1. Cervical Spine Arthur Jason De Luigi, DO
Program Director, Sports Medicine Fellowship
Director, Sports Medicine
Director, Interventional Pain
MedStar National Rehabilitation Hospital
MedStar Georgetown University Hospital
Medical Director and Head Team Physician
US Paralympic Alpine Ski Team

2. Overview
Cervical Anatomy
Physical Examination
Pathology
Treatment

3. Cervical Spine Anatomy
3-joint complex
50% Flex-Ext
Atlanto-occipital
50% rotation
C1-C2
Center of motion
Flex C 5-6
Ext C 6-7
C2 and C7 most prominent spinous processes

4. Anatomy Center of motion
Flex C 5-6
Ext C 6-7
Normal lordodic curve helps absorb energy of blows to head and neck
Lordosis 30 deg forward flexion

5. Cervical Nerves 8 cervical roots C1-C4 C5-T1 Sensory Brachial Plexus
Motor Branches

6. Cervical and Thoracic Nerve ROots
Cervical Nerve Roots
Exit above the vertebral body for which they are named
Thoracic Nerve Roots
Exit under the vertebral body and rib

7. C-Spine Exam Overview Inspection Palpation Range of Motion Strength
Neurovascular testing
Special tests

8. Inspection Overall posture Position of comfort
ROM when walking, talking
Deformity, ecchymosis, swelling
(All marketed devices to improve posture)

9. Palpation Spinous processes Paraspinal muscles Anterior & lateral neck
Bony TTP is a red-flag
Paraspinal muscles
Anterior & lateral neck
Upper back & scapula
Arms if symptoms there

10. Range of Motion Forward Flexion 60 degrees Extension 70 degrees
Side bending 45 degrees*
Rotation degrees*
Note mild/moderate/severe restriction
*compare to opposite side
AROM important when you want to clear a C-spine on the field.
Cervical Spine ROM measurements are notoriously inacurate. MILD MOD or SEVERe restriction based on gross motion is sufficient.

11. Motor Exam C5-Deltoid C6- Wrist Extension C7-Wrist flexion
Blocker
Beggar
Kisser
Grabber
Spock
Motor Exam
C5-Deltoid
Elbow Flexion
C6- Wrist Extension
C7-Wrist flexion
Elbow Extension
Finger Extension
C8- Finger flexors
T1-Hand intrinsics
C5-Deltoid, biceps
C6- Biceps, wrist ext
C7-elbow ext, wrist flex, finger ext
C8- finger flexors
T1-hand intrinsics

12. Exam- Sensory C5-anterior brachium C6- thumb C7- middle finger
Lateral arm
C7- middle finger
Posterior arm
C8-ulnar side hand
T1-inner brachium
Axilla

13. Deep Tendon Reflexes
C5: Biceps
C6: Brachioradialis
C7: Triceps

14. Post-Inf neck/shoulder C5 C4-5 Lat. neck and shoulder Ant. Arm C6 C5-6
Nerve
Root
Disc
Level
Pain/Sensory Loss
Weak-ness
DTR’s decr
C1,2
O-C2
Occiput C3
C2-3
Post-Sup neck
Ears and mastoid   C4
C3-4
Post-Inf neck/shoulder   C5
C4-5
Lat. neck and shoulder
Ant. Arm
Deltoid C6
C5-6
Post-Lat arm to
Thumb, +/- index finger
Biceps
& Br-rad C7
C6-7
Post-Mid arm to mid fngr
Triceps C8
C7-8
Post arm to ring/small fingr
Grip T1
T1-2
Proximal inner arm/axilla
Intrinsics

15. Special Tests
Spurling Test
Lhermitte’s Sign
Hoffman’s Sign

16. Spurling Test Cervical etiology Head is extended and rotated
pinched nerve rt.
Head is extended and rotated
Slight axial load
Practical Tip: Extend the pts head and then
tell them to ”look in their back pocket.”
If no symptoms then apply axial load.

