Chapters Transcript Cervical Spine Exam Course: 11th Annual NYU Concussion Conference: From Foundational Elements to Advanced Practice Thank you so much for that wonderful introduction. It's an honor and a pleasure to be presenting here today at today's conference. As a physiatrist, the cervical spine is uh near and dear to my heart and something that I do almost on a daily basis. Uh, so I have no financial relationships to disclose. Next slide please. Thank you. So, uh, in terms of intro introduction, why is the cervical spine important? Um, why exactly do we care about the cervical spine? Um, so we know if you could uh just advance one more please. That the cervical spine is very important in terms of concussions. We know that the literature has showed that 25 to 60% of patients who have a concussion can also have cervical pain. And that it's incredibly prevalent outside of concussions. So up to 70% of individuals experience neck pain in their life. And I often joke with patients that phones and computers give me job security, and I think that this slide or that picture on the right really emphasizes that. Um, unfortunately, when I walk into a room, especially with younger patients, they're often presenting as the uh right two pictures there, so with prolonged cervical flexion. And that cervical flexion, you can see that with 45 degrees of cervical flexion, that's almost 49 pounds of force through the cervical spine. So it's almost as if you're carrying a 50 pound child or a 50 pound backpack across your shoulders all day. So I think that's really important to identify and educate patients cause we know that head flex posture can lead to decreased cervical rotation, and in addition, can lead to increased work requirements of the muscles. Um, and this is now commonly being referred to as Texnec. Uh, can you advance just one more? So what I try to do is educate patients, so make them look less like the left and more like the right picture, um, and if you advance one more. And this graphic just really shows the muscle imbalances in play with that prolonged cervical um flexion. And we know that with this posture, which has been called multiple different things here, it's labeled as upper cross syndrome, that it could lead to cervical imbalance and dysfunction, specifically at the upper cervical levels. Uh, next slide please. So, in terms of the role of in terms of the studies that we've had with this, uh, this great study from Doctor Cheever from 2021 showed that cervicogenic symptoms, they're prevalent in both acute and chronic stages of concussion, and they can delay recovery and can increase chances of post-concussive syndrome. Next slide please. And Doctor Schneider, who presented earlier today and gave a fantastic talk, this was her study from 20 2014, if you could advance please. And what they did was they looked at sports related concussions, ages 12 to 30, and they looked at patients who have persistent post-concussive symptoms, and they divided these patients into two groups, and the group that received a dedicated cervical spine, and vestibular treatment actually recovered significantly faster, 73% at 8 weeks versus 7% in the control group. Uh, if you could advance the next to the next points, please, uh, 4 more times. Thank you. Um, so what this basically showed was that, um, if you have children and young adults with persistent post-concussive syndromes, if you focus on the cervical spine in treatment, it helps improve recovery. And this really laid the groundwork for the next study, if you could advance the slide. Which actually was just published last month, and I had the pleasure of listening to last year. This study was presented by both Doctor Ledy and Doctor McPherson, um, if you could advance. And this was a prospective cohort study done at the University of Buffalo, and they compared 134 children who had concussion with cervical impairment to 130 children who did not. And what they did is they identified these children early and got them into a management program. And what they showed is that while children who have cervical. Impairment reported high and symptom burden. They had no differences in recovery time. So, what that leads to is that early identification and management of cervical injuries concomitantly with a concussion may reduce the risk of delayed recovery. So it really reinforces the importance of finding um cervical symptoms and treating appropriately. Next slide, please. And this is why, you know, we have both the SAT 6 for on field and the SCOT 6 for in-office examination, and the next exam is part of those evaluations for both of these, um, for both of these criteria. And I think it's important, as we mentioned, to identify and treat appropriately. And early as that it can influence recovery time. And if you have the benefit of having a high school collegiate or club sport athlete that an athletic trainer is present, working in the cer