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Cervical and Thoracic Spinal
Conditions
Chapter 11
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Anatomy
• Spinal column
– Vertebrae
• Cervical (7)
convex anteriorly
• Thoracic (12)
concave anteriorly
• Lumbar (5)
convex anteriorly
• Sacral (5 fused)
concave anteriorly
• Coccyx (4 fused)
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Anatomy (cont.)
– Structure
• Rigid enough to support body and protect
spinal cord
• Flexible enough to produce a
variety of movements
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Anatomy (cont.)
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Anatomy (cont.)
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Anatomy (cont.)
• Cervical
– 7 vertebrae form curve – convex anteriorly
– Atlas
• 1st vertebra
• No body – filled with odontoid process
• Function: support the head
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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
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Anatomy (cont.)
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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
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Anatomy (cont.)
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Anatomy (cont.)
• Motion segment
– Functional unit
– Any 2 adjacent
vertebrae and soft
tissues between them
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Anatomy (cont.)
• Intervertebral discs
– Components
• Annulus fibrosus
 Thick fibrous ring
• Nucleus pulposus
 Gelatinous interior
– Function
• Shock absorption
• Allow spine to bend
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Anatomy (cont.)
• Ligaments
– Anterior longitudinal
– Posterior longitudinal
– Ligamentum flavum
– Interspinous
– Supraspinous
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Anatomy (cont.)
Muscles of the neck: lateral view
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Anatomy (cont.)
Muscles of the neck: posterior view
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Anatomy (cont.)
• Nerve plexus
– Cervical (C1–C4)
– Brachial (C5–T1)
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Anatomy (cont.)
• Blood supply
– Common carotid
– Vertebral
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Kinematics
• Movements involve a number of motion
segments
– Flexion/extension/ hyperextension
– Lateral flexion
– Lateral rotation
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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
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Kinetics (cont.)
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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
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Anatomic Variations: Injury Potential
• Kyphosis
– Excessive curve of thoracic spine
– Congenital – deficits in vertebral bodies
– Idiopathic
• Scheuermann’s disease
– Secondary to osteoporosis
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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
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Anatomic Variations: Injury Potential
(cont.)
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Prevention of Spinal Injuries
• Protective equipment
– Neck roll
– Rib protectors
• Physical conditioning
– Strength and flexibility
• Proper technique
– Spearing
– Proper lifting
– Posture
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Cervical Spine Conditions (cont.)
• “Red flags” indicating a possible cervical spine
injury: refer to Box 11.1
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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
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Brachial Plexus Injuries (cont.)
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Brachial Plexus Injuries (cont.)
Classification of Burners
Grade
Injury
Signs
Prognosis
I
Neurapraxia
injury
Temporary loss of sensation or loss of
motor function
Recovery within days to a few weeks
II
Axonotmesis
injury
Significant motor and mild sensory
deficits
Deficits last at least 2 weeks
Regrowth is slow, but full or normal
function is usually restored
III
Neurotmesis
injury
Motor and sensory deficits persist for
up to 1 year
Poor prognosis
Surgical intervention is often necessary
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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
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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
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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
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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
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Thoracic Spine Conditions (cont.)
• Thoracic spinal fractures and
apophysitis
– Wedge fracture
• Fracture of vertebral
end plates
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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
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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)
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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
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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)
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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
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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
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Spinal Assessment—Conscious Individual
(cont.)
• Observation/inspection
– Postural assessment
– Scan exam
– Gait analysis
– Inspection of injury site
– Gross neuromuscular assessment
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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
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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
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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
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AROM – Cervical Spine
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AROM – Thoracic Spine
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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°
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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
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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
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Stress and Functional Tests
Cervical Spine Tests
• Brachial plexus traction
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Cervical Spine Tests (cont.)
• Brachial plexus tension test
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Cervical Spine Tests (cont.)
• Cervical compression
• Spurling’s test
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Cervical Spine Tests (cont.)
• Cervical distraction
• Shoulder abduction
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Facet Joint Mobility
• Spring Test
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Nerve Root Impingement
• Valsalva Test
• First thoracic nerve root stretch
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Neurologic Tests
• Oppenheim
• Babinski
• Hoffman
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Neurologic Tests (cont.)
– Myotomes
Nerve Root Segment
Action Tested
C1–C2
neck flexion*
C3
lateral neck flexion*
C4
shoulder elevation
C5
shoulder abduction
C6
elbow flexion and wrist extension
C7
elbow extension and wrist flexion
C8
thumb extension and ulnar deviation
T1
intrinsic 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.
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Neurologic Tests (cont.)
– Reflexes
Reflex
Segmental Levels
Biceps
C5, C6
Brachioradialis
C5, C6
Triceps
C7, C8
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Neurologic Tests (cont.)
• Cutaneous patterns
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Neurologic Tests (cont.)
• Referred pain
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Activity-Specific Functional Testing
• Normal parameters
• Pain free and unlimited movement
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Rehabilitation
• Relief of Pain and Muscle Tension
• Restoration of motion
• Restoration of Proprioception and Balance
• Muscular strength and endurance
• Cardiovascular fitness
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