17. Spurling Test Also known as foraminal compression test
neck compression test
quadrant test

18. Spurling Test World War II Walter Reed General Hospital
Roy Greenwood Spurling
Hospital's first Chief of Neurosurgery
Organizer of neurosurgery for the entire Army
First noted this finding in patients of ruptured cervical discs.
Spurling and Scoville
Demonstrated a positive test on 12 patients with presumed ruptured cervical discs
confirmed surgically in 1943 and reported their findings in 1944
The original description of the test
Head and neck will be tilted toward the painful side to reproduce the patient’s typical radicular symptoms
Pressure will then be placed on the top of the head to further intensify the symptoms
Whereas tilted the head away from the painful side will alleviate the symptoms

19. Spurling Test Validity and Reliability
Shah and Rajshekhar in 2004
50 surgical patients with findings on MRI
Sensitivity 92%
Specificity 95%
Positive predictive value 96.4%
Negative predictive value 90.9%
Concluding that the Spurling’s test is the gold standard for evaluating cervical radiculopathy

20. Lhermitte’s Sign Also known as 1920 Previously described 1917 1918
Barber Shop Phenomenon
1920
Jean Jacque Lhermitte
patients with spinal cord concussion and later in other neurologic diagnoses
Previously described
1917
Marie and Chatelin
Transient pins and needles sensations into the limbs on flexion of the neck
1918
Babinski and Dubois
Electric discharges into the limbs with head flexion, sneezing, or coughing in a patient with Brown-Sequard syndrome

21. Lhermitte’s sign Passive or Active Neck Flexion
Pain/Electric sensation shooting down back or into legs
Myelopathy
Multiple Sclerosis

22. Lhermitte’s Sign Validity and Reliability Malanga Sandmark and Nissell
Review
Insufficient evidence of the inter-rater reliability, sensitivity, and specificity
Sandmark and Nissell
Active flexion and extension test
resembles the Lhermitte’s sign and was found to
Specificity (90%)
Sensitivity (27%)
Negative predictive value of 75%
Positive predictive value of 55%.

23. Hoffman’s sign “Babinski of the Upper Extremity”
Test for UMN lesion
Flick middle finger
Watch for reflexive flexion/adduction of thumb

24. Cervical Pathologies Cervical Strain/spasm Cervical Sprain
Cervical Instability
Stingers
Spondylosis
Stenosis
HNP
Cervical Cord Neuropraxia
Fractures/subluxation

25. Cervical Strain & Spasm
Usually minor trauma (or none)
“Slept Wrong”
Overuse/Posture
Sudden movement
Minor muscle fiber tears, secondary spasm

26. Myofascial Pain Travell & Simon “Trigger Points”
Discrete hyperirritable spots located within taut muscle band
Often with chronic MSK disorder
Hypersensitive area or firmer than normal tissue, usually quarter-size area
Can result in decreased ROM in the affected muscles

27. Trigger Points Treatments Spray and stretch Ultrasound Massage
Manipulation
Trigger point injection
Injection material
3cc lidocaine
+/- Corticosteroid
Dry needle (more post injection soreness)
Disrupts the pain cycle
Stops hyper-responsive signals

28. Myofascial Pain Muscle Relaxants Cyclobenzaprine Tizanidine
Relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions.
2RCTs
Both found no significant differences between the treatment groups.
Another RCT evaluated the effect of cyclobenzaprine12 in patients with jaw paiin
No evidence favoring cyclobenzaprine over clonazepam or placebo.
Cochrane review
nsufficient evidence to support its use due to a lack of high quality RCTs.9
Tizanidine
Alpha2 adrenergic agonist
Two prospective trials (not RCT) evaluated tizanidine for MPS14, 15.
Manfredini et al., in 2004
78 patients with MPS, and noted only a slight improvement in pain.
Malanga et al., in 2002
29 patients who were titrated on tizanidine for 3 weeks.
Significant decrease in VAS, disability and sleep improvement were noted
Two RCTs
patients with acute low back pain showed a significant difference in pain reduction favoring tizanidine to placebo.
Review article
Insufficient literature to support the use of tizanidine

