CERVICAL SPINE

Patients with moderate to severe radicular symptoms usually do not have to be directed into the Bakody sign position because it also is an antalgic pain–relieving posture. The more difficult the task is for the patient to lower the arm, the more difficult the condition will be to treat conservatively. If the patient cannot lower the arm without severe exacerbation of pain, surgery is probably indicated. Patients with moderate to severe cervical nerve root compression find the most comfortable sleeping positions to be those that involve abduction and elevation of the arm. Again, this position relieves the traction of the neural elements and is an antalgic position for someone experiencing cervical nerve root compression. A patient often voluntarily assumes the Bakody sign position while in the examination room.

BARRÉ-LIÉOU SIGN

Assessment for Vertebral Artery Syndrome

ORTHOPEDIC GAMUT 3-10 VERTEBRAL ARTERY COMPRESSION

Three mechanisms of vertebral artery compression are:

1. Osteophytes from the lateral disc margin

2. Anteriorly extending osteophytes from the facet joint

3. Compression from the inferior facet as a result of posterior subluxation and a scissoring effect by the adjacent superior facet

ORTHOPEDIC GAMUT 3-11 TRAUMA TO THE VERTEBRAL ARTERY

Three areas in which the vertebral artery is most susceptible to trauma:

1. The posterior atlantooccipital membrane, which is dense and inelastic and may become calcified (firmly attached to the artery)

2. The space between the occiput and posterior arch of the atlas, especially during extension

3. Between the lateral mass of the atlas and the transverse process of the axis, especially during extension and rotation

ORTHOPEDIC GAMUT 3-12 CLASSIFICATION OF LOCKED-IN SYNDROME

Locked-in syndrome is subdivided based on the extent of motor impairment:

A. Classical locked-in syndrome (LIS) is characterized by total immobility except for vertical eye movements or blinking.

B. Incomplete LIS permits remnants of voluntary motion.

C. Total LIS consists of complete immobility including all eye movements combined with preserved consciousness.

ORTHOEPDIC GAMUT 3-13 THE AMERICAN CONGRESS OF REHABILITATION MEDICINE (1995) DEFINITION OF LOCKED-IN SYNDROME

1. The presence of sustained eye opening (Bilateral ptosis should be ruled out as a complicating factor.)

2. Preserved basic cognitive abilities

3. Aphonia or severe hypophonia

4. Quadriplegia or quadriparesis

5. A primary mode of communication that uses vertical or lateral eye movement or blinking of the upper eyelid

ORTHOPEDIC GAMUT 3-14 LOCKED-IN SYNDROME

Locked-in syndrome characteristics include:

1. Retained consciousness

2. No volitional movement of the body

3. Nuclei of cranial nerves V to XII destroyed, resulting in their paralysis

4. Loss of sensations carried in the medial lemniscus

5. Normal hearing

6. Sparing of cranial nerve IV nucleus and the superior colliculus of the quadrigeminal plate

PROCEDURE

• The examiner instructs the patient to rotate the head slowly from side to side while in a seated position (Fig. 3-14).

• Rotating the head causes compression of the vertebral arteries.

• Vertigo, dizziness, visual disturbances, nausea, syncope, and nystagmus are signs of a positive test.

• A positive finding strongly indicates a buckling of the ipsilateral vertebral artery and indicates vertebrobasilar insufficiency.

FIG. 3-14 A VA syndrome is suggested by vertigo, blurred vision, nausea, syncope, or nystagmus. These symptoms may occur singly or in combination.

The patient with a positive Barré-Liéou sign is a poor risk for aggressive cervical spine manipulation. Such manipulation should not be undertaken until all vascular causes have been investigated. Aggravation of the sympathetic ganglia of the cervical spine can produce many, if not all, of these symptoms (vertigo, dizziness, visual disturbances, nausea, syncope, and nystagmus), in which case cervical spinal manipulation is not contraindicated. The examiner absolutely must distinguish between vascular and neural origins before manipulation is performed.

