Acute Cervical Spine

  1. Craniovertebral Scan
    • Neck rotation
    • Upper cervical sidebending
    • Upper cervical flex, then ext
    • Compression, then distraction (~5 lbs of pressure)

    (about 15 degrees in each direction)
  2. Cervical Cord Compression: Signs and Symptoms
    • Bi/tri/quadrilateral limb paresthesiae
    • Babinski Sign
    • Hoffman Sign (flick 3rd finger down, get flexor response in other fingers)
    • DTRs/Clonus
  3. Key Features of Normal Upper Cervical Spine Motion
    • Motion involving C0, C1 or C2 involve all three vertebrae!
    • Upper cervical spine allows head to move on neck
    • Midcervical spine positions head in space
    • Most flexion and rotation occurring at C1-C2
    • Most extension and sidebending occurring at C0-C1
    • Sidebending C0-C1 and C1-C2 coupled w/ ipsilateral side-glide and contralateral rotation
  4. Vertebral Artery
    • Arises from subclavian artery --> ascends on longs collie --> enters transverse foramen of C6 --> ascends to C1 --> winds around articular pillar --> joints partner to form basilar artery --> enters foramen magnum
    • Can be injured by long lever-arm cervical manipulations (esp due to rotation)
  5. Vertebral/Basilar Arterial Insufficiency: Signs
    • Dizziness
    • Dysphagia
    • Dysarthria
    • Diplopia
    • Drop Attacks
    • Nystagmus produced by neck movements
    • Ipsilateral posterior neck pain/occipital headache
    • Facial lip paresthesiae produced by neck movement
  6. Alar Ligaments
    • Limit rotation and sidebending¬†
    • Go from dens to inferior surface of anterior occiput
    • L ligament limits R sidebending and R rotation of the occiput (and limits L rotation of C2 relative to the head)
  7. Rule Out Red Flags!
    • Trauma = potential instability of high cervical spine
    • Non-Mechanical Lesions = systemic pathologies (brainstem or SC symptoms)
    • Use of anti-coagulants = aspirin/post-stroke/hemophilia
  8. Reasons to Suspect Instability of C-Spine (History)
    • Trauma
    • Suggesting current cervicogenic headache
    • Current dizziness/vertigo
    • Age > 50¬†
    • Systemic disease which could compromise stability (i.e. rheumatoid dz, other collagen dz)
    • Osteoporosis
  9. Transverse Ligament of Atlas Test
    • Anterior pressure applied to posterior arch of C1
    • Positive: no resistance to movement --> indicates ruptured ligament and/or fx dens
  10. Odontoid Stress Test
    • Attempt to side glide C1 on C2
    • Positive: no resistance to movement --> suggest fx dens or ruptured transverse ligament of atlas
  11. Tectorial Membrane Stability Test
    • Stress applied at 45 degree angle superiorly and anterior
    • Positive -- gag, feeling of nausea --> indicates possible torn tectorial membrane
  12. Alar Ligament Motion Test
    • Sidebend the head
    • Should feel SP go in opposite direction
  13. Alar Ligament Stress Test
    • Stabilize posterior arch of C2 and attempt to sideband head
    • Should have no motion occur
    • Somatic dysfunction at C2 will not give a false positive (as in alar ligament motion test)
  14. Vertebral Artery Test
    • Extension crimps both vertebral arteries, rotation further crimps ipsilateral artery
    • Low sensitivity and specificity (positive should still be a red flag!)
    • Negative does not clear cervical neuromuscular structures
  15. Neck-Tongue Syndrome
    • Sudden occipital pain accompanied by numbness of ipsilateral half of tongue
    • Associated w/ rotation of head
    • Related to instability of A-O jt
    • Subluxation causes compression of C2 ventral rams agains the joint (sensory afferents from tongue pass through C2 root)
    • Predisposing factors = RA, congenital hypermobility and contralateral hypomobility
  16. Syringomyelia: Congenital
    • Often associated w/ Chiari malformation
    • Symptoms begin btw ages of 25 and 40
    • Early symptoms: pain numbness, loss of temperature sensation, weakness
    • Late symptoms: progressive weakness, chronic pain, spasticity, loss of bowel and/or bladder function, sexual dysfunction, quadriplegia/paraplegia
  17. Syringomyelia: Traumatic
    • Fluid-filled cyst (syrinx) develops inside SC
    • Symptoms can arise after trauma, meningitis, stroke, tumor, or arachnoiditis
    • Early symptoms: pain, sensory impairment, weakness
    • Late symptoms: progressive weakness, chronic pain, spasticity, loss of bowel and/or bladder function, sexual dysfunction, quadriplegia/paraplegia
  18. Etiology of Atlanto-Axial Instability
    Can be symptomatic or asymptomatic)

    • Odontoid hypoplasia
    • Ligamentous laxity (down syndrome)
    • Congenital malformation
    • Odontoid fracture
    • JRA
    • Marfan syndrome
    • Secondary to resection of lower brainstem tumor
  19. Symptoms of Secondary Cervical Myelopathy
    • Acquired torticollis (secondary to rotary atlantoaxial subluxation)
    • Apneic episodes
    • Opisthotonus
    • Change in muscle tone
    • Hyperreflexia
    • Bradycardia
  20. Quick Test for Sympathetics
    • Cervical extension w/ thoracic and lumbar flexion
    • Puts maximum stress on sympathetic chain ganglia
  21. Muscular Influences
    • Levator: C1 to C4
    • Upper Trap: occiput to C1
    • Longus Capitis: C0-C2 to C5
    • Longus Colli: C1 to T2
    • Anterior Scalenes: C3 to rib 1
    • Middle Scalene: C1 to rib 1
    • Posterior Scalene: C5/6 to rib 2/3
Card Set
Acute Cervical Spine