cervical spine early can help with symptoms and recovery. Next slide, please. So, in terms of anatomy, you could advance one more. And one more. Thank you. Um, I won't, I know we are all well aware of the cervical anatomy. Um, I won't spend too much time on this, but the cervical spine is the most mobile part of the vertebral column, and it's usually at the expense of stability. We know we have 7 cervical vertebral bodies, and that the sagittal balance of that cervical spine is usually 15 to 20 degrees. The most common finding I see on a cervical X-ray is actually loss of that cervicalordosis, which is likely due to posture spasm or abnormal kinetics. Now, we really divide the cervical spine into an upper and a lower segment. If you could advance one more. Thank you. So for the upper segment, that's a very important segment for us to be aware, because that's where a lot of cervicogenic headaches and upper cervical dysfunction comes from. So we have the C1, which is the atlas, which has no vertebral body, but gets its stability from multiple ligaments, and at that. Atlanto-occipital junction or the AO junction, where most of the neck flexion, 50% of neck flexion and extension occur. At that next junction, the atlantoaxial junction, that's where a lot of rotation occur. And these two joints provide a lot of mechanical strength and they help stabilize the head, and they allow for complex movements of the cervical spine. So again, these are two main differentials when we're looking at cervicogenic headaches, because these are pain generators. Next slide, please. So We're gonna focus a little bit on the lower segment of the cervical spine, so 3 C3 C3 through 3 through 7. As we know, there's 7 vertebral bodies, but there are 8 cervical nerve roots. So in the spine, the nerve root. Comes above the cervical vertebral body. So if you see someone who has a C7 radiculopathy, Usually that's coming from a disc herniation or pathology in the C67 um area. In terms of discs, if you can advance once once more, we know that discs help provide shock absorption, and they resist axial loads. And if you can advance one more, but the structure I really want to focus on for here is the facets. So we know the facets which are also called the Z joints or the zygophyseal joints. They're a synovial joint and they have cartilage, and they have a capsule. And this helps provide rotational stability. And helps resist extension. And this is a huge source of pain because they have rich innervation for both mechano receptors and no susceptors. And cervical facet pain is one of the primary sources of pain in patients who have chronic neck pain. Up to 26 to 70% of those patients, the cervical facet has been the primary pain generator. In patients who have whiplash, that C2, C3 facet specifically causes pain in up to 50% of those patients. And that's something I'll touch base on a little bit later on. Uh, next slide, please. So I'm looking at the musculature of the of the cervical spine, he could advance, and one more. Thank you. Um, so, you know that the cervical spine musculature is usually broken down into regions. You have your suboccipital region, your paracervical region, and your midline. And the muscles of the cervical spine are really in layers, so you have a superficial, intermediate, and deep layer. The muscles I usually focus on are the trapezius, the levator, the rhohomboids. In the splenius. Now, that's important because I tend to inject those muscles if there's any sort of myofascial dysfunction or if I'm concerned, if that's a pain generator. Really, cause we know the trapezius does extension and for lateral bending or flexion, the scalings and the levator and the traps play a big role in that. Next slide, please. So in terms of evaluation, we know that a good evaluation incorporates all these elements. I will focus on the 1st 3 for the remainder of this lecture, and really the two questions are where is the pain generator? So where is the pain coming from? And secondly, is there neurological compromise that would warrant immediate imaging and further workup? Next slide. So in terms of history, mechanism mechanism of injury is extraordinarily important, especially if it was motor vehicle accident airbags where they deployed, was the car drivable? Were they wearing a seat belt, or if it's a sports related concussion, a lot of times parents or the patients will have a video of the injury that's nice to watch. You want to know, were they immobilized on scene? Were they taken to the ER? Was a CT done? Did they meet nexus criteria? Um, the other things you want to know is about the pain itself. Is it shooting down the arm, numbness, tingling, weakness, that would be concerning for a radicular symptom? Um, is it localized or radiating? Have they had neck pain in the past or surgery or any imaging? And I think that's important to know. Um, next slide. So in terms of the red flags and the yellow flags, as