In 1926, Barré studied and established a syndrome that was further described in 1928 by his student Liéou. So diverse and widespread is the combination of symptoms and signs that some people no longer regard the syndrome as a disorder associated with the cervical spine; rather, they view the syndrome as one caused by vertebral artery insufficiency and its multivariate characteristics. The symptoms of this syndrome include pain in the head, neck, eyes, ears, face, sinuses, and throat; sensory disturbances in the pharynx and larynx; paroxysmal hoarseness and aphonia; tinnitus that is synchronous with the pulse; various auditory hallucinations, such as whistling and humming; deafness; visual disturbances, such as blurring, scintillating scotomata, photophobia, blepharospasm, squinting sensations, and a peculiar pulling at the back of the eyes; flushing; sweating; salivation; lacrimation; nausea; vomiting; and rhinorrhea.

BIKELE SIGN

Assessment for Brachial Plexus Neuritis and Meningitis

PROCEDURE

• With the arm held upward and backward and the elbow fully flexed, the patient extends the elbow.

• If this movement meets with resistance and increases radicular pain from the cervicodorsal region, the test is positive (Fig. 3-15).

• This finding indicates brachial plexus neuritis or meningitis because this maneuver stretches the brachial plexus nerve roots or their coverings.

FIG. 3-15 The arm is fully extended at the elbow, and the patient attempts to reach behind. In the presence of radiculopathy or plexopathy, this maneuver produces the radicular pain.

Injury to the C8 and T1 roots, the lower trunk, or the medial cord of the brachial plexus may be caused by tumors, disease of the pulmonary apex, or a fractured clavicle or cervical rib. Aneurysm of the arch of the aorta, fracture or dislocation of the humeral head, or unusually abrupt and severe upward traction of the arm may also injure the nerves.

Although Bikele sign does not usually produce a profound finding in minor cervical nerve root compression syndromes, the maneuver often produces startling results in lower brachial plexopathy in the thoracic outlet. Reflex sympathetic changes may be present with the plexopathy and should be correlated with other physiologic findings.

BRACHIAL PLEXUS TENSION TEST

PROCEDURE

• The examiner passively elevates the patient’s shoulders through abduction.

• The elbows are extended to a point just short of the onset of pain and are maintained in this position.

• The shoulders are externally rotated to the point just short of the onset of pain and maintained.

• The examiner supports the shoulders and forearms in this position as the patient flexes the elbows (Fig. 3-16).

• Reproduction of symptoms suggests cervical spine disorders, most likely the C5 nerve root.

• In addition, from this challenge position, symptoms increase when the cervical spine is flexed.

FIG. 3-16

Although the brachial plexus tension test involves shoulder joint movement, it also provides maximal stretch on the brachial plexus, which affects the lower branches of the cervical spine (C5) the most. If this test is positive, the early stages of a C5 nerve root disorder may be present along with the subtle signs of a positive doorbell sign (pain that occurs at the superior scapulovertebral border and radiates with deep palpation to the C5 segment) and pain in the deltoid area. The deltoid pain is often misconstrued as an articular problem of the shoulder.

DEJERINE SIGN

DEJERINE TRIAD

TRIAD OF DEJERINE

Assessment for Herniated or Protruding Intervertebral Disc and Spinal Cord Tumor or Spinal Compression Fracture

PROCEDURE

• Coughing, sneezing, and straining during defecation may aggravate radiculitis symptoms (Fig. 3-17).

• This aggravation results from the mechanical obstruction of spinal fluid flow.

• Dejerine sign is present when one of the following exists: herniated or protruding intervertebral disc, spinal cord tumor, or spinal compression fracture.

• The course of the radiculitis helps identify the location of the lesion.

FIG. 3-17 Coughing, sneezing, or straining during defecation causes a reproduction of radicular symptoms, which suggests a space-occupying mass that is creating neurologic compression.

Patients with radicular symptoms and pronounced Dejerine sign, especially if it is in the lumbar spine, should be told to bend the knees and lean into a wall during a cough or sneeze. This maneuver reduces intradiscal pressure and minimizes the effect of the cough or sneeze on the nerve root. A more worrisome situation is the sudden, unexpected absence of Dejerine sign when all other clinical findings indicate an active nerve root compression. The loss of the sign indicates fragmentation of the disc with momentary decompression of the nerve.

