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67 Cards in this Set

  • Front
  • Back
Cardinal Signs & Symptoms - Definition
S/S indicative of CNS involvement
Require referral back to MD
Cardinal Signs & Symptoms - Listed
• bowel & bladder dysfunction
• incontinence
• loss of bowel control
• bilateral or quadrilateral paraesthesias or anaesthesias
• bilateral or quadrilateral paresis
• ataxia
• nystagmus
• diplopia (double vision)
• scotoma
• miosis (pupil constriction)
• +ve Babinski
• clonus
• hyper-reflexia
• +ve Hoffman test
• +ve Oppenheimer test
• periodic LOC
• lip anaesthesia
• facial anaesthesia
• facial muscle paresis
• recurrent syncope
• dysphasia
• dysarthria
• trapezius/SCM paresis
• drop attacks
• Horner's syndrome
Dizziness - Definition
Sensation of altered orientation in space
Dizziness - Causes
• postural hypotension
• drug side-effect
• vertebrobasilar
• cervicogenic
• vestibular
• TMJ dysfunction
• SCM trigger points
Vertigo - Definition
Spinning or swirling sensation
Frature Tests
• Battle’s sign
• raccoon eyes
• compression test
Cranial Nerve Dysfunction - Signs & Symptoms
• scotoma
• ↓ pupillary reflexes
• facial anaesthesia
• facial muscle paresis
• sensorineural hypoacusia associated with the trauma
• +ve Hautard's test
• SCM or trapezius weakness
• dysarthria
• dysphasia
• tongue deviation on protrusion
Quick Scan CN Testing - CN I
Olfactory Nerve - smell coffee or similar substance with eyes closed
Quick Scan CN Testing - CN II
Optic Nerve - read something with one eye closed
Quick Scan CN Testing - CN III, IV, VI
Occulomotor Nerve, Trochlear, Abducens - eye movements and note lid ptosis
Quick Scan CN Testing - CN V
Trigeminal Nerve - contract muscles of mastication - masseter & temporalis
Quick Scan CN Testing - CN VII
Facial Nerve - move eyebrows up & down, purse lips, show teeth, wink, whistle or close an eye

* most commonly injured
Quick Scan CN Testing - CN VIII
Vestibulcochlear Nerve/Auditory Nerve - eyes closed - talk to patient & have him/her repeat back what you said or rub your fingers together by his/her ears – should sound the same
Quick Scan CN Testing - CN IX & X
Glossopharyngeal Nerve & Vagus Nerve - swallow or say “Ahhhhh”
Quick Scan CN Testing - CN XI
Accessory Nerve - contract SCM muscle
Quick Scan CN Testing - CN XII
Hypoglossal Nerve - stick out tongue & move it to the (R) & (L)
Long Tract Spinal Cord Signs & Symptoms
• bilateral or quadrilateral anaesthesia
• bilateral or quadrilateral weakness
• spasticity/hypertonicity
• hyper-reflexia
• clonus
• ataxia
• presence of pathological reflexes
Types of Sensation Tested for in Long Tract Lesions
• light touch
• hot/cold
• vibration
• proprioception
DTR in UE
• jaw CN V
• biceps C5-6
• brachioradialis C5-6
• triceps C7
How do you test for clonus?
• the joint is rapidly taken to end range & held there
• > 3 contractions/relaxations (beats) indicates an UMNL
• elicits a dynamic stretch reflex
• assess how well the CNS inhibits the reflex
• in the UE, one can use elbow flexion or wrist extension
Ataxia - Definition
• erratic, uncontrolled UE movements - may be intention tremor
Babinski Reflex aka extensor plantar response
* pathological reflex

• foot is nociceptively stimulated by stroking the lateral aspect of the side of the foot & then across to the big toe
• normal response = down going and converging toes or no reaction at all
• abnormal response = upgoing of the big toe and splaying toes
• indicative of a corticospinal (pyramidal) traction lesion
Oppenheimer’s Test
* pathological reflex

