Orthopedics Cervical Spine - Askdrlehman.com

Cervical Spine Anatomy

Cervical Spine Orthopedics DX 611 James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic

James J. Lehman, DC, MBA, DABCO

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.


History Taking Process


Chief Complaint Interview

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History Taking Process 

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


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

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Establishing rapport Listening and questioning Observation Integration


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Obstacles to History Taking 1. 2. 3. 4. 5. 6.

Fear Antagonism Mental cloudiness Incoherence Language barriers Rambling and talkativeness


Mental Status    

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Appearance Alert Cooperative Oriented x3 / Memory

Vital Signs     

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Chief complaint History of present illness (OPQRST) Past, family, social, and occupational history Systems review (SHEENT)CR, GI, GU, MS, NS, VD, and OB James J. Lehman, DC, MBA, DABCO

History Taking and Observation    

Rust’s sign Dejerine’s sign Lhermitte’s sign Barre-Lieou sign

http://library.med.utah.edu/neurologicexam/html/me ntalstatus_normal.html


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History Taking Process

Height Weight Blood pressure Pulse rate Respiration rate Temperature



Patient Preparation

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Why should the patient be gowned prior to evaluation?


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Prepare Patient   

Environment Gowned Explain procedures


Inspection Involves Five Special Senses Allegory of Five Senses Theodore Rombouts     

Sight Hearing Touch Taste Smell


Inspection    

Nutrition Stature Body temperature Breath odors


Inspection 

General inspection is a series of accurate and meaningful observations


Inspection     

Posture Body movements Gait Speech Surface scars and wounds


Palpation  

Static palpation Flat palpation  

Superficial Deep


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Motion Palpation

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Technique evaluation includes motion palpation


Palpation Objectives

Palpation

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Percussion 

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


Superficial tissues Deep tissues Joint play

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Stroking with the reflex instrument Spinous processes Interspinous ligaments Paravertebral muscles


Instrumentation

Instrumentation

Dynamometer

Inclinometer

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


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


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Instrumentation

Instrumentation Reflex Hammer Babinski

Goniometer 

Easiest to utilize for most joint range of motion examinations


Instrumentation Buck Reflex Hammer


Instrumentation Taylor Reflex Hammer   

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DTR Testing 

Identify the grade of reflex being tested


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


Diagnostic Instruments Tuning Forks 

C128 and C 256 are utilized with orthopedic examinations


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Diagnostic Instruments Tuning Forks 

Test for osseous fracture pain and perception of vibration

Safety Pin

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Instrumentation Cotton Balls  

Test for light touch Superficial reflexes


Half Time

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Sterile Large enough Test for sharp and dull


Instrumentation Paper Clips

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Test for two-point discrimination but not for pain


Cervical Range of Motion Testing

Who is going to win?



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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


Cervical Spine Assessment Protocol   

History Observation Physical examination

Orthopedic Maneuvers 

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


Rust’s Sign 

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Inspection  Palpation  Range of motion  Orthopedic maneuvers 


Rust’s Sign 

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


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


Shoulder Abduction Test

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Bakody’s sign for nerve root irritation


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Valsalva Maneuver

Cervical Distraction Test 

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


Soto-Hall Test 

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


Cervical Compression Tests 

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Maximal foraminal compression (active) Jackson’s Spurling’s Maximums cervical rotary compression Extension/Flexion


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


Swallowing Test

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


Common Cervical Provocative Tests 

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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    

Nerve Injuries

Don’t 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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Pathological Neurological Responses 

Neuropraxia Axonotmesis Neurotmesis

Severe Pathological Neurological Responses

Most benign 

Dysesthesia, paresthesia Brachial plexopathy or neuropraxia  Motor or reflex changes  Atrophy or denervation 

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Most Severe Pathological Neurological Responses

Neuropraxia 

Hemiparesis or neurotmesis  Transient quadriparesis 


Axonotmesis Cervical cord neuropraxia Cervical stenosis Cervical myelopathy

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 "Identify Cause"

Neuropraxia 

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

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Neuropraxia 

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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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.


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


Axonotmesis 

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

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.


Neurotmesis

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


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 2000;62:106470,1073.) James J. Lehman, DC, MBA, DABCO

Neurotmesis

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


End of Cervical Orthopedic Tests 

Thank you for your attention and enjoy the day…


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