DEKLEYN TEST

PROCEDURE

• Coughing, sneezing, and straining during defecation may aggravate radiculitis symptoms (Fig. 3-18).

• This aggravation results from the mechanical obstruction of spinal fluid flow.

• Dejerine sign is present when one of the following exists: herniated or protruding intervertebral disc, spinal cord tumor, or spinal compression fracture.

• The course of the radiculitis helps identify the location of the lesion.

FIG. 3-18 The patient is supine with the head extending off the end of the examination table. The patient rotates and hyperextends the neck to one side and holds this position for 15 to 45 seconds. The examiner may provide minimal support for the weight of the skull. The maneuver is repeated for the opposite side. The production of vertigo, visual disturbance, nausea, syncope, or nystagmus indicates vertebrobasilar circulation compromise.

DISTRACTION TEST

Assessment for Cervical Nerve Root Compression, Intervertebral Foraminal Encroachment, and Facet Capsulitis

ORTHOPEDIC GAMUT 3-18 ZYGAPOPHYSEAL JOINT MENISCI

Four distinct types of cervical zygapophyseal joint (Z-joint) menisci exist:

Type I: Menisci are thin and protrude far into the Z-joints, covering approximately 50% of the joint surface (found only in children).

Type II: Menisci are relatively large wedges that protrude a significant distance into the joint space (found almost exclusively at the lateral C1–C2 Z-joints).

Type III: Folds are rather small nubs (found throughout the C2–C3 to C6–C7 cervical Z-joints of most healthy adults).

Type IV: Menisci are quite large and thick (found in degenerative Z-joints).

Pain and stiffness may result from weather changes or unexplained causes. Radiculopathy is not always present. Hyporeflexia, motor weakness, and sensory disturbance (especially paresthesia) are common (Table 3-7).

TABLE 3-7 COMMON CLINICAL FEATURES OF CERVICAL DISC SYNDROMES

TABLE 3-8 CLINICAL PRESENTATIONS IN CERVICAL RADICULOPATHIES

ORTHOPEDIC GAMUT 3-19 INDIRECT SIGNS OF CERVICAL TRAUMA OR INJURY

Abnormal Soft Tissue

Hemorrhage caused by injury of the paracervical soft tissues displaces certain physiologic spaces that are appreciated radiographically, representing a space-occupying lesion:

• Widened retropharyngeal space (in excess of 7 mm)

• Widened retrotracheal space (in excess of 21 mm)

• Displacement of the prevertebral fat stripe

• Tracheal deviation and laryngeal dislocation

PROCEDURE

• With the patient seated, the examiner exerts upward pressure on the patient’s head.

• This removes the weight of the patient’s head from the neck.

• Generalized, increased pain indicates muscle spasm.

• Relief of pain indicates intervertebral foraminal encroachment or facet capsulitis.

• The examiner continues the distraction for up to 30 to 60 seconds to completely relax the involved tissues (Fig. 3-19).

• This test provides some prediction of the effect of cervical spine traction in relieving pain or paresthesia.

• Nerve root compression may be relieved, with disappearance of the symptoms and signs, if the intervertebral foramina are opened or the disc spaces extended.

• Pressure on the joint capsules of the apophyseal joints is also decreased by distraction.

FIG. 3-19

The distraction test not only indicates the nature of the patient’s complaint but also identifies the merit of cervical traction in the treatment regimen. Notably, the higher the poundage of static cervical traction required for relief is, the more unstable the nerve compression syndrome will be. Indeed, the higher poundage requirement is often an indicator of the need for surgical resolution.

FORAMINAL COMPRESSION TEST

PROCEDURE

• With the patient in the seated position, the examiner rotates the patient’s neck while exerting strong downward pressure on the head (Fig. 3-20).

• The test is then repeated bilaterally with the head in a neutral position.

• When the neck is rotated and downward pressure is applied, closure of the intervertebral foramen occurs.

• Localized pain indicates foraminal encroachment.

• Radicular pain indicates pressure on the nerve root.

• If nerve root involvement is suspected, the neurologic level must be evaluated.

