Cervical Pathologies

Question 1

Cervical spondylosis is:

Answer 1

Degenerative disc disorder (DDD) affecting IV joint

Lower cervical spine most affected: C5-6, C6-7, C4-5

Question 2

Pathological changes in cervical spondylosis are:

Answer 2

• Loss of disc height due to disc dehydration & degeneration: stiffer less flexible more prone to tearing
• vertebrae approximate: ligaments slacken, allow more joint play thus increasing stress through disc & hastening degeneration
• formation of marginal osteophytes
• Possible nerve root entrapment & spinal cord compression due to degenerative changes
• May change loading of facet joints: increase load hastening facet joint OA hence disc degeneration often occurs before facet joint OA

Question 3

Subjective signs of cervical spondylosis

Answer 3

• Age group: 45 years+
• Onset – insidious or traumatic (trigger initial symptoms)
• Bilateral / unilateral neck pain
• Referred pain into shoulder, arm or head ( somatic referred pain or radicular referred if degenerative changes irritate a spinal nerve root)
• Neck stiffness

Question 4

Objective signs of cervical spondylosis

Answer 4

• Decreased cervical AROM & PIPIVM (SF & rotation)
• Pain on PAIVM of involved levels
• Altered posture
• Dermatomal changes if nerve root involved
• Degenerative changes on X-ray: Disc space narrowing, Anterior Osteophyte formation, Lipping & irregularity of vertebral bodies

Question 5

OA in facet joints is

Answer 5

Degenerative disorder affecting synovial joints

Question 6

Pathological changes in facet joint OA are:

Answer 6

Synovitis, disintegration of articular cartilage, osteophyte formation, joint space narrowing

Question 7

Subjective signs of facet joint OA are:

Answer 7

• More common in >65 y.o.
• Local, often unilateral neck pain
• Somatic pain referral into shoulder/scapula region depending on levels affected
  Stiff neck

Question 8

Objective signs of facet joint OA are:

Answer 8

• Decreased AROM + PPIVM into facet closed packed position (Extension + ipsilateral side flexion + ipsilateral rotation)
• Pain reproduced on PAIVM of affected levels
• Degenerative changes on x-ray: cartilage destruction of facet joints (loss of joint space), osteophyte formation around joint margins, IVD & vertebral bodies normal

Question 9

Cervical radiculopathy occurs:

Answer 9

8 cervical nerve roots, most commonly in lower Cx (C6,7 & 5 level)
Must consider cranial nerves - exit via foramen magnum
Could affect median, ulnar and/or radial nerve
Emerge above corresponding vertebrae but below IVD

Question 10

Cervical radiculopathy is caused by:

Answer 10

Irritation of a cervical nerve root in the IV foramina usually in the medial half (narrowest) by :-

• Inflammation
• Postero-lateral disc prolapse
• Degenerative changes of facet joints eg. osteophytes
• Lateral canal stenosis: Narrowing of I-V foramina, Causes nerve root compression & irritation, Neurological changes

Question 11

Clinical presentation of cervical radiculopathy

Answer 11

Unilateral symptoms of peripheral neuropathy mechanism of nociceptive drive:

• Acute severe arm pain and/or altered sensation in dermatomal distribution
• Myotomal / reflex changes
• May or may not have neck pain
• Arm pain worsened on movements or postures closing down IV foramina eg. ipsilateral rotation + extension
• Significant night pain
• ? Antalgic posture
• Overhead arm positions may relieve
• Very +ve UNDT
• Cloward’s signs: pain referral patterns related to the IVD with/without nerve root involvement

Question 12

Cervical myelopathy is:

Answer 12

a central canal stenosis (compression of the spinal cord) either by:
- Severe central degenerative changes eg. osteophytes
- Large central disc prolapse
Usually a medical emergency

Question 13

Signs of cervical myelopathy:

Answer 13

Neck, arms, legs and/or lower back pain
Tingling, numbness, weakness in the arms,, legs
Loss of fine motor control in the hand, seen as clumsiness, difficulty buttoning shirt
May have gait disturbances (ataxic gait)
Increased reflexes in extremities or development of abnormal reflexes
Bladder and bowel dysfunction if severe enough.
Loss of balance and co-ordination

Question 14

Whiplash is an:

Answer 14

acceleration-deceleration mechanism. May result from rear end or side impact MVA. Whiplash is a multi level, multi tissue, multi pathology disorder. Be aware of potential for instability & cervical artery trauma. Often involves a psychosocial component alongside biological component eg. post-traumatic stress disorder (best indicator of prognosis)

Question 15

Rear end collision mechanism is:

Answer 15

• hyperextension phase first and is the most damaging – affects anterior cervical structures
• hyperflexion phase follows and is limited by chin:chest or forehead:steering wheel

Question 16

Possible lesions in whiplash include:

Answer 16

• Muscle strain: SCM, scalenes & other precervical muscles
• Facet joint: capsule sprain/ #
• Ligament sprains/tears: ALL/PLL/IVL
• IVD: prolapse, annular tears, clefts in endplate
• Spinal cord & nerve root traction injuries
• Vertebral artery ischaemia (high speed)
• Concussion (high speed)
• Thoracic outlet syndrome
• TMJ dysfunction
• Retropharangeal haematoma

Question 17

Whiplash Associated Disorder (WAD) Classification

Answer 17

WAD 1 - neck pain only, no physical signs
WAD 2a - Neck pain with alterations in movement, muscle recruitment and local mechanical hyperalgesia
WAD 2b - above plus psychological impairment
WAD 2c - above plus generalized hyperalgesia
WAD 3 - above plus neuro signs
WAD 4 - fracture/ dislocation

Question 18

Biological symptoms of whiplash include:

Answer 18

Pain, stiffness, headaches, nausea, dizziness, referred pain, paraesthesia, blurred vision, difficulties swallowing

Question 19

Psychosocial symptoms of whiplash include:

Answer 19

depression, anxiety, anger, loss of job & income, marital & family disruption, PTSD, fear of driving

Question 20

Duration of symptoms of whiplash:

Answer 20

• In UK on average 6 weeks – 1 year. 10% of patients will go on to develop chronic pain
• In other countries minor neck pain for a few days-weeks-months depending on severity (total resolution by 3 months)

Question 21

Postural dysfunction (non-specific neck pain) is when:

Answer 21

There is no tissue damage / pathology. Pain is a result of tissue overstress/strain

Question 22

Signs of postural dysfunction include:

Answer 22

Widespread neck pain radiating into shoulders, down the arm, into the head or across scapula
Worsened by prolonged postures, activities eg. sitting at a computer / driving
Often easier in morning & worse at end of day
Often accompanied with paraesthesia or hyperaesthesia, but with no loss of sensation or muscle strength
Trigger points

Question 23

Cervicogenic headache is:

Answer 23

A dysfunction in an upper cervical spine structure which refers pain into the head affecting woman: men 3:1.
Mechanism is thought to be by referred pain from upper cervical spine structures (convergence theory): Irritation of cranial nerves as they exit foramina or transgeneral nucleus (TGN) - a collection of nuclei that link with cranial nerves

Question 24

Dysfunction in upper cervical spine can present as:

Answer 24

Headaches/migraines
Face/eye/TMJ/ear pain
Pain in suboccipital region
Nausea, Dizziness 
Classically unilateral
Rarely has other symptoms
AGG by neck movement or sustained head or neck posture

Question 25

Somatic referral patterns to the front of the head include:

Answer 25

Pain above eyebrows = O/C1 Pain at eyebrows = C1/2 Pain at the eyes = C2/3

Question 26

Somatic referral patterns to the back of the head include:

Answer 26

Pain is just in the head = O/C1 Pain at occiput & upper neck = C1/2 Pain in the head and into neck = C2/3

Question 27

Craniocervical muscle referral patterns into the head include:

Answer 27

Sub-occipital muscles SCM Upper fibres of trapezius

Question 28

Objective signs of cervicogenic headache include:

Answer 28

- Forward head posture - Positive upper cervical joint findings: decreased upper cervical AROM (C0 - C3 segments), decreased upper cervical PAIVM - Weakness in deep neck flexors - Trigger points in muscles supplied by C1-3 nerves eg. SCM

Question 29

Cervical disc herniation is caused by:

Answer 29

degenerative weakening of annulus – nucleus prolapses through. Uncommon, less common than disc prolapse in lumbar spine

Question 30

Cervical disc herniation is most common in:

Answer 30

individuals in 30’s, C6-7 & C5-6 most common levels, female = male

Question 31

Risk factors for cervical disc herniation is:

Answer 31

Age / Smoking / Lifting heavy objects / Diving

Question 32

Why is cervical disc herniation uncommon?

Answer 32

Nucleus pulposus in Cx is largely fibrocartilaginous, PLL 4 x thicker than in Lx provides barrier to central prolapse and uncovertebral joints provide barrier to lateral prolapse

Question 33

Types of disc prolapse are:

Answer 33

1. Centrally - bilateral of all 4 limbs if compression is sufficient enough 2. Posterolaterally 3. Bulge (4. anterior uncommonlu cause dysphagia)

Question 34

Signs of disc herniation include:

Answer 34

S & S depend on size & level: - Acute & rapidly worsening neck pain – central or unilateral - Referred pain to scapula (somatic) - Pain worse on ext & prolonged flexion activities; coughing & sneezing - Antalgic posture: head held in flexion - If prolapse is postero-lateral and spinal nerve involved will produce: a. radicular referred pain into arm & hand (lateral canal stenosis), b. paraesthesias & or anaesthesia into UL - If prolapse is posterior and central spinal cord may be involved = myelopathy, may get signs and symptoms of cord compression (central canal stenosis)