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Cervical and Thoracic and Lumbar Spinal Conditions Chapters 10 and 11 Anatomy Spinal column – Vertebrae Cervical (7) Thoracic (12) Lumbar (5) Sacral (5 fused) Coccyx (4 fused) Anatomy (cont.) – Structure Rigid enough to support body and protect spinal cord Flexible enough to produce a variety of movements Anatomy (cont.) Anatomy (cont.) Anatomy (cont.) Cervical – 7 vertebrae form curve forward – Atlas 1st vertebra – No body – filled with odontoid process – Function: support the head – Axis 2nd vertebra Odontoid process – tooth-like Allows head to rotate Thoracic – 12 vertebrae form curve backwards – Extra facets for articulation with ribs Anatomy Lumbar spine – Forms concave curve anteriorly – 5 lumbar, 5 fused sacral, and 4 small, fused coccygeal vertebrae Sacrum articulates with ilium – sacroiliac joint Anatomy (cont.) Anatomy (cont.) 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 Anatomy (cont.) Motion segment – Functional unit – Any 2 adjacent vertebrae and soft tissues between them Anatomy (cont.) Intervertebral discs – Components Annulus fibrosus Thick fibrous ring Nucleus pulposus Gelatinous interior – Function Shock absorption Allow spine to bend Anatomy (cont.) Ligaments – – – – – Anterior longitudinal Posterior longitudinal Ligamentum flavum Interspinous Supraspinous Anatomy (cont.) Muscles of the neck: lateral view Anatomy (cont.) Muscles of the neck: posterior view Anatomy (cont.) Muscles of trunk – Paired – Unilaterally: produce lateral flexion and/or rotation of the trunk – Bilaterally: trunk flexion or extension Primary movers for back extension – erector spinae muscles Anatomy (cont.) • Nerve plexus – Cervical (C1–C4) – Brachial (C5–T1) Anatomy (cont.) Nerve plexus – Lumbar (T12–L5) – Sacral (portion of lumbar [L4–L5]) Anatomy (cont.) • Blood supply – Common carotid – Vertebral Kinematics Movements involve a number of motion segments Directions of movement – Flexion/extension/ hyperextension – Lateral flexion – Lateral rotation Anatomic Variations: Injury Potential Kyphosis – Excessive curve of thoracic spine – Congenital – deficits in vertebral bodies – Idiopathic Scheuermann’s disease – Secondary to osteoporosis 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 Anatomic Variations: Injury Potential Lordosis – Abnormal exaggeration of lumbar curve – Causes include: Congenital deformities Weak abdominal musculature Poor posture Activities with excessive hyperextension Anatomic Variations: Injury Potential (cont.) Sway back – Increased lordotic curve and kyphosis – Causes include: Muscle weakness; compensatory muscle tightness – Entire pelvis shifts anteriorly, causing the hips to move into extension – Impact on center of gravity (COG) Anatomic Variations: Injury Potential (cont.) Flat back – Decrease in lumbar lordosis (20°) – Clinical sign: tendency to lean forward when walking or standing – Impact on center of gravity (COG) Anatomic Variations: Injury Potential (cont.) Anatomic Variations: Injury Potential (cont.) Prevention of Spinal Injuries Protective equipment – Neck roll – Rib protectors Physical conditioning – Strength and flexibility Proper technique – Spearing – Proper lifting – Posture 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 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 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 Cervical Spine Conditions (cont.) – S&S Varying degrees of neck or arm pain, may radiate Pain exacerbated by Valsalva maneuvers and neck movement Severe cases—potential loss of motor function below injury level – Management: rest, activity modification, NSAIDs 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 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 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 Brachial Plexus Injuries (cont.) 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 Brachial Plexus Injuries (cont.) Chronic burners – 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 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 Lumbar Spine Injuries Contusions, strains, and sprains – Estimated 80% of population has low back pain (LBP) at some time – Nearly 97% stems from mechanical injury to muscles, ligaments, or connective tissue – Chronic LBP: associated with LBP, reduced spinal flexibility, repeated stress, and activities that require maximal extension of the lumbar spine Lumbar Spine Injuries (cont.) – LBP Pain and discomfort can range (local or diffuse) No radiating pain No signs of neural involvement – Management: standard acute; stretching Lumbar Spine Injuries (cont.) LBP in runners – Associated with tightness in hip flexors and/or hamstrings – S&S Localized pain, ↑ with active and resisted back extension No radiating pain No signs of neural involvement Possible anterior pelvic tilt and hyperlordosis – Management Ice, NSAIDs, muscle relaxants, TENS, and EMS Avoiding excessive flexion activities and a sedentary