FIG. 3-20

This test, as well as other compression maneuvers, often produces a cervical collapse sign in addition to radicular complaints. In the presence of capsular sprain with radicular components, compression overcomes the modicum of muscular strength that remains in the neck and is required for postural control. This condition means that the neck will collapse or buckle during the test. This collapse is found in grade II or greater sprain syndromes.

HALLPIKE MANEUVER

Assessment for Vertebrobasilar Artery Insufficiency

ORTHOPEDIC GAMUT 3-21 COMMON VERTEBROBASILAR ARTERIAL ISCHEMIC SYMPTOMS

Ischemic attacks that involve the section of the brain that is supplied by the vertebral and basilar arteries have an extremely wide range of symptoms:

• Vertigo

• Dizziness is the most common complaint with transient ischemic attacks that are caused by vertebrobasilar insufficiency. However, dizziness is commonly associated with other physiologic disturbances and is rarely the only symptom of brainstem ischemia.

• Tinnitus

• Tinnitus, hearing loss, and ataxia may be present.

• Patients may complain of unilateral or bilateral face, arm, and leg weakness and unilateral or bilateral sensations of numbness and tingling in the face, arms, or legs.

• In addition, patients with brainstem ischemia experience drop attacks in which they suddenly lose postural tone and fall to the ground without losing consciousness; they then immediately regain postural control and rise quickly.

PROCEDURE

• The Hallpike maneuver is an enhanced DeKleyn test and must be performed with extreme caution.

• The patient lies in the supine position, with the head extending off the end of the examination table.

• The examiner provides support for the weight of the skull.

• The examiner brings the patient’s head into positions of reclination (extension), rotation, and lateral flexion.

• The patient’s eyes are open so that the examiner may look for nystagmus and other neurovascular signs.

• The test is repeated for the opposite side.

• These positions are held for 15 to 45 seconds.

• In a final maneuver the patient’s head is allowed to hang freely in extreme extension (hyperextension) off the end of the examination table (Fig. 3-21).

• Vertigo, blurred vision, nausea, syncope, and nystagmus are signs of a positive test.

FIG. 3-21

Cervical spine manipulation and adjunctive therapeutic techniques are safe to use. Nevertheless, the patient’s welfare is always of prime concern, and screening tests will help identify patients who may be predisposed to cerebrovascular problems. During these procedures, symptoms of vertigo, nystagmus, dizziness, fainting, nausea, vomiting, visual blurring, headache (onset), or other sensory disturbances may identify a possible vertebrobasilar insufficiency. Problems in the cervical spine apart from the vertebral arteries may cause the same signs and symptoms. In suspected vertebral artery constriction, resisted neck extension may be painful, and prolonged cervical extension may produce a feeling of faintness. The transverse processes of the atlas are often tender on the side of involvement. These symptoms may improve significantly by using manipulative procedures. Therefore manipulation should not necessarily be abandoned; rather, the manipulative technique should be modified so that simultaneous extension and rotation are not used.

HAUTANT TEST

PROCEDURE

• While seated, the patient extends the arms out in front with the palms up.

• With eyes closed, the patient extends and rotates the head to one side (Fig. 3-22).

• The patient repeats this maneuver with the head extended and rotated to the opposite side.

• Drifting of the arms, vertigo, blurred vision, nausea, syncope, and nystagmus are signs of a positive test.

• The test indicates vertebral, basilar, or carotid artery stenosis or compression.

FIG. 3-22

JACKSON COMPRESSION TEST

Assessment for Cervical Nerve Root Compression Resulting from a Space-Occupying Lesion, Subluxation, Inflammatory Edema, Exostosis of Degenerative Joint Disease, Tumor, or Intervertebral Disc Herniation

ORTHOPEDIC GAMUT 3-23 CERVICAL NERVE ROOT COMPRESSION SYNDROME

Clinical axioms regarding cervical nerve root compression syndrome:

1. When sensory manifestations occur in C7 radiculopathy, the index or middle finger always is involved.

2. When sensory manifestations occur in C8 radiculopathy, the little or ring finger always is involved.

3. The thumb is never involved exclusively in C7 radiculopathy.

4. Significant triceps weakness is seen only in C7 radiculopathy.

5. Significant supraspinatus and infraspinatus weakness is seen only in C5 radiculopathy.

6. Significant interossei and hand intrinsic weakness is seen only in C8 radiculopathy.

Comment

Despite the variability in sensory and motor presentations of cervical radiculopathies, certain classic symptoms and signs exist and are extremely helpful in localizing the compressed root (Table 3-9).

