Ortho Path - Lecture 8

Front 1

Describe c/s flexion glide and rotation.

Back 1

Superior glide of facet joint. Anterior rotation of vertebral body

Front 2

Describe c/s extension glide and rotation.

Back 2

Inferior glide of facet joint. Posterior rotation of vertebral body

Front 3

Describe c/s side flexion glide and rotation.

Back 3

Inferior glide ipsilateral side. Superior glide contralateral side. Rotation is combined and is ipsilateral

Front 4

Describe c/s rotation glide.

Back 4

Inferior glide ipsilateral side. Superior glide contralateral side. Side flexion is combined ipsilaterally

Front 5

What are three types of congenital cervical spine disorders?

Back 5

(1)Congenital Torticollis, (2)Klippel-Feil Syndrome, (3)Cervical Rib (Thoracic outlet syndrome—TOS)

Front 6

What are two types of traumatic cervical spine disorders?

Back 6

(1)Whiplash, (2)Acute Torticollis

Front 7

What is another name for congenital muscular torticollis?

Back 7

Wry neck

Front 8

What is the cause of congenital muscular torticollis?

Back 8

Exact cause unknown. At least 40% of infants who have difficult deliveries → wry neck. Deformity minimal at birth.

Front 9

How do infants with congenital muscular torticollis present?

Back 9

First few weeks a large and firm swelling develops in one sternocleidomastoid (SCM). Swelling gradually disappears but left with a contracture of SCM.

Front 10

How does congenital muscular torticollis progress?

Back 10

Head becomes laterally flexed toward the affected side and rotated toward the opposite side. Progressive facial asymmetry (due to contracture of SCM).

Front 11

Do infants with congenital muscular torticollis have any other conditions?

Back 11

20% of all infants with condition have dysplasia of one or both hips

Front 12

How is congenital muscular torticollis treated?

Back 12

Early recognition and daily stretching - one year can reverse condition in 90% of children affected

Front 13

What is acute acquired torticollis?

Back 13

Painful unilateral shortening or spasm of neck muscles resulting in an abnormal head position

Front 14

What are five causes of acute acquired torticollis?

Back 14

(1)Activation of latent trigger points, (2)Subluxation of C1 or C2 due to trauma such as whiplash or sudden turning of the head, (3)Facet joint irritation, (4)Infection, (5)Disc related pain

Front 15

What is spasmodic torticollis?

Back 15

Spasmodic torticollis is a localized dystonia (abnormal tonicity of muscle) resulting in an involuntary spasm of cervical muscles and an abnormal head position

Front 16

What are three causes of spasmodic torticollis?

Back 16

What are three causes of spasmodic torticollis?

Front 17

What is another name for Klippel-Feil syndrome?

Back 17

Synostosis of the cervical spine

Front 18

What is Klippel-Feil syndrome?

Back 18

Failure of segmentation results in congenital fusion of several cervical vertebrae. Neck normally short and very stiff.

Front 19

How may patient with Klippel-Feil syndrome present?

Back 19

Posterior hairline is low and transverse. Head is usually straight but occasionally tilted to one side (resembling Torticollis). A congenital high scapula may exist. Sometimes have a bilateral soft tissue web from mastoid process to shoulder.

Front 20

What is the most common cause of TOS?

Back 20

cervical rib disorder

Front 21

What is cervical rib disorder?

Back 21

Cervical rib (extra rib) arises from C7 transverse process. Rib narrows interval between scalenes creating a higher barrier for nerves and vessels to pass over.

Front 22

What two things worsen the compressions of cervical rib disorder?

Back 22

(1)Shoulder sag (in elderly or muscle weakness), (2)Carrying heavy object in hand

Front 23

Which area of the c/s is most commonly affected by cervical rib disorder?

Back 23

Levels C8 to T1 most commonly affected

Front 24

What are four symptoms of cervical rib disorder?