29. Myofascial Pain Sedatives/Hypnotics Clonazepam Alprazolam and Diazepam
Benzodiazepinederivative with anticonvulsant, muscle relaxant, and anxiolytic properties.
Two RCTs19, 20 evaluated the efficacy of clonazepam for MPS treatment
Found it to be effective
However, caution was advised due to side effects such as depression and liver function
Review article
Better than placebo for MPS pain relief.
Analysis of the above literature
Strongly supports the use of clonazepam, a traditional agent, in the treatment of MPS.
Alprazolam and Diazepam
Potent benzodiazepines.
alprazolam or diazepam in combination with ibuprofen is better than placebo.
RCT
significant reduction of pain in both the diazepam and the diazepam with ibuprofen groups.

30. Myofascial Pain Anti-Depressants Amitriptyline and Nortriptyline
TCA traditionally studied in the treatment of a wide variety of painful conditions including MPS
Nortriptyline
Second generation TCA with less incidence of side effects compared to amitriptyline.
Two RCTs
Bendsten and Jensen
Significant reduction in pain and myofascial tenderness.
Plesh et al
Effective for myofascial pain

31. Myofascial Pain Topical Agents Topical Lidocaine Patch
Case report in 2002
did not demonstrate significant evidence for pain reduction
Open labeled non randomized trial
Showed some relief of pain and improvement in quality of life in 27 patients
RCT
topical lidocaine patch demonstrated a significant reduction of pain episodes, intensity of pain at rest and with activity, improvement of mood and quality of life as compared to a placebo patch.
Topical Methyl Salicylate and Menthol Patches
Methyl Salicylate
Rubefacient in deep heating liniments For myalgias and muscle spasms
Menthol
Organic compound with local anesthetic and counterirritant qualities
weak kappa opioid receptor agonist.
A single RCT
demonstrated a significant global satisfaction and reduction of pain at rest and with movement compared to placebo
Topical Diclofenac Patch and Solution
single RCT
significant difference in pain, range of motion and disability scores compared to placebo
Lone RCT studying topical diclofenac solution
no significant differences between the groups.
Topical Thiocolchicoside Ointment
Muscle relaxant with anti-inflammatory and analgesic effects
Competitive GABA-A receptor antagonist and also inhibits glycine receptors
Single blind, RCT
Significant improvement in pain and range of motion in all treatment groups.

32. Whiplash

33. Cervical Sprain Usually higher-energy trauma (MVA)
Often d/t rapid or excessive ROM in one or more planes
Ligamentous injury usually coupled with muscle strain/spasm
Non-radicular neck/shoulder pain
worsened by neck motion
Careful exam to r/o nerve injury
Consider X-rays to r/o fracture & instability

34. Imaging No imaging required if patient meets all of the following…
No midline tenderness
No focal neuro sx
Normal LOC
No drugs/meds
No distracting injuries

35. Cervical Spine Trauma Imaging
AP view
Lateral view (must include entire C7)
Odontoid view
IF NORMAL, consider FLEX/EXT VIEWS

36. Flexion & Extension Views

37. Cervical Sprain w/ Instability
Can present subacutely
Persistent pain after appropriate time to recover
Flex/Ex view criteria:
>3.5 mm AP displacement
>11 deg angulation
IMMOBILIZE & REFER ASAP

38. Cervical Sprain w/o Instability
Treatment:
Analgesics, +/- muscle relaxer
+/- Hard/Soft collar
Relative rest; encourage resumption of ADL soon
Early referral to PT
ROM emphasized (decrease risk disability)
Modalities

39. Strain/Spasm Treatment
NSAID/Tylenol
Muscle relaxer?
Trigger point injections?
Soft collar (rarely)
Relative rest & active stretching
Usually improvement starts after 3-4 days
If recurrent refer to PT

40. Cervical Spondylosis Degeneration of discs and facets joints
Space narrowing
Osteophytes
Sclerosis

41. Cervical spondylosis s/sx
Paramedian neck tenderness
Reduced ROM
GRADED
Mild: HA’s, neck pain (limited to disc, facet jt)
Moderate: radicular sxs (foramen)
Severe: myelopathy (canal)
gait, balance, bladder sx’s
May predispose to spinal cord or nerve root injury depending on the amount of stenosis or degeneration