TABLE 3-9 MODIFIED QUEBEC TASK FORCE CLASSIFICATION SYSTEM FOR ACUTE WHIPLASH ASSOCIATED DISORDERS (WAD)

Proposed Grade	Classification	Physical and Psychological Impairments Present
WAD 0		No complaint about neck pain No physical signs

WAD 1

Neck complaint of pain, stiffness or tenderness only

WAD II A

WAD II B

Neck pain

Motor Impairment

Decreased ROM

Elevated Psychological distress (GHQ-28, TAMPA)

Psychological Impairment

WAD II C

Neck pain

Motor Impairment

Decreased ROM

Increased JPE

Generalised sensory hypersensitivity (mechanical, thermal, BPPT)

Some may show SNS disturbances

Psychological Impairment

Psychological distress (GHQ-28, TAMPA)

Elevated levels of acute posttraumatic stress (IES)

WAD III

Neck pain

Motor Impairment

Decreased ROM

Increased JPE

Generalised sensory hypersensitivity (mechanical, thermal, BPPT)

Some may show SNS disturbances

Psychological Impairment

Psychological distress (GHQ-28, TAMPA)

Elevated levels of acute posttraumatic stress (IES)

Neurological signs of conduction loss including:

Decreased or absent deep tendon reflexes

Muscle weakness

Sensory deficits

WAD IV Fracture or dislocation

BPPT, Brachial plexus provocation test; CCFT, cranio-cervical flexion test; GHQ, general health questionnaire; IES, impact of events scale; JPE, joint positioning error; TAMPA, Tampa scale of kinesophobia.

Adapted from Sterling M. A proposed new classification system for whiplash associated disorders—implications for assessment and management, Man Ther 9(2):60-70, 2004.

PROCEDURE

• Cervical compression is commonly performed by having the patient sit up and bend the head obliquely backward while the examiner applies downward pressure on the vertex.

• However, with the Jackson cervical compression test, the head is only slightly rotated to the involved side (Fig. 3-23).

• In either case, the sign is positive if localized pain radiates down the arm.

• A positive sign indicates nerve involvement from a space-occupying lesion, subluxation, inflammatory swelling, exostosis of degenerative joint disease, tumor, or disc herniation.

FIG. 3-23

Closure of the intervertebral foramina occurs on the side of flexion in this maneuver. This test should be performed without excessive discomfort. The cervical collapse sign may be present.

LHERMITTE SIGN

Assessment for Myelopathy of the Cervical Spine

Comment

Peripheral neuropathy is a disorder that affects the peripheral motor, sensory, or autonomic nerves to a variable degree. If only one nerve is affected, mononeuropathy is indicated. If several nerves are involved in a distal symmetric or asymmetric fashion, polyneuropathy is indicated. A patter with multiple, single-peripheral nerves or their branches are involved is considered mononeuritis multiplex (Table 3-10).

TABLE 3-10 CLINICAL SIGNS OF CERVICAL RADICULOPATHY AND MYELOPATHY ^*

	Cervical Radiculopathy	Myelopathy
Muscle wasting	Path, unilateral	Path, bilateral
Sensory deficit radicular	Path	Norm
Vibratory sense diminished	Norm	Path, lower extremities
Muscle stretch reflexes	Path (weak)	Path (hyper)
Abdominal reflexes	Norm	Path (absent)
Spurling	Path	Norm
Babinski sign	Norm	Path
Hypertonicity	Norm	Path
Gait	Norm	Path

Norm, Normal; Path, pathologic.

* Classic findings include limitations in cervical range of motion, spasticity (with increased muscle tendon reflexes below the level of canal compromise), a positive Babinski sign, absent abdominal reflexes, decreased joint position and vibratory sensation, and an abnormal gait.