Back 24

(1)Affects hand and inner forearm, (2)Pain and Paresthesia along Ulnar Nerve, (3)Hand weakness, numbness, and clumsiness, (4)Associated symptoms may be variably present (Hand cold sensation & gangrene)

Front 25

What are five signs of cervical rib disorder?

Back 25

(1)Palpable cervical rib, (2)Tender Brachial Plexus distribution, (3)Muscle weakness and atrophy (lower trunk), (4)Sensation decreased, (5)Circulatory insufficiency

Front 26

Which two muscle groups are affected by weakness and atrophy with cervical rib disorder?

Back 26

(1)Interosseous muscles, (2)Hypothenar muscles

Front 27

What three areas can experience decreased sensation with cervical rib disorder?

Back 27

(1)Ulnar forearm, (2)Arm, (3)Ulnar 1.5 fingers

Front 28

What four areas can experience circulatory insufficiency with cervical rib disorder?

Back 28

(1)Swelling, (2)Cold sensation, (3)Distal cyanosis, (4)Trophic skin change

Front 29

What are four types of acquired cervical spine disorders?

Back 29

(1)Degenerative, (2)Nerve Root Compression, (3)Vertebral Artery Compression, (4)Rheumatoid Arthritis

Front 30

What are three types of degenerative cervical spine disorders?

Back 30

(1)Osteoarthritis, (2)Degenerative Disc Disease, (3)Disc herniation/protrusion

Front 31

What are three additional names for osteoarthritis of cervical spine?

Back 31

(1)cervical spondylosis, (2)degenerative disc disease, (3)degenerative joint disease

Front 32

What part of the neck does cervical spondylosis affect?

Back 32

Involves degeneration of the facet joints and discs. Affects the C5/6 and C6/7 segments primarily. Upper-mid cervical spine (C1-4 rarely affected with OA)

Front 33

What is the incidence of cervical spondylosis?

Back 33

Is very common in adults over 45 years

Front 34

What are causes of C5-7 segments being most commonly affected with cervical spondylosis?

Back 34

(1)Maximal lordosis, (2)Most of flexion/extension occurs here, (3)Poor posture

Front 35

What are two causes of nerve root impingement in cervical spondylosis?

Back 35

(1)Narrowing of intervertebral foramina, (2)Disc herniation

Front 36

T/F: Most persons over 50 years have degenerative changes on x-rays

Back 36

True

Front 37

How may a patient with a degenerative c/s present?

Back 37

Some have mild symptoms such as stiffness and others have severe neck pain and arm pain +/- paresthesia.

Front 38

T/F: All nerve roots compressed give the same signs and symptoms

Back 38

False, specific nerve roots compressed give different signs and symptoms

Front 39

What are four specific signs/symptoms of a compressed nerve at C6?

Back 39

(1)Weak deltoid, biceps + wrist extensors, (2)Decreased brachioradialis reflex, (3)Decreased skin sensation thumb and index finger, (4)Paresthesia C6 dermatome

Front 40

At what age is blood supply cut off to the intervertebral discs?

Back 40

Age 20

Front 41

Why are nerve roots at C5-8 more likely to be compressed?

Back 41

They are larger

Front 42

What is the most commonly compressed nerve root?

Back 42

C7

Front 43

What is radiculopathy?

Back 43

Compression of nerve root at intervertebral foramen

Front 44

Where is the pain of radiculopathy felt?

Back 44

Radiating pain is felt along the affected nerve root

Front 45

What can cause radiculopathy in the c/s?

Back 45

osteophytes or discherniation

Front 46

Which nerve root will a disc herniation at C5-6 affect?

Back 46

C6

Front 47

Which nerve root will a disc herniation at C6-7 affect?

Back 47

C7

Front 48

Where is radiculopathy paresthesia experienced?

Back 48

Paresthesia may be felt in one or two digits innervated by the nerve root or slight clumsiness or weakness of the hand

Front 49

Are the affects of radiculopathy paresthesia sensory, motor, or reflex?