42. Cervical Stenosis Narrowing of the AP diameter of the cervical canal
Developmental
Acquired: secondary to degenerative dz, HNP, etc.
MRI for diagnosis
EMG can reveal nerve damage

43. Tx of spondylosis/stenosis
Analgesics +/- muscle relaxer
Soft collar prn
Relative rest from offending activity
Physical Therapy if persistent
Cervical Epidural if refractory
Surgical indications:
Myelopathy
Radicular sxs not responding to tx
Get MRI, talk to surgeon

44. Herniated Nucleus Pulposus (HNP)
Acute Radiculopathy
Rupture of nucleus pulposus through tear in the annulus fibrosus
Chronic Radiculopathy
Gradual Onset d/t
disc degeneration, thinning, bulge, and
osteophytes

45. HNP Neck pain with radiation into the shoulder/arm
Burning pain or weakness
Sensory changes in a specific nerve root
Motor if C5-T1 involvement
Spurling’s maneuver reproduces symptoms
Improved with distraction maneuvers
No upper motor neuron deficits
Neg Hoffman, Babinski
No rigidity, gait dysfx, hyper-reflexia

46. HNP Treatment Conservative therapy: 40-80% respond by 6-12wk
Rest, NSAID, ROM ex’s, neck collar, cervical pillow
Consider oral steroids if severe radicular sx’s
Physical therapy if poor response 1-2 wks
Traction, TENS
Consider referral for invasive tx if:
Patient is ready
Progressive neurological symptoms
sxs persist despite tx
MRI, EMG/NCV

47. Epidural Steroid Injections
Epidural steroid injections (ESI) commonly used intervention to treat radicular pain
In the cervical and thoracic spine, this pain is most commonly caused by herniated disc and/or foraminal stenosis
Mechanism of pain generation: mechanical compression and chemical inflammation
Corticosteroids thought to reduce chemical inflammation and pain

48. Introduction - ESI
2 methods for delivering medication to the epidural space in the cervical and thoracic spine:
Interlaminar epidural steroid injection (ILESI)
Transforaminal epidural steroid injection (TFESI)

49. Cervical TFESI – ISIS Guidelines
Pre-injection procedures
IV access
VS Monitoring: BP,HR,pulse-ox
Patient Positioning: supine, oblique, lateral decubitus position
Sterile Prep: antibacterial solution, sterile draping

50. Cervical TFESI – ISIS Guidelines
Target Identification
Oblique View
Identify target foramen
Rotate C-arm to open foramen
Consider magnification

51. Cervical TFESI – ISIS Guidelines
Within foramen:
Posterior Wall
Anterior surface of SAP

52. Cervical TFESI – ISIS Guidelines
Puncture Point
Skin directly over target
Mark with sterile marker or small wheel of local anesthetic
+/- Local anesthetic (shallow)
Needle Insertion
25-guage needle (2.5 inch, SB)
Needle tip should lie directly over anterior part of SAP, not foramen (or can be over posterior foramen if checking A/P early and often)
Ideally, advance needle down the beam - “hubogram”
Once SAP is reached, adjust needle to pass into foramen
Subsequent insertion should not be more than a few mm in depth, and should never stray into anterior aspect of foramen

53. Cervical TFESI – ISIS Guidelines
Needle Insertion – AP view: target is sagittal midline of articular pillar

54. Cervical TFESI – ISIS Guidelines
Contrast injection:
Under real-time fluoro, inject non-ionic contrast
Contrast should disperse in intervertebral foramen, outlining spinal nerve and DRG

55. Big Red and his little friends
SAP
DRG

56. Epidural Veins
DISC
SPACE
DRG
SAP
cord

57. What to watch out for DRG/Spinal Nerve Vascular flow:
Arterial
Vertebral artery – rapid upward flow
Radicular artery – narrow vessel with transverse flow medially toward cord
ISIS recommends procedure aborted in this case
Venous (radicular and epidural veins): slow clearance of contrast – can reposition needle
Subarachnoid flow
Rapid dilution of contrast
Can be from medial position, or lateral dilatation of dural root sleeve in foramen
Procedure should be aborted

