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

2. Cervical Spine Anatomy
James J. Lehman, DC, MBA, DABCO

3. 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.
James J. Lehman, DC, MBA, DABCO

4. Chief Complaint Interview
The O, P, Q, R, S, T process is suggested for all patients presenting with neuromusculoskeletal conditions.
James J. Lehman, DC, MBA, DABCO

5. History Taking Process
The history should precede all physical exam procedures but include observation.
James J. Lehman, DC, MBA, DABCO

6. History Taking Process
Establishing rapport
Listening and questioning
Observation
Integration
James J. Lehman, DC, MBA, DABCO

7. Obstacles to History Taking
Fear
Antagonism
Mental cloudiness
Incoherence
Language barriers
Rambling and talkativeness
James J. Lehman, DC, MBA, DABCO

8. 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
James J. Lehman, DC, MBA, DABCO

9. James J. Lehman, DC, MBA, DABCO
Mental Status
Appearance
Alert
Cooperative
Oriented x3 / Memory
James J. Lehman, DC, MBA, DABCO

10. History Taking and Observation
Rust’s sign
Dejerine’s sign
Lhermitte’s sign
Barre-Lieou sign
James J. Lehman, DC, MBA, DABCO

11. James J. Lehman, DC, MBA, DABCO
Vital Signs
Height
Weight
Blood pressure
Pulse rate
Respiration rate
Temperature
James J. Lehman, DC, MBA, DABCO

12. James J. Lehman, DC, MBA, DABCO
Patient Preparation
Why should the patient be gowned prior to evaluation?
James J. Lehman, DC, MBA, DABCO

13. James J. Lehman, DC, MBA, DABCO
Prepare Patient
Environment
Gowned
Explain procedures
James J. Lehman, DC, MBA, DABCO

14. James J. Lehman, DC, MBA, DABCO
Inspection
General inspection is a series of accurate and meaningful observations
James J. Lehman, DC, MBA, DABCO

15. James J. Lehman, DC, MBA, DABCO
Inspection Involves Five Special Senses Allegory of Five Senses Theodore Rombouts
Sight
Hearing
Touch
Taste
Smell
James J. Lehman, DC, MBA, DABCO

16. James J. Lehman, DC, MBA, DABCO
Inspection
Posture
Body movements
Gait
Speech
Surface scars and wounds
James J. Lehman, DC, MBA, DABCO

17. James J. Lehman, DC, MBA, DABCO
Inspection
Nutrition
Stature
Body temperature
Breath odors
James J. Lehman, DC, MBA, DABCO

18. James J. Lehman, DC, MBA, DABCO
Palpation
Static palpation
Flat palpation
Superficial
Deep
James J. Lehman, DC, MBA, DABCO

19. James J. Lehman, DC, MBA, DABCO
Motion Palpation
Technique evaluation includes motion palpation
James J. Lehman, DC, MBA, DABCO

20. James J. Lehman, DC, MBA, DABCO
Palpation
Superficial tissues
Deep tissues
Joint play
James J. Lehman, DC, MBA, DABCO

21. James J. Lehman, DC, MBA, DABCO
Palpation Objectives
Detect abnormal tissue textures
Evaluate symmetry
Detect and assess movements
Detect and evaluate changes in findings
James J. Lehman, DC, MBA, DABCO

22. James J. Lehman, DC, MBA, DABCO
Percussion
Stroking with the reflex instrument
Spinous processes
Interspinous ligaments
Paravertebral muscles
James J. Lehman, DC, MBA, DABCO

23. Instrumentation Dynamometer
Elbow flexion to 90 degrees
Record 3 readings with each hand
Record dominant hand
James J. Lehman, DC, MBA, DABCO

24. Instrumentation Inclinometer
Most accurate mensuration of spinal or joint motion
Record 3 readings
Impairment ratings and independent medical exams
James J. Lehman, DC, MBA, DABCO

25. Instrumentation Goniometer
Easiest to utilize for most joint range of motion examinations
James J. Lehman, DC, MBA, DABCO

26. Instrumentation Reflex Hammer Babinski
James J. Lehman, DC, MBA, DABCO

27. Instrumentation Buck Reflex Hammer
James J. Lehman, DC, MBA, DABCO

28. Instrumentation Taylor Reflex Hammer
Patient position
Doctor position
Relaxed patient and doctor
Stroke tendon for rebound
James J. Lehman, DC, MBA, DABCO

29. James J. Lehman, DC, MBA, DABCO
DTR Testing
Identify the grade of reflex being tested
James J. Lehman, DC, MBA, DABCO

30. Diagnostic Instruments Tuning Forks
C128 and C 256 are utilized with orthopedic examinations
James J. Lehman, DC, MBA, DABCO

31. Diagnostic Instruments Tuning Forks
Test for osseous fracture pain and perception of vibration
James J. Lehman, DC, MBA, DABCO

32. James J. Lehman, DC, MBA, DABCO
Safety Pin
Sterile
Large enough
Test for sharp and dull
James J. Lehman, DC, MBA, DABCO

