the tests and practice
• Marinate, practice and discuss the relevance of
  the tests and signs

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Nerve Injuries

• Neuropraxia
• Axonotmesis
• Neurotmesis

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Pathological Neurological Responses

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

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Severe Pathological Neurological Responses

• Axonotmesis
• Cervical cord neuropraxia
• Cervical stenosis
• Cervical myelopathy

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Most Severe Pathological Neurological Responses

• Hemiparesis or neurotmesis
• Transient quadriparesis

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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.

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Neuropraxia

• This is a transient lesion and recovery is
  spontaneous after a few days or weeks.

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Neuropraxia"Identify Cause"

• In neuropraxic insult,  the offending compressive
  agent, must be eliminated to protect the nerve
  from further damage.   

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Neuropraxia

• Otherwise, Wallerian Degeneration would  likely
  result.  Therefore, it is imperative that the
  mechanism of compression  be identified to insure
  optimal recovery.

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Neuropraxia

• Neuropraxia may be caused by a ligamentous
  structure, extended pressure, or repetitive
  motion.

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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. 

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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. 

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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.

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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 2000621064-70,107
  3.)

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Neurotmesis

• Implies complete disruption of all the axon and
  supporting connective tissue structures. 

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Neurotmesis

• Without surgical repair, this injury has a very
  poor prognosis.

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End of Cervical Orthopedic Tests

• Thank you for your attention and enjoy the day