58. Use Digital Subtraction Angiography in Cervical and Thoracic Spine

59. Digital Subtraction Angiography – Same patient

60. Cervical TFESI – ISIS Guidelines
Medication Injection: once injection of contrast has identified acceptable needle position in 2 views, therapeutic solutions can be delivered
Corticosteroid:
Dexamethasone (7.5-15mg)
Betamethasone (3mg – 12mg)
Short-acting local anesthetic
1% Lidocaine ( ml)
0.5% Lidocaine ( ml)
Normal Saline

61. Cervical Interlaminar ESI (ILESI)
Cervical epidural space much more narrow (1.5-2mm at C7 to less than 1mm at higher levels) compared to lumbar spine
If less than 1 mm on MRI, avoid interlaminar
Interlaminar approach: usually 2 cc celestone/dexamethasone, 2-3 cc of 1-1.5% lidocaine and 0-2 cc of saline for 4-7 cc total; usually at C6-7-T1

62. C5-6

63. C7-T1

64. Cervical ILESI Position patient prone with pillow under chest
Sterile prep with betadine and drape
Identify target interlaminar space (C6-7,7-1)

65. Cervical ILESI Target: superior border of inferior lamina at midline
Mark and anesthetize (1% lidocaine)
18- or 20- gauge Touhy needle advanced using:
Frequent lateral imaging
Loss of resistance technique with normal saline

66. Cervical ILESI
Once epidural space entered (based on LOR), inject non-ionic contrast (1cc) under live fluoro.
Should see even spread of contrast, and lateral imaging should show posterior flow.
If no vascular flow, no subarachnoid flow…inject medication (1-2 cc celestone / dexamethasone, 2-3 cc of 1-1.5% lidocaine and 0-2 cc of saline for a total of 4-7cc)

67. Cervical ESI - Complications
Botwin 5/2003: 157 patients receiving a total of 345 cervical ILESI for cervical radicular pain caused by cervical spondylosis or HNP
All complications: 16.8%. All resolved without morbidity, and no patient required hospitalization: Transient increased neck pain (6.7%), transient headaches (4.6%), insomnia the night of injection (1.7%), Vasovagal reaction (1.7%), facial flushing (1.5%), Transient Fever 1(0.3%), Dural puncture: 1 (0.3%)
Ma 8/2005: 844 patients, 1036 Extraforaminal Nerve Root Blocks (TFESI):
All complications: 1.66%. No death, paralysis, stroke, vertebral artery injury or infection recorded: Transient neuro deficit (pain or weakness): 6 pts, HA/Dizziness: 5 patients, Hypersensitivity rxn: 1 pt, Vasovagal rxn: 1 pt, Transient global amnesia, dizziness, nausea:1 pt (admitted to hospital overnight, neuro w/u negative, resolution of dizziness by 2 weeks), Injection at incorrect level: 2 pts, Inadvertent facet injection: 1 pt
Case reports – cervical TFESI (Scanlon 2007): death, vertebrobasilar infarcts/TIA/RIND, cervical spinal cord infarcts, combined brain and SCI infarcts, high spinal anesthesia, Seizures, severe HA, brainstem edema with herniation, cortical blindness from air embolus, cervical epidural hematoma, paraspinal hematoma
Mechanism unclear, but thought to be related to particulate steroid causing vascular embolism – SCI, stroke, death
Safety measures: Small/no particulate steroid (dexamethasone) and DSA