Adapted from Salvi FJ, Jones JC, Weigert BJ: The assessment of cervical myelopathy, Spine J 6(6, suppl 1):S182-S189, 2006.

ORTHOPEDIC GAMUT 3-24 CAUSES OF PROGRESSIVE DEGENERATIVE NARROWING OF THE CERVICAL SPINAL CANAL

• Osteophytic growth from the edge of the end plates of the vertebral bodies

• Disc herniation

ORTHOPEDIC GAMUT 3-25 OTHER COMMON CAUSES OF CERVICAL MYELOPATHY

• A focus of multiple sclerosis

• Intra- and extraaxial tumor

• Huge cervical disc herniation

• Hydrosyringomyelia

ORTHOPEDIC GAMUT 3-26 NEUROPATHY

Neuropathy evolving over many weeks or months suggests several possibilities:

1. Exposure to toxic agents or drugs

2. Nutritional deficiencies

3. Chronically abnormal metabolic state

4. Remote effect of a malignant disease

5. Genetic polyneuropathy, which may have an insidious onset at any age

PROCEDURE

• The patient is seated on the examining table.

• The patient’s head is passively flexed.

• A sharp pain radiating down the spine and into the upper or lower limbs is a positive finding (Fig. 3-24).

• Dural irritation in the spine is indicated.

• The test is similar to a combination of other meningeal irritation challenges.

FIG. 3-24

Although Lhermitte sign is often construed as a pathognomonic test for multiple sclerosis, it is not. However, Lhermitte sign does reveal or suggest myelopathy resulting from multiple sclerosis, stenosis, tumor, or disc herniation.

MAXIMUM CERVICAL COMPRESSION TEST

ASSESSMENT FOR CERVICAL NERVE ROOT SYNDROME OR FACET SYNDROME (CONCAVE TESTING) AND CERVICAL MUSCULAR STRAIN (CONVEX TESTING)

Comment

The vulnerability to injury of the cervical region is so great that even low- to moderate-intensity trauma can compromise a multitude of systems. As a result, a variety of signs and symptoms may develop. As is known, the secondary effects of whiplash are sometimes as disabling, if not more so, than the soreness and muscular stiffness of the initial symptoms (Table 3-11).

TABLE 3-11 SYMPTOMS EXPERIENCED WITH CERVICAL ACCELERATION-DECELERATION SYNDROMES

Symptom	Lesion Site
Headache	Suboccipital muscles, greater occipital nerve, myofascial trigger points, facet point irritation
Disorientation, irritability	Brain
Visual disturbances	Vertebrobasilar artery network, brainstem, cervical spinal cord
Memory and concentration disturbances	Brain
Vertigo	Cervical sympathetic nerves, vertebral artery, inner ear
Arm and hand numbness	Brachial plexus, scalenes
Thumb, index finger, middle finger numbness; weakness; temperature changes	Median nerve, carpal tunnel
Difficulty swallowing	Pharynx
Ringing in ears	Temporomandibular joint, vertebral and basilar arteries, cervical sympathetic chain, inner ear
Dizziness, light-headedness	Cervical sympathetic nerves, brain, inner ear
Neck and shoulder pain	Paravertebral muscles, apophyseal joints, cervical nerve roots, cervical disc
Poor balance, proprioception, and posture	Inner ear

Adapted from Brier SR: Primary care orthopedics, St Louis, 1999, Mosby.

ORTHOPEDIC GAMUT 3-27 MYOFASCIAL INVOLVEMENT

Two common areas of myofascial involvement of the cervical spine are:

1. Levator scapulae

2. Scalenes

ORTHOPEDIC GAMUT 3-28 TESTS OF DIFFERENTIATION

Three tests help in differentiating other thoracic outlet syndrome causes from the scalene trigger point hyperirritability:

1. The cramp test: The patient fully rotates the head to the affected side and drops the chin to the clavicle. The test is positive if a firm contraction or cramp of the scalene muscles occurs.

2. The finger-flexion test: A positive finding is present when all of the medial fingertips cannot press tightly against the metacarpophalangeal joints when the proximal phalanges are extended.