you are all aware, um, red flags weren't usually pretty immediate workup in imaging, but I think the yellow flags are, are very, very important to note because those yellow flags, which are the psychological risk factors, we tend to see more in our chronic concussion and our chronic cervical pain patients, and that could lead to avoidance, catastrophizing, hypervigilance, and can cause a delay in recovery. Next slide, please. So, in terms of the examination itself, we use the SCOT 6, which is the new criteria that's come out, which does a great job of outlining the cervical exam. Now, I know we have very limited time when we're clinicians evaluating for concussions. We're dealing with headache and vestibular symptoms and mood and sleep, returning to work and school. We're then talking about medications and therapy and imaging, and we're going through a whole algorithm and often. Sometimes the cervical spine can be overlooked. However, I think you can do a really quick and effective, effective cervical exam in less than 2 minutes, right? And for myself, I usually do this part of the exam right after I do the balance testing. So after they finish the balance testing, For the SCOT 6, I keep them upright and I do inspection of range of motion, and then I get them sitting and I do palpation, the neurological exam, and the special tests. Technically, a lot of the therapists and other clinicians do evaluate them prone as well, but in the for my time constraints in my clinic, I usually do everything sitting and upright. Next slide, please. So, um, if you could advance 2 more. One more. Thank you. So for the inspection, I usually have them take off a sweater, or I have them take off a jacket and get them either in a t-shirt, a tank top, or a gown, which usually takes longer than the inspection part of the exam itself. So when I'm looking at inspection, I'm looking for scars, ecchymosis. I'm looking for shoulder height difference. I'm looking to see if there's any atrophy or hypertrophy. And this patient specifically, usually a Little hypertrophies over here over our prominence of that trapezius. I usually see on the dominant side. Um, so I don't really, um, you think of that as pathological unless it's painful. Um, I look to see how head forward their posture is, right? Do they, what's the cervicalordosis look like? I usually like to see the picture on the left, but I usually see the middle picture in terms of my patients. Uh, next slide, please. So for the examination, I usually do active range of motion. I do not do passive range of motion in the clinic. I only do active with the exception of is if it's an acute concussion and it's on the field and I'm concerned about spinal instability. Obviously you're just doing palpation and then immobilizing and sending into the ER. But for an outpatient visit in the clinic, I usually do active. If you could advance. Um, thank you. So, for active range of motion, I usually have the patients do this in isolation. So I do cervical flexion, and then I do cervical extension. And what I ask is if there is pain with each maneuver. So I have them do cervical flexion, and most people, you could do it to yourself. If you tuck your chin to your chest, you should be able to get about 60 degrees, right? And I asked them if there is pain, and then I have them use one finger and show me exactly where that. Pain is. So I try to localize where that pain is. The same with cervical extension. So I try to have them look up at the ceiling. I will say out of all the range of motion I do, cervical extension tends to be the most restricted. I think just because we spend so much time looking down. So, most people, when they initially start with cervical extension, they give me about 10 degrees, maybe 15. But then I encourage them. I say, can you go a little bit more? Can you try a little harder? And they're usually able to go back for. Especially with my younger patients. With my older patients, usually, as we get older, we have degeneration of the spine, so we tend to see loss of range of motion. If there is significant restriction in cervical extension, I do not push those patients. And usually, if there's secondary signs like intrinsic hand atrophy, or if they're hyperreflexic, or when you're watching them walk, they look unstable, it's usually an indication for me to get uh further imaging. Otherwise, I have them do rotations, so I have them right ear. I have them look over their right shoulder, left ear over the left shoulder, and then I have them do side bending again asking specifically where the pain is, cause we know with extension and lateral rotation that can exacerbate the facet joints or reproduce a radiculopathy. Next slide, please. So in terms of palpation, right? Um, the main question I ask when I palpate someone is, does this reproduce your pain or is it just me pushing? Cause I want to know where the pain generators are. Because of our head