1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical and Thoracic Spinal Conditions Chapter 11

2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Spinal column –Vertebrae Cervical (7) convex anteriorly Thoracic (12) concave anteriorly Lumbar (5) convex anteriorly Sacral (5 fused) concave anteriorly Coccyx (4 fused)

3. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) –Structure Rigid enough to support body and protect spinal cord Flexible enough to produce a variety of movements

4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

5. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

6. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Cervical –7 vertebrae form curve – convex anteriorly –Atlas 1st vertebra No body – filled with odontoid process Function: support the head

7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) –Axis 2nd vertebra Odontoid process – tooth-like Allows head to rotate Thoracic –12 vertebrae form curve – concave anteriorly –Extra facets for articulation with ribs

8. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

9. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Vertebral structure –Body –Vertebral arch –Superior and inferior articular processes Facet joints –Spinous process –Transverse processes Progressive increase in vertebral size Change in angulation

10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.)

11. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Motion segment –Functional unit –Any 2 adjacent vertebrae and soft tissues between them

12. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Intervertebral discs –Components Annulus fibrosus  Thick fibrous ring Nucleus pulposus  Gelatinous interior –Function Shock absorption Allow spine to bend

13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Ligaments –Anterior longitudinal –Posterior longitudinal –Ligamentum flavum –Interspinous –Supraspinous

14. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles of the neck: lateral view

15. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Muscles of the neck: posterior view

16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Nerve plexus –Cervical (C1–C4) –Brachial (C5–T1)

17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) Blood supply –Common carotid –Vertebral

18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics Movements involve a number of motion segments –Flexion/extension/ hyperextension –Lateral flexion –Lateral rotation

19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics Effects of loading –Primary load Cervical spine: weight of head Thoracic: weight of body above and any load in hands Effects of impact forces –High speed and collision →  risk –Cervical flexion (large bending moment) + axial compression load = danger

20. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics (cont.)

21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinetics (cont.) Cervical spine compression deformation –Angular deformation and buckling occurs as load continues and maximum compression deformation is reached –Continued force results in an anterior compression fracture, subluxation, or dislocation

22. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomic Variations: Injury Potential Kyphosis –Excessive curve of thoracic spine –Congenital – deficits in vertebral bodies –Idiopathic Scheuermann’s disease –Secondary to osteoporosis

23. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomic Variations: Injury Potential (cont.) Scoliosis –Lateral curvature of spine; “C” or “S” curve –Structural Inflexible curve, persists with lateral bending –Nonstructural Flexible, corrected with lateral bending –Commonly idiopathic –Symptoms vary with severity Mild 20 and moderate = 20–45  Treated with exercise Severe

24. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomic Variations: Injury Potential (cont.)

25. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Spinal Injuries Protective equipment –Neck roll –Rib protectors Physical conditioning –Strength and flexibility Proper technique –Spearing –Proper lifting –Posture

26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions Cervical sprain –Extreme motions or violent mechanism –S&S Pain, stiffness, restricted ROM Pain can persist for several days –Management: standard acute; cervical collar; consult physician –No return to competition until pain free and ROM is normal

27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Cervical strain –Usually, sternocleidomastoid or upper trapezius –Same mechanism as sprain; injuries often simultaneous –S&S Pain, stiffness, spasm, restricted ROM  pain with active contraction or passive stretch of involved muscle –Management: standard acute; cervical collar; consult physician –No return to competition until pain free and ROM is normal

28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Cervical spinal stenosis –Structural Torg ratio –Functional Loss of CSF around the cord →  cord’s ability to decompress –Asymptomatic until external force to head

29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) –S&S On impact, may develop immediate quadriplegia with sensory changes or motor deficits in both arms, both legs, or all 4 extremities Transient with full recovery in 10 – 15 minutes (or 36 – 48 hrs) –Management: activate EMS –Continued participation

30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Spear tackler’s spine –Mechanism: cervical flexion + axial loading –S&S Immediate pain with sensory changes and motor deficits distal to injury site –Management: activate EMS –Criteria to return to play—controversial

31. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Cervical disc injuries –Soft disc herniation Nucleus pulposus herniates through posterior annulus Acute mechanism: uncontrolled lateral bending of neck –Hard disc disease Chronic, degenerative Diminished disc height and formation of marginal osteophytes

32. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) –S&S Varying degrees of neck or arm pain, may radiate Pain exacerbated by Valsalva maneuvers and neck movement + Spurling’s maneuver + Babinski’s sign Severe cases—potential loss of motor function below injury level –Management: rest, activity modification, NSAIDs

33. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Cervical fracture/dislocation fracture –MOI—axial loading with violent flexion of neck –Dislocation: add rotation –S&S Pain over spinous process with or without deformity Constant neck pain Muscle spasm

34. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) Signs of neural damage  Muscle weakness in extremities; inability to move  Abnormal sensations in extremities  Absent or weak reflexes  Loss of bladder or bowel control Suspect injury with violent mechanism –Management: activate EMS

35. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Conditions (cont.) “Red flags” indicating a possible cervical spine injury: refer to Box 11.1

36. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries Mechanism –Tension (stretching) Violent lateral movement of head and neck Arm forced into excessive external rotation, abduction, and extension –Compression Location where plexus is most superficial (Erb’s point) Forced lateral flexion, causing increased pressure between shoulder pad and superior medial scapula

37. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries (cont.)

38. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries (cont.) GradeInjurySignsPrognosis INeurapraxia injury Temporary loss of sensation or loss of motor function Recovery within days to a few weeks IIAxonotmesis injury Significant motor and mild sensory deficits Deficits last at least 2 weeks Regrowth is slow, but full or normal function is usually restored IIINeurotmesis injury Motor and sensory deficits persist for up to 1 year Poor prognosis Surgical intervention is often necessary Classification of Burners

39. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries (cont.) Acute burners –S&S Immediate, severe, burning pain and prickly paresthesia radiates into hand Pain transient; subsides in 5–10 minutes Weakness in abduction and external rotation –Management: return to play—full strength, ROM, & sensation; cryotherapy

40. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries (cont.) Chronic burner syndrome –S&S Frequent acute episodes that may not produce areas of numbness Muscle weakness may develop hours or days after initial injury; dropped shoulder or visible atrophy in shoulder muscles –Management: same parameters as acute; frequent re-examination

41. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Brachial Plexus Injuries (cont.) Suprascapular nerve injury –Innervates the supraspinatus, infraspinatus, and glenohumeral joint capsule –Same mechanism –S&S Muscles weak and atrophied Improper functioning of muscles → other problems (e.g., rotator cuff tendinitis, impingement syndrome, bicipital tenosynovitis, or bursitis) –Management: standard treatment; refer to physician

42. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoracic Spine Conditions Sprains/strains –MOI: overload; overstretch –S&S Painful spasms of back muscles  May develop as a sympathetic response to sprains  Presence of spasms makes it difficult to determine sprain or strain Sprain—dramatic improvement in 24–48 hours; severe strains—3–4 weeks to heal –Management: standard acute care

43. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoracic Spine Conditions (cont.) Thoracic spinal fractures and apophysitis –Wedge fracture Fracture of vertebral end plates

44. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoracic Spine Conditions (cont’d) Mechanism  Large compressive loads or landing on the buttock area  Compressive stress during small, repetitive loads S&S: standard fracture; pain and muscle guarding Management: physician referral

45. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoracic Spine Conditions (cont.) –Scheuermann’s disease Leading cause of fractures among adolescents Osteochondrosis of the spine Abnormal epiphyseal plate behavior allows herniation of disc into vertebral body After physician referral, treatment: activity modification, stretching (shoulder, neck, and back muscles), and strengthening (abdominal and spinal extensor muscles)

46. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Thoracic Spine Conditions (cont.) –Apophysitis Repeated flexion–extension of thoracic spine Progressive condition characterized by local pain and tenderness After physician referral, treatment: eliminate flexion–extension stress; strengthening of abdominal and other trunk muscles

47. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Spinal Conditions Traumatic episode –When in doubt, always assume a severe spinal injury and activate emergency care plan –Do not move head, neck, or spine (or helmet)

48. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment of Spinal Conditions (cont.) “Red flags”—warrant immobilization and immediate referral –Severe pain, point tenderness, or deformity along vertebral column –Loss or change in sensation anywhere in the body –Paralysis or inability to move a body part –Diminished or absent reflexes –Muscle weakness in a myotome –Pain radiating into the extremities –Trunk or abdominal pain referred from visceral organs –Any injury involving uncertainty about severity or nature

49. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Assessment—Conscious Individual History –Important to ask questions about: Pain  Location (i.e., localized or radiating)  Type (i.e., dull, aching, sharp, burning) Sensory changes (i.e., numbness, tingling, or absence of sensation) Muscle weakness or paralysis –Neck injury –Determine both long- and short-term memory loss that may indicate an associated brain injury

50. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Assessment—Conscious Individual (cont.) Observation/inspection –Postural assessment –Scan exam –Gait analysis –Inspection of injury site –Gross neuromuscular assessment

51. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Assessment—Conscious Individual (cont.) Palpation –Seated, standing, supine, or prone position –Relax the neck and spinal muscles—lying position –Posterior neck structures Patient supine –Thoracic region Patient prone Pillow under the hip region to tilt the pelvis back and relax the lumbar curvature

52. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Assessment—Conscious Individual (cont.) Physical examination testing –If, at anytime, movement leads to increased acute pain or change in sensation or the individual resists moving the spine, a significant injury should be assumed and EMS activated

53. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Range of Motion (ROM) Active range of motion (AROM) –Cervical flexion –Cervical extension –Lateral cervical flexion (left and right) –Cervical rotation (left and right) –Forward trunk flexion –Trunk extension –Lateral trunk flexion (left and right) –Trunk rotation

54. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AROM – Cervical Spine

55. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins AROM – Thoracic Spine

56. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Normal ranges –Cervical flexion—80–90° –Cervical extension—70° –Lateral cervical flexion (left and right)—20–45° –Cervical rotation (left and right)—70–90° –Forward trunk flexion—40–60° –Trunk extension—20–35° –Lateral trunk flexion (left and right)—15–20° –Trunk rotation—35–50°

57. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Passive ROM –Cervical spine Do not perform if motor and sensory deficits are present Normal end feel—tissue stretch –Thoracic is seldom performed

58. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ROM (cont.) Resisted ROM –Cervical spine Stabilize the hip and trunk to avoid muscle substitution Patient seated; one hand stabilizes the shoulder or thorax while other hand applies manual overpressure –Thoracic region Weight of the trunk will stabilize the hips

59. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress and Functional Tests Brachial plexus traction Cervical Spine Tests

60. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Tests (cont.) Brachial plexus tension test

61. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Tests (cont.) Cervical compression Spurling’s test

62. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Cervical Spine Tests (cont.) Cervical distraction Shoulder abduction

63. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Facet Joint Mobility Spring Test

64. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Nerve Root Impingement Valsalva Test First thoracic nerve root stretch

65. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests Oppenheim Babinski Hoffman

66. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) –Myotomes Nerve Root SegmentAction Tested C1–C2neck flexion* C3lateral neck flexion* C4shoulder elevation C5shoulder abduction C6elbow flexion and wrist extension C7elbow extension and wrist flexion C8thumb extension and ulnar deviation T1intrinsic muscles of the hand (finger & adduction) *These myotomes should not be performed in an individual with a suspected cervical fracture or dislocation, as they may cause serious damage or death.

67. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) –Reflexes ReflexSegmental Levels BicepsC5, C6 BrachioradialisC5, C6 TricepsC7, C8

68. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Cutaneous patterns

69. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Neurologic Tests (cont.) Referred pain

70. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Activity-Specific Functional Testing Normal parameters Pain free and unlimited movement

71. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Rehabilitation Relief of Pain and Muscle Tension Restoration of motion Restoration of Proprioception and Balance Muscular strength and endurance Cardiovascular fitness