3. The scalene relief test: Elevation of the arm and clavicle lifts the clavicle from the underlying scalenes. To accomplish this task, the patient places the forearm of the involved side across the forehead (similar to reverse Bakody sign); this action produces pain relief within minutes.

PROCEDURE

• While in the seated position, the patient is instructed to approximate the chin to the shoulder and extend the neck (Fig. 3-25).

• The test is performed bilaterally.

• Pain on the concave side indicates nerve root or facet involvement.

• Pain on the convex side indicates muscular strain.

FIG. 3-25

The patient with lower cervical nerve root compression syndrome has already discovered that looking up or down with the head rotated is uncomfortable and produces neck and arm pain. If these positions are already producing pain, then attempts to use manipulative procedures incorporating these positions will be difficult for the patient to tolerate.

NAFFZIGER TEST

Assessment for Space-Occupying Mass in the Cervical Spine or Canal

PROCEDURE

• Naffziger compression test is performed by having the patient sit erect while the examiner holds digital pressure over the jugular veins for 30 to 40 seconds.

• The patient is then instructed to cough deeply.

• Pain along the distribution of a nerve may indicate nerve root compression (Fig. 3-26).

• Although this test is more commonly used for lower back involvement, cervical or thoracic root compression may also be aggravated.

• Local pain in the spine does not positively indicate nerve compression but may indicate the site of a strain or sprain injury or other lesion.

• The sign is always positive in the presence of cord tumors, particularly spinal meningiomas.

• The resulting increased spinal fluid pressure above the tumor causes the growth to compress or pull on certain sensory nerve structures, which produces radicular pain.

• The test is contraindicated for a geriatric patient, and extreme care should be taken when performing this test on anyone suspected of having atherosclerosis.

• In all cases, the patient should be alerted that jugular pressure may result in light-headedness or dizziness.

FIG. 3-26

This test is not a good one for a geriatric or atheromatous patient to endure. The resulting increase in cerebrospinal fluid pressure is uncomfortable, and the momentary circulatory obstruction may result in significant syncope.

O’DONOGHUE MANEUVER

Assessment for Cervical Muscular Strain (Isometric) and Cervical Ligamentous Sprain (Passive Range of Motion)

Comment

Most patients with cervical strain complain of paraspinal muscular aches and stiffness that may extend as far cephalad as the suboccipital region (Table 3-12). Chronic muscular strain of the cervical spine can affect distant organ systems. Pain may be referred to the head, orbits, or scapula.

TABLE 3-12 CERVICAL STRAIN ASSESSMENT

Physical examination findings

Paravertebral muscle tenderness

Intermittent stiffness

Loss of cervical mobility

Headaches and alterations of postural reflexes in chronic sufferers

Normal neurologic signs

No instability; screening for postural distortion

Intersegmental posterior joint dysfunction

X-ray findings

Findings generally normal

Possible decrease in cervical lordosis

Adapted from Brier SR: Primary care orthopedics, St Louis, 1999, Mosby.

ORTHOPEDIC GAMUT 3-29 CERVICAL SPINE MUSCULAR INJURY

The mechanism of cervical spine muscular injury is usually one of the following:

1. Athletic participation, which is by far the most frequent means of sustaining a strain injury

2. Overuse

3. Overstretching

4. Contraction of the muscle against resistance

5. Direct blow

ORTHOPEDIC GAMUT 3-30 STRAINS

Strains are divided into three categories according to the degree of muscle tissue damage:

1. A mild strain is a low-grade inflammatory reaction accompanied by no appreciable hemorrhage, minimal amounts of swelling and edema, and some disruption of adjacent fibers.

2. A moderate strain involves laceration of fibers and appreciable hemorrhaging into the surrounding tissue (hematoma), followed by an inflammatory reaction with swelling and edema.

3. A severe strain is the consequence of a single, violent incident that results in complete disruption of the muscle unit. These strains occur when a tendon is torn from the bone or pulled apart, when the musculotendinous junction ruptures, or when the muscle ruptures through its belly.