68. Cervical ESI - Evidence
Transforaminal ESI: No RCT’s, just descriptive studies, generally with positive short-term (<6 weeks) and long-term (>6 weeks) results for radiculopathy. Limited evidence for axial neck pain.
Morvan 1988: 51 pts with radicular pain - 14% obtained complete and long lasting relief, 86% derived incomplete relief, transitory relief, or no relief
Bush 1996: 68 pts with radicular pain- Transforaminal +/- Interlaminar – 76% complete relief of arm pain (7 mos)
Slipman 2000: 20 pts with radicular pain – 60% success (pain reduction, return to FT work, decreased meds, patient satisfaction) at avg. 22 mos f/u
Vallee 2001: 32 pts with radicular pain - at 6 mos – 53% of patients had >75% pain relief
Cyteval 2004: CT guided TFESI – 30 pts with radicular pain – good pain relief in 60% of patients at 2 wks and 6 mos
Kolstad 2005: 21 surgical candidates (discectomy): significant decrease in radicular pain at 6 wks and 4 mos, 5 patients avoided surgery
Lin 2006: 70 surgical candidates (HNP): 63% had significant relief of symptoms and decided against surgery

69. Cervical ESI - Evidence
Interlaminar ESI
2 RCT for radiculopathy
Castagnera 1994: Group 1 (14 pts: LA + Steroid) vs.. Group 2 (10 pts: LA + Steroid + Morphine) – no diff between groups, but good overall pain relief (>50mm decrease on VAS):
Initial: 96%
1 Month: 75%
3, 6 and 12 mos: 79%
Stav 1993: Group 1 (25 pts: ESI) vs. Group 2 ( 17 pts: intramuscular LA + steroid). Significant outcomes (good-very good pain reduction, return to FT work, decreased meds, change in ROM)
1 week: 76% group 1, 36% group 2
1 year: 68% group 1, 12% group 2
Axial neck pain: limited evidence

70. Patient Selection for Cervical ESI
Indications:
Cervical radicular pain +/- radiculopathy
Hx, PE and imaging c/w nerve root impingment/irritation
Failed conservative treatment (PT, meds, activity modification) >6weeks
Contraindications (ABCDEFGHIJK)
Absolute: Relative:
Coagulopathy (Bleeding) -Allergy
Local Infection (Fever) -Hx steroid psychosis (Krazy)
Spinal Malignancy (CA) -CHF (decreased EF)
Uncontrolled DM -Pregnancy (Gravid)
Pt. unable to lie still Systemic infection (Fever)
(“Jimmy legs”) -Heart/Respiratory issues
-Immunosupression

71. Stingers (Burners) Transient UE neuropraxia of root or brachial plexus
Tractionplexus
Compressionroot
Burning in arm
Weakness in C5 and C6 distribution
Deltoid, biceps, RC, wrist extensors, pronator teres
+/- Positive Spurling’s

72. Stingers Treatment May Return to Play when: Protection Rest until
asymptomatic
May Return to Play when:
Full cervical ROM w/o pain
Normal sensory, motor exam
Negative Spurling

73. Cervical Cord Neurapraxia
Sxs or neuro findings in ≥2 limbs
Axial load with hyperextension or flexion
Cervical cord “pinch”
Sx last 10 min-48 hrs
Burning Hands Syndrome
Transient Quadraparesis

74. C-spine Injury On-Field Management
Assess LOC and simple neuro exam by question without moving athlete
Stabilize C-spine and log-roll if necessary to move athlete to back
“Leave helmet on”
Helmet & shoulder pads
Manage airway by removing face mask

75. Immediate Transport for…
Unconscious athlete
Neuro symptoms in ≥2 limbs
Spinous process tenderness with concerning MOI
Any distracting injuries

76. References
Abdi S, et al. Epidural Steroids in the Management of Chronic Spinal Pain: A systematic review. Pain Physician 2007; 10:
International Spine Intervention Society: Practice Guidelines – Spinal Diagnostic and Treatment Procedures ISIS
Manchikanti, et al. Evidence-Based Practice Guidelines for Interventional Techniques in the Management fo Chronic Spinal Pain. Pain Physician 2003;6:3-81
Rathmal JP, et al. Cervical Transforaminal Injections of Steroids. Anesthesiology 2004; 100:
Fenton, DS and Czervionke LF: Image-Guided Spine Intervention. Saunders 2003
Botwin KP, et al. Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections. AJPMR 1/06

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