flex posture, a lot of us have tight traps, a lot of us have tight muscles, but is that where the pain is coming from, right? So, when it comes to the palpation exam, as I said, I usually do this upright. prone is better to help those muscle relax and palpate the facet joints, but for time's sake, I do it upright. So, what I do is you can either use two ways of palpating. You can either find the external occipital protuberance, which is the most prominent area of the base of the skull, and then go directly posterior to that, and you should feel the C2 spinous process, or you can find the C7 spinous process, which is actually the most prominent bone on the base of the neck. So if you want to palpate on yourself. You can likely feel the C7 process, spinus process. However, sometimes it's difficult to distinguish and studies shown that it's very difficult to distinguish between C7 and T1. So the way to really bring out C7 is you have them flex while palpating, and then you have them extend. And C7 should move, and T1 is usually fixed because of the ribs. So then you could then use that anatomical landmark to then um go more approximately to be able to palpate the rest of the spinous process. After I finished that, I go 2 centimeters laterally, especially in the upper cervical spine because that's where the facets are located and I'm palpating for pain, especially. In the upper region of the spine, because cervical facet syndrome is so prominent um and so common with chronic neck pain. In the lower spine, I'm usually palpating the muscles, again, the trapezius, the levator, trying to get to those deep cervical, uh, muscles to see if it reproduces pain. Next, uh, next slide, please. In terms of the neurological exam, if you could advance, uh, one more and one more again. This is something that we do on all our patients. It's very important to do, um, as an, as an aside, I saw a patient a couple weeks ago that presented with acute right foot drop that was painless with no other signs or symptoms, and his exam, his neurological exams are hyperreflexia, clonus and fasciculations. He had a huge cervical disc herniation, um, that was causing cord compression. So he was in his early 40s, acute right foot drop that's painless, usually really you get concerned about neuromuscular dysfunction, but in for this gentleman, his neurological exam pointed more towards the cervical origin. So it's something that we should definitely do. Um, next slide. So in terms of the special tests, there are 3 special tests listed on this slide, but there's only 1 test that I really do um in my clinic every time I see a neck patient. So, the test I do is the Sperling's compression test, also known as the foraminal compression test, and this is examining for cervical radiculopathy, right? So, what you usually do is have them extend and laterally rotate as the picture is showing, and that reproduces radicular signs going to the arm. Again, I Use this with history and exam, and it reinforces if there is a radiculopathy. It's very specific, but not sensitive. In the picture, you can see that that individual is giving an axial load. Usually for my concussion patients, especially acutely, they do not like me pushing on their head. And I really do not give an axial load. I don't think it provides extra diagnostic value. Usually, this position will irritate it if it's a radiculopathy, and then the pain will improve if you get them out of that position. The next two tests, so the shoulder a deduction test, I included on here because I've, I've actually had multiple patients in my clinic who I walk into the exam room and they're, they're sitting like this. And when you talk to them, they mention that the reason they do that is because it resolves their symptoms. So when you do see it and it relieves the radicular pain or their pain, it's highly specific for a pinched nerve, usually. C5 or C6. And we know that the shoulder and the neck can commonly refer. So, and it can be difficult to distinguish is it shoulder or is it neck. But usually in that position, the shoulder is irritated and relief of pain in that position points to a cervical radicular, um, origin. Cervical distraction, this is basically gentle traction, seeing if it resolves pain. Again, I don't really do this. In my clinic, um, but I do have patients who note that when they do, they've had neck pain before and when they do traction, it helps. Usually, if I think it's uh cervical disc or radicular, I will write for gentle traction in my PT script, but this is uh uh examine you can try, um, if you're really suspicious for discogenic or radicular pain. Next slide, please. So in terms of the additional tests, I do not do these testing. I wanted to include them, because this was a great study done by Doctor Cheever from 2016. These tests are usually done by therapists, so if you get a therapy referral notes or updated notes, you might see these listed here, and