Download Head and Cervical Spine Evaluation

ATTR 322
Krzyzanowicz- Spring 13
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Understand bony and soft tissue anatomy of the
head and neck
Understand movement relationships of the neck
and thoracic spine
Describe common injuries to the head and neck
Demonstrate the proper evaluation of the head
and neck to include
◦ Special tests
◦ Palpation
◦ Concussion evaluation
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Utilize EBP principles' in evaluation techniques
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Scanning examination
◦ Anytime patient c/o of p! in upper extremity- look
back to cervical spine
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Cervicoencephalic
◦ Upper cervical spine (C0-C2)
 Brain, brainstem, spinal cord
 Sx of HA, vertigo, fatigue, poor concentration, irritibility
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Atlanto-occipital joints (C0-C1)
◦ Atlas (C1) has no vertebral body- developed into
odontoid process which is part of C2- flex/ext
◦ Axis (C2)- pivot
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Most mobile joints of spine
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Vertebral Artery
◦ Passes though the transverse processes at about C6
◦ Supplies 20% of blood to the brain
◦ Lies close to the facets- compression of the facet
can cause injury
 Geriatrics but could be in anyone
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Cervicobrachial area (C3-C7)
◦ P! in this area is commonly referred into upper
extremity
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14 facet joints in C-Spine- articulate with Tspine
Intervertebral discs
◦ No disc is found between atlas and occiput (C0-C1)
or between atlas and axis (C1-C2)
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Nerve roots
◦ C1- is above C1, i.e., C5 is between C4 and C5
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Ligaments
◦ Anterior and posterior longitudinal ligaments
 Anterior- sacrum to C2, strengthens anterior portion
of the disc and vertebrae- limits extension
 Posterior- sacrum to C2, densest of C-Spine limits
flexion
◦ Ligamentum nuchae- broad triangular ligament
that serves as a muscle attachment
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Spinal nerves consist of
◦ Anterior (ventral root)
◦ Posterior (dorsal root)
◦ Two Rami (dorsal and ventral)
 Carry sensory and motor information
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Cervical Plexus
◦ Composed of the anterior (ventral) rami of C1-C4
 Provides sensory input to the occipital, supraclavicular,
shoulder and upper thoracic regions
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Brachial Plexus
◦ C5-C8 and T1
 Provides input to shoulder, arm, and hand
◦ Consists of five segmental areas: roots, trunks,
divisions, cords and branches
 Anterior (ventral) portion- motor
 Posterior (dorsal) portion- sensory
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Need to understand this
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Starkey pages 521-523
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History
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Hx of spinal pathology?- why is this important?
Recurrent brachial plexus trauma- why?
Chest/breast p!- can males have breast cancer?
Headaches- C2/C3 nerve root
Psychosocial factors-such as what?
Location of pain
Onset- acute vs. insidious
Pattern of pain
Posture
Other sx
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Inspection
◦ Functional assessment- SFMA?
 Cervical curvature
 Shoulder height/level
 Position of head on shoulders
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Palpation
◦ Review in lab
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Range of Motion
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Flexion, Extension
Rotation
Lateral flexion
Combination?
Symptoms with any of these?
◦ Nystagmus, dizziness, lightheadedness?
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Manual Muscle Testing
◦ Against gravity-awkward testing
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Circulation
◦ Carotid artery
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Neurological examination
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Cranial nerves
Dermatomes/Myotomes
Upper limb tension tests (in lab)
Reflexes
 Babinski
 Oppenheim
Cervical Pathologies
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DDD, acute disk trauma, degenerated facet
joint, osteophytes, inflammation
◦ All cause cervical radiculopathy!
 P! and spasm in the cervical region with possible P!
and paresthesia in affected dermatome, muscular
weakness, altered reflexes, atrophy of region supplied
by nerve root
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Signs and symptoms mimic carpal tunnel and
other neuro disorders of the arm
◦ Upper quarter screen may by + for altered
sensation, decreased strength, reflexes Diminished or absent biceps is strongly suggestive of
cervical radiculopathy
◦ Narrowing of intervertebral foramen
 Due to bony growth, irritation of dural sheath,
degeneration
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Supplies 20% of blood to brain
◦ When impinged can cause HA, dizziness,
nystagmus
◦ ALWAYS perform the vertebral artery test on a
patient before moving forward in an
evaluation/treatment
 If positive- stop evaluation and refer to physician
immediately
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Disk herniation- common at C5-C6 level and
the C6-C7 nerve roots
◦ Patients p! is influenced by position of head/c-spine
 Limited annulus fibrosis in lateral region disk- P! in cspine pathology is usually due to tension on lateral
aspect of posterior longitudinal ligaments
 Could also be due to presence of a tumor
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MOI
◦ Overtime, compression of c-spine
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Signs and symptoms
◦ P! with valsava’s maneuver
◦ P! down one arm* (includes dermatome, myotome)
 Numbness, tingling down nerve
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Tx
◦ Conservative- traction, NSAID’s
◦ Surgical- fusion- can be medically disqualified
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DDD
◦ Usually due to aging (older patients)
 However- what about football players?
◦ Repetitive stress/trauma
 Osteophyte formation and bony hypertrophy to
compensate for spine hypermobility
 You will see this!!
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S&S
◦ Hx of joint aggravation- episodes of joint p! and
stiffness
◦ Possible acute neck injury or an occupation/activity
that repetitively stresses the neck
 Suboccipital p!, HA’s, radicular sx , decreased ROM
(can increase p!)
◦ C6-C7 most affected
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Tx
◦ Conservative usually- traction, NSAIDs
 Medical disqualification?
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Usually after whiplash mechanism or
repetitive motion
◦ Posterior neck p! with extension and rotation,
clicking or catching sensations
◦ Localized p! in paraspinal region just lateral to
spinous process of involved segment
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“stinger or burner”- don’t use these terms!