• application of a nociceptive stimulus to the ridge of the tibia
• normally there is no response to this
• +ve response = a Babinski response (ie. upgoing of the big toe & splaying toes)
• indicative of a corticospinal (pyramidal) tract lesion
Hoffman’s Test
* pathological reflex

• apply a noxious stimuli to the D3 DIP joint (eg. pinching or squeezing)
• normally = no response
• +ve response = reflex flexion of the DIP joint - part of a flexor withdrawal response
• indicative of a pyramidal tract lesion
Signs & Symptoms of VBI
• 5D’s
• facial paralysis or paresis
• hemiparesis
• rapid lateral nystagmus
• ataxia
• blurred vision
• nausea
• vertigo
• hypoacusia
• hx of LOC
• Horner’s syndrome
• vomiting
• unsteadiness
• loss of concentration
• SCM & trapezius muscle atrophy
Tests for VBI
• palpation of carotid pulse
• CN testing (before VA tests)
• CV ligament stress tests (before VA tests)
• VA tests
• Hautard’s (Hautant’s) test
Causes of CV Instability
• trauma
• sports related injuries
• ankylosing spondylitis
• rheumatoid arthritis (RA)
• Grisel’s syndrome
• Down’s syndrome
Grisel’s Syndrome
• involves the subluxation of the AA joint from inflammatory ligamentous laxity following an infectious process – usually URTI
• rare -usually affects children but can affect adults
CV Instability Signs & Symptoms
• cord findings (eg. ataxic gait, clonus, hyperreflexia, +ve Babinski)
• VA findings (5 D’s & other S/S’s described previously)
• patient holding head
• sub-occipital numbness
• lump in throat
Mandatory Features of Cervicogenic Headaches
• unilateral headache that may or may not spread to the other side
• pain is always on the same side (ie. does not change between or within headache episodes)
• associated suboccipital, neck or neck-shoulder pain
• pain starts in the cervical area & spreads to the frontal, retro-orbital or temporal areas
• long lasting headache (ie. few hours to a few weeks)
• can fluctuate in intensity
• dull, deep, achy in nature
• headache episodes of varying duration
• mild to moderate intensity of headache
• analgesics & NSAIDs offer little relief
• stress or tension may aggravate a cervical headache
Cervicogenic Headache - Causes
• trigeminocervical nucleus extends from the pons to C3 or C4
• receives afferent input from the upper 3 cervical spinal nerves, CN V, VII, IX & X
• receives all the nociceptive afferents from the head & upper c-spine
• convergence of afferent input = any structure innervated by above nerves can cause headache
• may include: muscles, z-joints, capsules & ligaments of the upper 3 cervical segments, nerves, dura mater, SC or VA
Order of Sequencing for C-Spine Assessment
• cardinal symptoms - ask & observe
• fracture tests
• neurological tests
• CV stress tests
• VA tests
• detailed cervical joint assessment
Implications of Positive C-Spine Screenings
If any are positive, send to physician
Cardinal S/S - Indication
CNS involvement
Peri-Oral Numbness - Why is it a significant neurological finding?
• area innervated by 2 branches of trigeminal nerve (upper & lower lip)
• innervation comes from central trigeminal nucleus - not a peripheral origin
Ataxic Gait - How can trauma cause it?
• cerebellum supplied by basilar artery
• concussive force can disrupt the vessels supplying the area
- superior cerebellar artery
- anterior inferior cerebellar artery
- posterior inferior cerebellar artery
Blurred Vision - Cardinal Finding?
No
Reduced Visual Acuity - Cause (CN nerve involvement)
Optic Nerve - CN 1
Scotoma - What is it
Loss of visual field in a certain area, surrounded by unaffected vision
Miosis - What is it
• Unequal pupil constriction (should be symmetrical)
• PNS
• Due to damage of occulomotor nerve (??)
Significance of SCM/Trapezius Atrophy
• CN 11 - Accessory nerve innervates them
