How to evaluate cervical spine disorders?

How to evaluate cervical spine disorders?

How does the evaluation of a patient with a spine complaint begin?
A complete history and physical examination are performed. The purpose of the history and physical examination
is to make a provisional diagnosis that is confirmed by subsequent testing as medically indicated.

  1. What are some of the key elements to assess in the history of any spine problem?
    • Chief complaint: pain, numbness, weakness, gait difficulty, deformity
    • Symptom onset: acute versus insidious
    • Symptom duration: acute, subacute, chronic, recurrent
    • Pain location: Is the pain primarily axial neck pain, arm pain, or a combination of both?
    • Pain quality and character: sharp versus dull; radiating versus stabbing versus aching
    • Temporal relationship of pain: Night pain, rest pain, or constant unremitting pain suggests systemic problems
    such as a tumor or infection. Morning stiffness that improves throughout the day suggests an arthritic problem
    or an inflammatory arthropathy.
    • Relation of symptoms to neck position: increased arm pain with neck extension suggests nerve root
    impingement
    • Aggravating and alleviating factors: Is the pain mechanical (activity-related) or nonmechanical (not influenced
    by activity) in nature?
    • Family history: inquire about diseases such as ankylosing spondylitis or rheumatoid arthritis.
    • Concurrent medical illness: diabetes, peripheral neuropathy, peripheral vascular disease
    • Systemic symptoms: a history of weight loss or fever suggests possibility of tumor or infection
    • Functional impairment: loss of balance, gait difficulty, loss of fine motor skills in the hands
    • Prior treatment: include both nonoperative and operative measures
    • Negative prognostic factors: pending litigation, Workers’ Compensation claim
  2. What disorders should be considered in the differential diagnosis of neck/arm pain?
    • Degenerative spinal disorders: discogenic pain, radiculopathy, myeloradiculopathy, myelopathy, facet jointmediated
    pain
    • Soft tissue disorders: sprains, myofascial pain syndromes, fibromyalgia, and whiplash syndrome
    • Rheumatologic disorders: rheumatoid arthritis, ankylosing spondylitis
    • Infections: discitis, osteomyelitis
    • Tumors: metastatic versus primary tumors
    • Intraspinal disorders: tumors, syrinx
    • Systemic disorders with referred pain: angina, apical lung tumors (Pancoast tumor)
    • Shoulder and elbow pathology: rotator cuff disorders, medial epicondylitis
    • Peripheral nerve entrapment syndromes: radial, ulnar, or median nerve entrapment, suprascapular neuropathy
    • Thoracic outlet syndrome or brachial plexus injury
    • Psychogenic pain
    • Cervicogenic headache
  3. What are the basic elements of an examination of any spinal region?
    • Inspection
    • Palpation
    • Range of motion (ROM)
    • Neurologic examination
    • Evaluation of related areas (e.g., shoulder, elbow, and wrist joints; scapula; supraclavicular area)
  4. What should the examiner look for during inspection of the cervical region?
    During the initial encounter, much can be learned from observing the patient. Assessment of gait and posture
    of the head and neck is important. Patients should undress to allow inspection of anatomically related areas,
    including the neck muscles, shoulder, elbow and wrist joints, scapula, and supraclavicular area.
  1. What is the purpose of palpation during assessment of the cervical region?
    To examine for tenderness and locate bone and soft tissue pathology. Specific areas of palpation correspond to
    specific levels of the spine:
    • Hyoid bone C3
    • Thyroid cartilage C4–C5
    • Cricoid membrane C5–C6
    • First cricoid ring C6
    • Carotid tubercle C6
    Spinous processes should be palpated and checked for alignment. If tenderness is detected, it
    should be noted whether the tenderness is focal or diffuse, and the area of maximum tenderness should
    be localized.
  2. In which three planes is range of motion assessed in the cervical spine?
    • Flexion/extension
    • Right/left bending
    • Right/left rotation
  3. What is a normal range of motion of the cervical spine?
    • Flexion 45°
    • Extension 55°
    • Right/left bending 40°
    • Right/left rotation 70°
    Clinical estimates of motion are more commonly used in office practice. Flexion may be reproducibly measured
    using the distance from the chin to the sternum. For extension, the distance from the occiput to the dorsal
    spine may be helpful. Distances can be described in terms of fingerbreadths or measured with a ruler. The normal
    patient, for example, can nearly touch chin to chest in flexion and bring the occiput to within three or four fingerbreadths
    of the posterior aspect of the cervical spine in extension. Normal rotation permits the chin to align with
    the shoulder.

Describe an overview of the approach to the neurologic examination for cervical disorders.
The goal of examination is to determine the presence or absence of a neurologic deficit. If present, the level
of a neurologic deficit is determined through testing of sensory, motor, and reflex function. The neurologic deficit
may arise from pathology at the level of the spinal cord, nerve root, brachial plexus, or peripheral nerve.
Examination of the cervical region is focused on the C5–T1 nerve roots because they supply the upper
extremities. For each nerve root, the examiner tests sensation, strength, and if one exists, the appropriate
reflex

How is sensation examined?
Sensation can be examined using light touch, pin prick, vibration, position, temperature, and two-point discrimination.
In assessing sensation, it is helpful to assess both sides of the body simultaneously. In this manner, sensation
that is intact but subjectively decreased compared with the contralateral side can be easily documented. Light
touch and pinprick sensation are graded as 0 5 absent, 1 5 impaired (partial or altered appreciation including
hyperesthesia), or 2 5 intact.

  1. What neural pathways are tested during sensory examination?
    • Spinothalamic tracts: transmit pain and temperature sensation
    • Posterior columns: transmit two-point discrimination, position sense and vibratory sensation

What is the significance of hyperreflexia? An absent reflex?
Hyperreflexia signifies an upper motor neuron lesion (interruption in the neural pathway above the anterior horn
cell). An absent reflex implies pathology at the nerve root level(s) that transmits the reflex (in the lower motor
neuron, between the anterior horn cells of the spinal cord and the target muscle).

  1. What is radiculopathy?
    Radiculopathy is a lesion that causes irritation of a nerve root (lower motor neuron). It involves a specific spinal level with
    sparing of levels immediately above and below. The patient may report pain, a burning sensation, or numbness that radiates
    along the anatomic distribution of the affected nerve root. Other signs may include severe atrophy of muscles and loss of
    the reflex supplied by the nerve. Severe radiculopathy may result in the flaccid paralysis of muscles supplied by the nerve.
  2. What symptoms are associated with a C5–C6 disc herniation? Explain.
    A disc herniation at the C5–C6 level causes compression of the C6 nerve root. Thus weakness of biceps and wrist
    extensors, loss of the brachioradialis reflex, and diminished sensation of the radial forearm into the thumb and
    index finger, are expected. The nerve root of the inferior vertebra of a given motion segment (e.g., C3 for C2–C3
    disc, C7 for C6–C7 disc) is the one typically affected by a herniated disc. Note that in the cervical region there
    are eight nerve roots and seven cervical vertebrae. The first seven cervical nerve roots exit the spinal canal
    above their numbered vertebra. The C8 nerve root is atypical because it does not have a corresponding vertebral
    element; it exits below the C7 pedicle, and occupies the intervertebral foramen between C7 and T1.
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