Back 49

All three

Front 50

Which nerve roots are most commonly affected by radiculopathy paresthesia?

Back 50

6th and 7th

Front 51

60 - 70% of radiculopathy paresthesia occurs in which nerve root?

Back 51

7th

Front 52

How can cervical myelopathy develop?

Back 52

Cervical spondylosis can progress to cause spinal cord compression

Front 53

What may patients with cervical myelopathy present with?

Back 53

Patients usually present with difficulty in walking with slight unsteadiness of one or both legs. Legs feel stiff and heavy and can ‘give out’ quickly on activity or exercise. The patient reports tingling and numbness of the hands and/or feet.

Front 54

How do the symptoms of cervical myelopathy begin and progress?

Back 54

Symptoms began insidiously and progress slowly

Front 55

T/F: Fine hand movements may be impaired with cervical myelopathy

Back 55

True

Front 56

Is pain associated with cervical myelopathy?

Back 56

No, there is usually no pain

Front 57

What are five signs/symptoms associated with cervical myelopathy?

Back 57

(1) Increased frequency or dribbling incontinence, (2)Increased muscle tone in lower extremities, (3)Babinski positive, (4)Vibratory and tactile sensation may be impaired from hip down, (5)Flexion of neck may cause electric-like sensation down the spine/limbs (Lhermitte’s sign)

Front 58

What is the vertebral artery?

Back 58

It is the main blood supply for the brainstem nuclei but also supplies many structures along its path

Front 59

Where does the vertebral artery originate?

Back 59

Comes off the subclavian artery

Front 60

What is the route of the vertebral artery from the subclavian artery?

Back 60

It then enters the Cervical spine at C6. It ascends the cervical spine in the transverse foramina. It enters the foramen magnum and joins the other VA and forms the Basilar artery

Front 61

What four structures does the vertebral artery supply?

Back 61

(1)Upper spinal cord, (2)brainstem, (3)cerebellum, (4)posterior part of brain

Front 62

What could cause compression or dissection of the vertebral artery?

Back 62

Instabilities, prolonged, sudden /extreme rotation, extension or traction (i.e.Trauma: MVA, sports, falls)

Front 63

What are eight signs/symptoms of vertebral artery ischemia?

Back 63

(1)Drop Attacks, (2)Diplopia, (3)Dizziness, (4)Dysarthria, (5)Dysphagia, (6)Bilateral or Quadrilateral paresthesia, (7)Nystagmus, (8)Perioral paresthesia

Front 64

Describe rheumatoid arthritis

Back 64

It is a systemic inflammatory disorder affecting the synovial membrane of joints. RA is an immune response

Front 65

What is the incidence of RA?

Back 65

It is relatively common (1.5% of the adult population). Women:men = 3:1.

Front 66

What is the peak period of onset of RA?

Back 66

Peak period of onset is between the ages of 40 and 60 years (but can occur at any age).

Front 67

What is the incidence of RA in First Nation people?

Back 67

First Nation people have 5-6% incidence.

Front 68

How does RA develop?

Back 68

Remains a mystery. Could be related to some bacterial or viral infection, Vitamin deficiency, Hormonal imbalance, Emotional stress.

Front 69

What is the target of RA?

Back 69

The target of the disease is the synovial membrane of joints and tendon sheaths.

Front 70

*How do the synovial membranes react to the inflammation of RA?

Back 70

The synovial membranes react to inflammation by congestion, edema, fibrin, exudation and proliferation. *The RA synovial membrane that extends to the cartilage and bone is known as pannus (“a rug”).

Front 71

How does the pannus affect the joint?

Back 71

The pannus (fibrous tissue produced by synovial cells) interferes with nutrition of the articular cartilage and causes cartilage necrosis.

Front 72

Describe the four steps of degeneration with RA.

