Why is the location of the vertebral artery in the neck particularly important for protecting it?
- It runs at the axis of flexion/extension (mediolateral axis), which helps protect it from excessive stretching or pinching during flexion/extension (other movements can disrupt it more)
What is the overall incidence (words, not numbers) of cancer, infection, and fracture in the C-spine?
- Cancer: relatively uncommon (more often than rare)
- Fracture: rare
- Infection: rare
Who is the Canadian C-Spine Rule for?
- For alert and stable trauma pts where c-spine injury is a concern
Canadian C-Spine Rule: What is the first question, and what are the three things that need yes/no answers?
What do you do next?
- Any High-Risk Factor Which Mandates Radiography?
- Age equal or greater to 65, or
- Dangerous mechanism, or
- Paresthesias in extremities
If yes, send to radiograph
If no to all, ask second question?
Canadian C-Spine Rule: What is considered a dangerous mechanism? (5)
- Fall from elevation equal or greater to 3 feet/5 stairs
- Axial load to head, e.g. diving
- MVC high speed (> 100km/hr), rollover, ejection
- Motorized recreational vehicles
- Bicycle collision
*MVC = Motor Vehicle Collision/Accident
** 100km/hr = 62 mph
Canadian C-Spine Rule: What is the second question, and what are the five things that need yes/no answers?
What do you do next?
Any Low-Risk Factor Which Allows Safe Assessment of Range of Motion?
- Simple rearend MVC*
- Sitting position in ED
- Ambulatory at time
- Delayed** onset of neck pain
- Absence of midline c-spine tenderness
If yes to any, ask question 3
If no to all, send for radiograph
*MVC = Motor Vehicle Collision/Accident
**Delayed: i.e. not immediate onset of neck pain
Canadian C-Spine Rule: What is the third question, and what is the one thing that needs a yes/no answer?
What do you do next?
Able to Actively Rotate Neck?
- 45* left and right
Able, no radiograph
Unable, send for radiograph
Canadian C-Spine Rule: What are four exceptions to the definition of Simple Rearend MVC?
Simple Rearend MVC Excludes:
- Pushed into oncoming traffic
- Hit by bus/large truck
- Rollover
- Hit by high speed vehicle
*MVC = Motor Vehicle Collision/Accident
How does cervical rotation and extension affect the vertebral artery?
- It can cause Internal Carotid Artery Dissection.These movements compress the artery against the transverse process of the upper cervical vertebra
- Vertebral Artery Dissection is associated with contralateral cervical rotation that stretches or compresses the artery between the 1st two cervical vertebra
(I thought extension was one of the movements that the v-artery was mostly protected from)
Should you do end range CAD provocative test if pt’s index of suspicion for CAD is low?
No, there is no need.
What is cervicogenic dizziness (CD)?
A specific sensation of altered orientation in space and disequilibrium originating from abnormal afferent activities from the neck.
Dr. Mincer thought it best matched the disequilibrium type of dizziness, but later I think she said it could have a vascular cause too (but I don’t think she went as far as to say presyncope was cervicogenic dizziness). Maybe she meant just cervicaogenic dizziness that is appropriate to treat with PT (since we would not treat the vascular issues).
What are 6 CAUSES of dizziness?
- Cardiovascular
- Neurological
- Metabolic
- Psychiatric
- Vestibular
- Cervicogenic (cervical MSK origin)
WHat does CSI stand for?
Cervical Spine ligamentous instability
Why is rheumatic disease important to identify? (3 points)
- RA is the most common inflammatory disease that affects the C-spine
- The diarthroidal joints (dens joints) are primarily affected, but extra-articular features manifest in the skin, eyes, lungs, and nervous system.
- These effects occur early in the disease process
What can lead to ACS?
Increased myocardial oxygen and nutrition requirements relating to exertion, emotional stress or physiological stress, such as dehydration, blood loss, and infection or surgery, can lead to ACS.
What is Angina? How is it described? (include percentages)
Angina is a typical symptom of myocardial ischemia often describe as a sensation of substernal or retrosternal chest pressure, squeezing, or heaviness during exertion of 70% to 90% incidence, but only 33% or less complain of chest pain.
What is a key sign of ACS in women?
A key sign of ACS in women is unexplained severe, episodic fatigue that interferes with performing daily activities. (emphasized in class)
What can occur up to a month prior to an acute MI?
Weakness, fatigue, trouble sleeping, and nausea may occur up to a month prior to an acute MI.
What are some less common warning signs of heart attack, especially in women? women? (9 points)
- Unusual chest pain quality and location (ie. burning, heaviness; left chest), and stomach or abdominal pain
- Continuous midthoracic or interscapular pain
- Continuous neck or shoulder pain
- Isolated right biceps pain
- Pain relieved by antacids
- Pain unrelieved by rest or nitroglycerin
- Nausea and vomiting
- Flu-like manifestations without chest pain/discomfort
- Unexplained intense anxiety, weakness or fatigue, breathlessness, and dizziness.
How can the cluster of 5 tests be used to rule cervical myelopathy in/out?
- Age > 45 years (THIS CONFLICTS WITH 55 AND 70 ABOVE)^^^
- Positive Babinski sign
- Positive inverted supinator sign
- Positive Hoffman
- Gait dysfunction described as (SAW) Spastic, Ataxic or Wide-based gait
Absence of a + finding, or presence of 1 of 5 tests, provides a moderate level of confidence that the patient does not have CM, whereas 3 of 5 positive test findings assists with ruling in CM if CM is suspected. based on clinical examination, a referral for additional testing is warranted.
Hoffman, Babinski’s, Clonus, and Deep tendon reflexes associated with hyperreflexia are more specific than sensitive, and therefore considered better tests for ruling in CM. The inverted supinator sign (i.e. finger flexion or elbow extension during the brachioradialis reflex test) may be the most sensitive test for ruling out CM.
What are the two most common causes of cervical radiculopathy?
- Most common is degeneration of the c-spine (which includes loss of disc height, degeneration of disc, osteophytes) – 68%,
- second most common is due to disc herniation. – 22%
What is the relative frequency of cervical radiculopathy by level?
- 7th spinal nerve most commonly affected (70%)
- 6th spinal nerve root next most common affect
- 8th spinal nerve root is the next most commonly affected
What are the typical symptoms of cervical radiculopathy? (General)
- Symptoms with this classification include
- Neck pain with an associated radiating or narrow band of lancinating pain in the involved upper extremity, upper extremity paresthesia, and related numbness and weakness
- What 7 clinical findings that assist with diagnostic classification of cervical radiculopathy?
- Clinical findings that assist with diagnostic classification are
- Upper extremity symptoms
- Radicular or referred pain produced or aggravated with Spurling’s test
- ULNDTs
- Decreased with neck distraction
- Decreased cervical rotation of less than 60 degrees to the involved side
- Signs of nerve root compression (hard neural signs)
- Success in reducing UE symptoms using initial examination and intervention procedures, such as distraction.