◦ Traction force placed on the brachial plexus
(stretch) or impingement of cervical nerve roots
(compression) through extension and lateral flexion
to same side
 Common football injury
 Stretching occurs when head is forced laterally while
opposite shoulder is depressed
 Traction on nerve on side opposite of lateral bending of
neck
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Stretching occurs when head is forced
laterally while opposite shoulder is depressed
◦ Traction on nerve on side opposite of lateral
bending of neck
 Lateral and posterior cords of C5-C6 usually affectedwhich nerves are these?
 Electrical shock feeling, burning p!, dermatome and
myotome issues, arm dangling to the side shaking it out
◦ Symptoms usually resolve quickly
 Reoccurring injuries can cause degenerative changes
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Tests
◦ Spurling’s
◦ Brachial plexus traction test
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RTP
◦ Do not allow return to play until all symptoms are
gone
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Discussion
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Caused by pressure on the trunks and medial
cord of the brachial plexus, subclavian
artery/vein
◦ Usually diagnosed after other pathologies have
been ruled out
 Presence of cervical rib, placing pressure on
neurovascular bundle- pectoralis minor and rib cage
 Poor posture, prolonged pressure (backpack) on first
rib overhead movements can make it worse
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S&S
◦ Neurological- arm numbness, decreased radial
pulse, coldness into the hand, radicular numbness
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Test
◦ Allen’s, adson’s
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Tx
◦ Correction of posture, decrease muscle tightness,
can be surgical if needed but not great outcomes
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Torticollis
◦ Spasm of the neck muscles- could include levator
scapulae or upper trapezius
◦ Very common when sleeping weird
 Muscle is in an awkward position and goes into spasm
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Strain
◦ Injury to muscle due to overloading
 Not as common in the neck
On-Field Management of
Head/C-Spine Injuries
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CSF circulates around the brain and spinal
cord
◦ Dissipates high-velocity impacts such as collisions
in football and repetitive forces such as running
 When you have a head injury this can leak out of the
ears
 Halo test
 Straw colored fluid
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ALL UNCONSCIOUS ATHLETES MUST BE
MANAGED AS IF A FRACTURE OR
DISLOCATION OF THE C-SPINE EXISTS UNTIL
THE PRESENCE OF SUCH INJURIES CAN BE
RULED OUT
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Athlete’s position
◦ Supine is easier to deal with than prone
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Consciousness
◦ 1. are they moving or talking? –ABCs are okay
◦ 2. stabilize head- do not move from the head
 Part of primary survey
◦ 3. stabilize spine but inspect for other trauma
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History
◦ Cervical p!- do they have numbness, p! Or burning
into extremities (both arms)
◦ Head p!- brain trauma?
◦ MOI
 Coup- stationary skull hit by an object-trauma is
usually on side of head that was struck
 Contrecoup- skull is moving and is suddenly stopped Repeated subconcussive forces- boxing, heading a
soccer ball
 Spine angle- axial compression?
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History
◦ Loss of consciousness- good evidence says the
longer your out the more severe your trauma is
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Inspection
◦ Position of head
◦ Cervical vertebrae- palpate
◦ Mastoid process- battle’s sign
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Palpation
◦ Spinous procecsses
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Reviewed in another lecture
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Rupture of blood vessels supplying the brain
Epidural hematoma
◦ Bleeding between dura mater and skull
 Rapid formation- usually hours after initial injury
 Blow to head
 As hematoma increases condition deteriorates
 Disoriented, abnormal behavior, c/o or shows drowsiness
 HA increases in intensity
 Unilateral dilated pupil
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Subdural hematoma
◦ Bleeding between brain and dura mater (venous)
 Slow bleed – could be days before symptoms show
 Initially very lucid but develops HA’s, clouding of
consciousness
 Impairment of cognitive, behavioral and motor ability,
cranial nerve dysfunction
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Usually not wearing headgear
◦ 3 types
 Linear- hairline fractures caused by blunt impact
 Depressed- traumatic force, gross deformity
 Comminuted- fragmentation of the skull
 Could lacerate meninges and brain
◦ Depressed fracture
 Control bleeding, do not insert material into laceration
 Leakage of CSF or bleeding from ears
 Battle’s sign
◦ All need emergency medical treatment
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Compression Mechanisms
◦ Impact to top of head with or without neck flexion
(i.e., axial loading)
◦ Car accidents, FB, ice hockey, gymnastics, rugby,
diving into shallow water, etc.
◦ Normal lordotic curve allows for greater energyabsorbing capacity
◦ Spine becomes straight when flexed to 30°
◦ Impact becomes distributed to vertebral bodies
◦ Potential for spine to fail or buckle
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Burst Fx – Jefferson Fx (C1)
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Hangman’s Fx – C2;
◦ rarely results in spinal cord damage; C3 and
below burst fxs commonly involve spinal cord
injury; WHY?
◦ if spinal cord injury occurs, the injury is fatal;
 WHY?
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Spinal cord function inhibited in two ways
◦ Impingement or laceration secondary to bony
displacement (fracture/dislocation)
◦ Compression secondary to hemorrhage, edema,
ischemia of the cord (after injury)
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Trauma above C4 increased chance of death
◦ Disruption of brain stem and phrenic nerve
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Fractures
◦ Alone do not cause spinal cord trauma- usually a
bony fragment lacerates spinal cord, swelling
compresses cord, narrowing of the canal
 Typically minimal p! or symptoms- something just
feels off
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Dislocations
◦ C4-C6, compresses cord
 Unable to move, burning, numbness,
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On field management was discussed earlier
What about equipment?
◦ Practice proper removal of equipment
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Practice EAP with EMS
When in doubt place them on the spineboard