Back 72

(1)Chronic inflammation of synovium, (2)Decreased movement of joint, (3)Pannus formation, (4)Erodes cartilage and bone.

Front 73

What will happen if the pannus burrows into the subchondral bone?

Back 73

It will cause osteolysis in the bone.

Front 74

What are three causes a joint to become unstable and sublux (a slight misalignment of the vertebrae)?

Back 74

(1)Articular instability, (2)Tendon pathology, (3)Ligament laxity

Front 75

*What do 30% of RA patients develop?

Back 75

Rheumatoid nodules - non-tender subcutaneous bump on exterior surface.

Front 76

T/F: Tenosynovitis is present in the majority of patients with RA.

Back 76

True

Front 77

What are the seven most commonly involved joints with RA?

Back 77

(1)Metacarpal, (2)Wrist, (3)Shoulder, (4)Knees, (5)Subtalar, (6)Metatarsal, (7)Craniovertebral region (C1/2)

Front 78

What are three systemic symptoms of RA?

Back 78

(1)Systemic flu-like symptoms (Generalized aching, Stiffness, Fatigue, Weight loss), (2)Affected joints are hot, swollen and skin over joint is shiny and tight, (3)Morning stiffness for 1 hour or more.

Front 79

*What are seven later clinical features of RA?

Back 79

(1)C1/C2 instability & neurological symptoms (transverse ligament affected. Can cause nausea, vertigo, paralysis in UE/LE), (2)Positive Sharp Purser Test, *(3)Sjogren’s syndrome (dry eyes and mouth) 15% of those with RA (autoimmune disorder affecting saliva and lacrimal glands, skin, respiratory and GI tracts), (4)Muscle spasm (secondary to inflammation or joint instability), Muscle atrophy, (5)Muscle contracture, (6)Subluxation & luxation due to stretched joint capsule & ligaments, (7)Rupture of tendons

Front 80

Can RA be cured?

Back 80

No, it can only be managed

Front 81

What are seven treatment goals for RA?

Back 81

(1)Help patient understand the nature of the disease, (2)Provide psychological support, (3)Treat pain, (4)Suppress inflammatory reactions (NSAID’s, steroids, cortisone injections), (5)Maintain joint function & prevent deformity, (6)Correct existing deformity, (7)Improve function

Front 82

What are two ways treatment goals of RA can be achieved?

Back 82

(1)External support commonly required (brace/splint), (2)Surgery is often indicated.

Front 83

What is whiplash?

Back 83

The term ‘whiplash’ is not diagnostic but rather synonymous with the mechanism of injury. It merely implies that the cervical spine has been whipped in some direction

Front 84

What is a better term for whiplash?

Back 84

A better term is ‘acceleration/deceleration’ injury or ‘flexion/extension’ injury

Front 85

What are six causes of whiplash?

Back 85

(1)MVA, (2)Blows to head, face or neck, (3)Blows to the body, (4)Pulls and thrusts on the arms, (5)Blows to the top of the head, (6)Falls landing on shoulder

Front 86

If whiplash symptoms have an immediate onset are the injuries more or less severe?

Back 86

Immediate onset typically implies more severe injuries

Front 87

T/F: If the head is turned, whiplash injuries are less severe

Back 87

False, injuries are more severe if the head is turned

Front 88

Are rear end collisions a hyperextension or hyperflexion injury?

Back 88

hyperextension

Front 89

What is the first step of a rear end collision?

Back 89

Sudden acceleration of the portion of the body in contact with the seat

Front 90

What is the second step of a rear end collision?

Back 90

The head (mass at rest) remains at rest until acted on by an external force

Front 91

What is the third step of a rear end collision?

Back 91

The flexible neck, with its 8-12 pound weight, is initially hyperextended as the body accelerates forward

Front 92

What is the fourth step of a rear end collision?

Back 92

The head hits the top of the back of the seat or the headrest

Front 93

What is the fifth step of a rear end collision?