these are To remove vestibular and vision influences and really isolate the cervical spine um to see if there's any cervicogenic dizziness or cervicogenic pain contributing to patients symptoms. So if you happen to see these exam maneuvers, that's what they're there for. Next slide, please. So in terms of differential diagnosis, there are multiple areas where pain can be coming from in the neck. You don't really need to worry about isolating a source, as many of these, um, as many of these symptoms are usually not symptomatic in isolation, right? So it's usually never 100% from the nerve root or 100% from the discs. Usually they're multiple sources of pain. And as you can see, there's a lot of overlap and referral patterns between these different areas. So this is a picture from Trevell showing cervical trigger points and their referral patterns. And as you can see, it would be hard pressed to say what's myofascial versus discogenic or facet driven, right? Because they do share common referral patterns, which is why sometimes I like to do injections in the muscles in the neck to take that out of the equation and see what's left. Next slide, please. So in terms of differential diagnosis, I also rate them acute versus chronic. We know that the majority of acute neck pain, especially in concussions, resolves spontaneously. By the time you see them in 2 weeks, the neck pain is gone. Most common ideology of neck pain is strains and sprains. But you can also have disc herniations, which was, which is what the bottom left hand picture is showing, and you can also have cervical radiculopathy, especially involving that C7 nerve root, which is the most common. You can also have vertebral artery injuries which usually thankfully are rare, um, and present with a certain constellation of symptoms. However, uh, if you could advance one more. Thank you. For chronic pain, specifically, when you're thinking chronic cervical pain, you think facet, facet, facet, and then you can think discogenic degeneration. Studies have consistently shown that the cervical facet is the primary source of pain in up to 26 to 70% of chronic neck pain patients and patients who have whiplash, 50% of their pain can come from that C23 joint, right? So this is something that's very important to be aware of. Next slide. Thank you, uh, advanced. And advance one more. So, in terms of cervical facet pain, I think it's very important to break it down into two sections. So when they have head pain, you're really thinking about the upper cervical spine. So the C1 to 2, C2 to 3, and C3 to 4. Facets or the discs. The facets in the discs overlap, but facets are more common. And as you can see, this was a study that had pictures drawn where their pain was and then they injected it to eliminate it. That C2 to C3 facet can extend pain over the vertex of the head to the forehead, right? So this can be. Very easily confused with migraines, or you can initially treat them like a migraine, right? The C4, C5, and lower cervical facets usually refer pain into the shoulder blade. Specifically with C5 going out into the lateral shoulder and then C6 going into the medial inferior border of the shoulder, so over the rhomboid. But really that C2, C3, facet is the main driver of pain, and you can see how it can go to the front of the head. If we can go to the next slide. In advance? So, and one more. So this is my last slide. So in terms of cervicogenic headaches versus other headache syndromes, when you're thinking of a cervicogenic headache, you're really, as I said, thinking of pathology from the upper cervical spine. So C1, C2, C3. Usually, it's unilateral. It can go to the front of the head. So and, and I thought this was a great distinguishing factor. Usually C1 or C2 pain from the atlantoaxial junction goes to the front. The upper portion of the forehead and C2 and C3 goes to the supraorbital or right above the eyebrows. Um, you can also see abnormal cervical spine exam or symptoms. We know that for facet pain, the biggest symptom that correlates with resolution of pain with diagnostic block is actually palpation, right? So that palpatory exam that we talked about earlier. And these patients, if you're treating them for migraines and they're not getting Together, send them over to pain management. Have them do some diagnostic injections. It can be very beneficial to help determine where the pain is. And if this is a pain generator, and usually the pain guys will block multiple levels cause it's rare to have one level in isolation. And lastly, the mechanism of injury, if there's a whiplash injury, um, if there was a mechanical injury to the neck, a hyperextension injury, that'll also kind of point more towards a cervicogenic origin of their pain. Um, next slide. Thank you so much. It was an honor presenting here today. Published February 8, 2024 Created by Related Presenters Maria Janakos, MD View full profile
CME Knowledge Hub