posture – Decrease incidence—use progressive training techniques Anatomic Variations: Injury Potential (cont.) Pars interarticularis – Area between superior and inferior facets Weakest part of the vertebrae – Spondylolysis—fracture Congenital or mechanical stress Repeated weight loading in flexion, hyperextension, and rotation Occurs at an early age (8 years); asymptomatic until ages 10–15 years Anatomic Variations: Injury Potential (cont.) – Spondylolisthesis—bilateral separation Anterior displacement of a vertebra Common site—lumbosacral joint Ages 10–15 years Anatomic Variations: Injury Potential (cont.) Anatomic Variations: Injury Potential (cont.) Spondylolisthesis – MRI demonstrates anterior shift of L5 Lumbar Spine Injuries (cont.) Lumbar disc conditions – Protruded disc (A) Eccentric accumulation of nucleus with slight deformity of annulus – Prolapsed disc (B) Eccentric nucleus produces a definite deformity as it works its way through fibers of annulus fibrosus – Extruded disc (C) Nuclear material bulges into spinal canal and runs risk of impinging adjacent nerve roots – Sequestrated disc (D) Nuclear material from intervertebral disc is separated from disc itself and potentially migrates Lumbar Spine Injuries (cont.) Lumbar Spine Injuries (cont.) – S&S Sharp pain and spasm at site of herniation; pain shoots down extremity Walk in slightly crouched position, leaning away from side of lesion Compression on spinal nerve – Sensory and motor deficits – Alteration in tendon reflex Lumbar Spine Injuries (cont.) Lumbar fractures and dislocations – Transverse or spinous process fracture Due to: Extreme tension from attached muscles Direct blow Additional injury to surrounding soft tissues – Compression fracture Hyperflexion crushes anterior aspect of vertebral body Primary danger—possibility of bony fragments moving into spinal canal, damaging cord or spinal nerves Lumbar Spine Injuries (cont.) – Dislocations Occur only when a fracture is present Rare in sports – S&S Localized, palpable pain may radiate down the nerve root if a bony fragment compresses a spinal nerve Lumbar Spine Injuries (cont.) – Spinal cord ends—L1 or L2 level Fracture below not a serious threat, but handle with care to minimize potential damage to cauda equina – Management Fracture or dislocation: activate EMS Conservative treatment: initial bed rest, cryotherapy, and minimizing mechanical loads Sacrum and Coccyx Conditions Sacroiliac joint sprain – Mechanisms Single traumatic episode involving bending and/or twisting Repetitive stress from lifting Fall on buttocks Excessive side-to-side or up-and-down motion during running Running on uneven terrain Suddenly slipping or stumbling forward Wearing new shoes or orthoses Sacrum and Coccyx Conditions (cont.) – S&S Unilateral, dull pain that extends into buttock and posterior thigh ASIS or PSIS may appear asymmetric bilaterally Leg length discrepancy ↑ pain with standing on one leg and stair climbing Forward bending reveals block to normal movement with the PSIS on injured side moving sooner than uninjured side ↑ pain with lateral flexion toward injured side ↑ pain with straight leg raises beyond 45° – Management: standard acute; gentle stretching 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) 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 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 Spinal Assessment—Conscious Individual (cont.) Observation/inspection – – – – – Postural assessment Scan exam Gait analysis Inspection of injury site Gross neuromuscular assessment Spinal Assessment—Conscious Individual (cont.) Palpation – Seated, standing, supine, or prone position – Relax the neck and spinal muscles—lying position – Posterior cervical structures Patient supine – Thoracic and/or Lumbar region Patient prone Pillow under the hip region to tilt the pelvis back and relax the lumbar curvature 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 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 AROM – Cervical Spine AROM – Thoracic Spine AROM – Lumbar Spine 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 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 Stress and Functional Tests Brachial plexus traction Cervical compression Stress and Functional Tests (cont.) Straight leg raise test – for sciatic Well straight leg raise test – for disc injury Bowstring test – for sciatic Stress and Functional Tests (cont.) Valsalva’s – for disc injury Milgram test – for disc injury Stress and Functional Tests (cont.) Single leg stance – for fracture Quadrant test – for neuropathy Stress and Functional Tests (cont.) Hoover test – for malingering Stress and Functional Tests (cont.) Sacroiliac compression and distraction test – for SI sprain Approximation test – for SI sprain/fracture Stress and Functional Tests (cont.) FABER (Patrick) test – for SI joint pathology Neurologic Tests Babinski – for spinal neuropathy Oppenheim – for spinal neuropathy