• Indicates central involvement
Horners Syndrome - Presentation
• ptosis + miosis + anhidrosis + litosis
• decreased sweating
Horners Syndrome - Causes
• problem with sympathetic nervous system (autonomic nervous system )
• cervico-sympathetic chain is supplied by vertebral artery - if injured, sympathic chain may be affected
Dizziness/Vertigo - Cardinal Finding?
No
Dizziness - VA Involvement
• VA supplies cerebellum (via vertebral/basilar artery) & vestibulocochlear system (via labyrinthine artery)
• damage results in dizziness/vertigo
Most Common/Least Common Causes of Dizziness
• most common: cervicogenic
• least common: TMJ dysfunction
Cervicogenic Dizziness - How?
there’s an integrated proprioceptive loop between eyes and craniovertebral region
MOI of Vestibular System Injury
• trauma
• flexion
• extension
• rotation
Battle Sign - Location/Cause/Implications
• bruising behind ear
• caused by injury/fracture of temporal bone
• middle meningeal artery is at risk of trauma due to location behind temple (weakest area)
• at risk of subdural hematoma
Racoon Eyes - Causes
• high facial fracture
• frontal bone fracture
CN Dysfunction - Signs & Symptoms
• scotoma - optic nerve (CN 1)
• decreased pupillary reflexes (CN II - occulomotor)
• facial anesthesia (CN V - trigeminal)
• facial muscle paresis (CN V & VII - trigeminal & facial)
• sensorineural hypoacusia (CN VIII - vestibulcochlear nerve)
• + Huatards Test - may indicate vertebrobasillar insufficiency and loss of bloodsupply to cerebellum - lose positional sense & proprioception
Sensorineural Hypoacusia - What is it?
• loss of hearing
• due to damage of vestibulocochlear nerve - CN VIII
• dammage to inner ear/brain
Hautard's Test
• positional test
• when positive indicates vascular compromise
implicates cerebellum (positional sense, proprioception etc..)
• positive test = drift on contralateral side to head turn
Hypoglossal Nerve Palsy
• CN XII is affected
• tongue will be pushed to weak side (i.e., contralateral to UMN lesion, ipsilateral if LMN)
Muscles of Mastication - Trigeminal Nerve
• temporalis
• masseter
Jaw Jerk Reflex - What CN?
• quick stretch of masseter & temporalis
• CN test for trigeminal nerve
• hyper-reflexive = snapping jaw shut
Most Commonly Injured CN
• facial nerve - CN VII
Conductory Hearing Loss
• problem with conducting sound waves
• problem with outer hear, tympanic membrane or middle ear
Uvula Palsy
• indicated problem with pharyngeal branch of vagus nerve (CN X)
• look at symmetry
• will deviate to strong side (unlike hypoglossal nerve)
Vertebral Artery Tests - Clinical Decision Making
• use to rule out VA compromise - not confirm
• do not use within first 6 weeks of MVA/trauma
Vertebrobasilar Signs & Symptoms
• 5 d’s (dysphagia, diplopia, drop attacks, dysarthria, dizziness)
• facial paralysis
• hemiparesis
• lateral nystagmus
• ataxia
• blurred vision
• nausea
• vertigo
• hypoacusia
• LOC
• Horners syndrome
• vomiting
• unsteadiness
• loss of concentration
• SCM/trapezius atrophy
Importance of VA Anatomy in S/S
VA supplies the cerebellum & upper part of cord
Downs Syndrome - Reason for CV Instability
• during resegmentation (development) the dens doesn’t ‘become’ part of C2 like it should normally
CV Instability - Diagnostic Investigations
• open mouth x-rays
• dynamic flexion/extension
Common Trigeminal Nucleus - Innervation
• CN nerves V, VII, IX, X
• upper cervical spinal nerves (C 1, 2, 3)
• all nociceptive affarents from upper c-spine and head
Common Trigeminal Nucleus - Association w/ Headaches
• common trigeminal nucleus & convergence theory
• any structure innervated by said nerves is capable of causing headache
Headache - Possible Structures Causing Pain
• muscles
• z-joints
• capsules
• ligaments of upper 3 cervical segments
• nerves
• dura mater
• SC
• VA