33. Instrumentation Cotton Balls
Test for light touch
Superficial reflexes
James J. Lehman, DC, MBA, DABCO

34. Instrumentation Paper Clips
Test for two-point discrimination but not for pain
James J. Lehman, DC, MBA, DABCO

35. James J. Lehman, DC, MBA, DABCO
Half Time
Who is going to win?
James J. Lehman, DC, MBA, DABCO

36. Cervical Range of Motion Testing
James J. Lehman, DC, MBA, DABCO

37. Range of Motion Evaluation
Symmetrical motion
Free of restriction or aberrant
Pain free or provocative
Passive, active, and restricted isometric movements
James J. Lehman, DC, MBA, DABCO

38. James J. Lehman, DC, MBA, DABCO
Orthopedic Maneuvers
Anatomical structure tests
Dural tension
Foraminal canal patency
Spinal canal patency
Ligamentous
Muscle
Tendon
James J. Lehman, DC, MBA, DABCO

39. Cervical Spine Assessment Protocol
History
Observation
Physical examination
Inspection
Palpation
Range of motion
Orthopedic maneuvers
James J. Lehman, DC, MBA, DABCO

40. James J. Lehman, DC, MBA, DABCO
Rust’s Sign
May grab head upon removal of cervical collar
May use hand to lift head when rising from supine position
James J. Lehman, DC, MBA, DABCO

41. James J. Lehman, DC, MBA, DABCO
Rust’s Sign
Suspect upper cervical spine instability
History of roll-over MVA or blow to head
James J. Lehman, DC, MBA, DABCO

42. Shoulder Abduction Test
Bakody’s sign for nerve root irritation
James J. Lehman, DC, MBA, DABCO

43. James J. Lehman, DC, MBA, DABCO
Valsalva Maneuver
Valsalva maneuver for IVD syndrome or tumor (space occupying lesion)
James J. Lehman, DC, MBA, DABCO

44. Cervical Distraction Test
Distraction test for nerve root, facet, or myospasm
Positive test relieves pain
Negative test increases pain
James J. Lehman, DC, MBA, DABCO

45. James J. Lehman, DC, MBA, DABCO
Soto-Hall Test
Non-specific test for cervical spine injury or lesion
Passive flexion of neck with sternum stabilized
Contraindicated with severe injury
James J. Lehman, DC, MBA, DABCO

46. James J. Lehman, DC, MBA, DABCO
Swallowing Test
Difficulty swallowing might be related to a space occupying lesion anterior to the cervical spine.
James J. Lehman, DC, MBA, DABCO

47. Cervical Compression Tests
Maximal foraminal compression (active)
Jackson’s
Spurling’s
Maximums cervical rotary compression
Extension/Flexion
James J. Lehman, DC, MBA, DABCO

48. Common Cervical Provocative Tests
All of them test for dural sheath, nerve root, or spinal nerve involvement
Positive findings all indicate radicular pain
James J. Lehman, DC, MBA, DABCO

49. Cervical Orthopedic Tests
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
James J. Lehman, DC, MBA, DABCO

50. James J. Lehman, DC, MBA, DABCO
Nerve Injuries
Neuropraxia
Axonotmesis
Neurotmesis
James J. Lehman, DC, MBA, DABCO

51. Pathological Neurological Responses
Most benign
Dysesthesia, paresthesia
Brachial plexopathy or neuropraxia
Motor or reflex changes
Atrophy or denervation
James J. Lehman, DC, MBA, DABCO

52. Severe Pathological Neurological Responses
Axonotmesis
Cervical cord neuropraxia
Cervical stenosis
Cervical myelopathy
James J. Lehman, DC, MBA, DABCO

53. Most Severe Pathological Neurological Responses
Hemiparesis or neurotmesis
Transient quadriparesis
James J. Lehman, DC, MBA, DABCO

54. James J. Lehman, DC, MBA, DABCO
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.
James J. Lehman, DC, MBA, DABCO

55. James J. Lehman, DC, MBA, DABCO
Neuropraxia
This is a transient lesion and recovery is spontaneous after a few days or weeks.
James J. Lehman, DC, MBA, DABCO

56. Neuropraxia "Identify Cause"
In neuropraxic insult,  the offending compressive agent, must be eliminated to protect the nerve from further damage.   
James J. Lehman, DC, MBA, DABCO

57. James J. Lehman, DC, MBA, DABCO
Neuropraxia
Otherwise, “Wallerian Degeneration” would  likely result.  Therefore, it is imperative that the mechanism of compression  be identified to insure optimal recovery.
James J. Lehman, DC, MBA, DABCO

58. James J. Lehman, DC, MBA, DABCO
Neuropraxia
Neuropraxia may be caused by a ligamentous structure, extended pressure, or repetitive motion.
James J. Lehman, DC, MBA, DABCO

59. James J. Lehman, DC, MBA, DABCO
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. 
James J. Lehman, DC, MBA, DABCO

60. James J. Lehman, DC, MBA, DABCO
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. 
James J. Lehman, DC, MBA, DABCO

61. James J. Lehman, DC, MBA, DABCO
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.
James J. Lehman, DC, MBA, DABCO

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

63. James J. Lehman, DC, MBA, DABCO
Neurotmesis
Implies complete disruption of all the axon and supporting connective tissue structures. 
James J. Lehman, DC, MBA, DABCO

64. James J. Lehman, DC, MBA, DABCO
Neurotmesis
Without surgical repair, this injury has a very poor prognosis.
James J. Lehman, DC, MBA, DABCO

65. End of Cervical Orthopedic Tests
Thank you for your attention and enjoy the day…
James J. Lehman, DC, MBA, DABCO