Back 93

This impact plus the reflex contraction of the anterior neck muscles starts the head in a forward motion

Front 94

What is the sixth step of a rear end collision?

Back 94

The head continues forward until it contacts a stationary part of the car/chest and/or is restrained by the soft tissues of the posterior neck (hyperflexion)

Front 95

Which joints are most commonly affected in whiplash hyperextension injuries?

Back 95

With hyperextension, the joints between C4-5 are compressed the most

Front 96

Do hyperextension injuries have the best, worst, or neutral prognosis?

Back 96

Worst

Front 97

What can decrease hyperextension whiplash injuries?

Back 97

Proper headrest height/position

Front 98

What are 10 hyperextension injuries that can result from whiplash?

Back 98

(1)Traction of ALL, (2)Alar ligament if head rotated, (3)Avulse disc from end plate of vertebral body, (4)Compression fracture of facet joint or spinous process, (5)Posterior subluxation of facet joints, (6)Tearing of anterior muscles, (7)Vertebral artery compressed, (8)Nerve roots or spinal cord damaged, (9)Head injury (impact or contrecoup), (10)Esophagus tearing

Front 99

Are head on collisions hyperextension or hyperflexion injuries?

Back 99

Hyperflexion

Front 100

What is the first step of a head on collision?

Back 100

The body is thrown forward until it contacts an immovable object (seatbelt, steering wheel, dashboard)

Front 101

What is the second step of a head on collision?

Back 101

The head continues moving forward until it hits an immovable object or is restrained by posterior cervical tissues

Front 102

What is the third step of a head on collision?

Back 102

The head then recoils into extension

Front 103

Which joints are most commonly affected in whiplash hyperflexion injuries?

Back 103

With hyperflexion, the joints between C5-6 are stretched the most

Front 104

What are 10 hyperflexion injuries that can result from whiplash?

Back 104

(1)Posterior ligament sprain, (2)Posterior muscle strains, (3)Subluxation of facet joint, (4)Posterior bulge of IVD, (5)Vertebral artery traction, (6)Fractures of anterior vertebral body, (7)Nerve root or cord injury, (8)Head injury

Front 105

Describe what happens to the body in a side collision?

Back 105

The body, head and neck are thrown first in the direction opposite the impacting force and then in the direction of the force. Rotation combines with side flexion so there is additional torque involved. If the head is already in rotation at impact the damage is usually more severe.

Front 106

What is a rim lesion?

Back 106

A horizontal tear of the end plate

Front 107

What type of injury can cause a rim lesion?

Back 107

Occur with hyperflexion or hyperextension injuries

Front 108

How is a rim lesion diagnosed?

Back 108

Do not show on x-ray. MRI will confirm rim lesion.

Front 109

How long can it take for a rim lesion to heal?

Back 109

May take 18 months to heal.

Front 110

What are eight clinical features of whiplash?

Back 110

(1)Neck, thoracic or arm pain, (2)Headache, (3)Visual disturbance, (4)Dizziness, (5)Concentration and memory disturbances, (6)Paresthesia, (7)Weakness, (8)Swallowing difficulties

Front 111

What percentage of patients are symptomatic at 2 year follow-up (after settlement)?

Back 111

45%

Front 112

What percentage of patients develop early OA?

Back 112

39%

Front 113

What percentage of MVA patients have persistent headache and dizziness for 2-4 years?

Back 113

20%

Front 114

How is treatment determined for whiplash injuries?

Back 114

Must look at the SIN (severity, intensity and nature) of the injuries. Rule out any serious injuries. Open mouth x-rays taken?? (checks for dens fracture).

Front 115

What are five treatments for whiplash?

Back 115

(1)Rest, (2)Collar (no longer than 4 weeks), (3)Maintain joint mobility and proper muscular healing i.e.: chiro/massage, (4)Medication, (5)Active exercise when ready