ORTHOPEDIC GAMUT 3-31 SPRAINS

Sprains are divided into four categories according to the severity of the ligamentous injury:

1. A mild sprain describes an injury in which only a few of the ligamentous fibers are severed.

2. A moderate sprain is a more severe tearing but less than a complete separation of the ligament.

3. A severe sprain is a complete tearing of a ligament from its attachments or a complete separation within its substance.

4. A sprain-fracture has occurred when the ligamentous attachment pulls loose with a fragment of bone (avulsion).

ORTHOPEDIC GAMUT 3-32 CERVICAL ACCELERATION-DECELERATION INJURY

Five types of cervical acceleration-deceleration injury:

Type I: Patients can have severe injuries as a result of seemingly small degrees of acceleration trauma. The symptoms include mild discomfort and stiffness of the cervical spine and loss of small increments in range of motion.

Type II: Injury with palpable muscle splinting, restriction of motion, and mild to moderate spasm. No neurologic deficits or evidence of radiculopathy is observed.

Type III: Injury symptoms include moderate ligamentous sprain, advanced musclea swelling, and muscle spasm. Loss of range of motion in all planes is observed.

Type IV: Injury produces radicular symptoms that may be bilateral or unilateral. Motor and reflex changes are common.

Type V: Injury usually produces signs of neurologic instability. Cervical fracture or facet dislocation are common. Myelopathy and frank disc herniation commonly occur. Swelling and disc fragmentation are possible at the level of the spinal canal.

Separating various grades of cervical whiplash injury is possible according to the degree of external trauma, orthopedic, and neurologic findings, as well as patient disability (Table 3-13).

TABLE 3-13 CERVICAL ACCELERATION-DECELERATION INJURY TYPES

PROCEDURE

• While the patient is sitting, the cervical spine is actively moved through resisted range of motion and then through passive range of motion.

• Pain during resisted range of motion, or isometric contraction, signifies muscle strain (Fig. 3-27).

• Pain during passive range of motion signifies ligamentous sprain (Fig. 3-28).

FIG. 3-27

FIG. 3-28 If isometric testing is negative, the examiner passively rotates the patient’s head and neck to one side to the limit of joint play. Pain produced in this maneuver suggests ligamentous injury. The maneuver is performed bilaterally.

This maneuver can be applied to any joint or series of joints to determine ligamentous or muscular movement. By remembering that resisted range of motion stresses mainly muscles and passive range of motion stresses mainly ligaments, the examiner should be able to differentiate between strain and sprain and should be able to determine whether a combination of both is present.

RUST SIGN

Assessment for Severe Cervical Spine Sprain, Upper Cervical Rheumatoid Arthritis, Upper Cervical Spine Fracture, and Severe Upper Cervical Spine Subluxation

ORTHOPEDIC GAMUT 3-33 ODONTOID PROCESS FRACTURES

The Anderson/D’Alonzo classification of odontoid process fractures:

Type I: Fractures of the odontoid are thought to represent an avulsion injury of the tip of the dens by the alar ligament. This injury is very rare, and because it is located above the transverse ligament, no associated atlantoaxial instability occurs.

Type II: Fractures through the body or base of the odontoid have a reported prevalence of nonunion of up to 64%.

Type III: Fractures that extend into the cancellous bone of the axis have an excellent prognosis with adequate reduction and external immobilization.

PROCEDURE

If the patient spontaneously grasps the head with both hands when lying down or when arising from a recumbent position, this action is a positive sign that indicates severe sprain, rheumatoid arthritis, fracture, or severe cervical subluxation (Figs. 3-29 and 3-30).

FIG. 3-29

FIG. 3-30 No less significant is the patient who cannot rise from the supine position without lifting the head manually, suggesting gross upper cervical spine instability as a result of fracture or severe sprain.

No other physical finding is as important or as revealing as Rust sign. The presence of this sign mandates that (1) no further passive or active testing be undertaken, (2) imaging be performed immediately, and (3) the neck be adequately supported by using a cervical collar. Rust sign has never been observed in conditions of minor consequence.

SHOULDER DEPRESSION TEST

Assessment for Cervical Dural Sleeve Adhesion (Nerve Root) and Shoulder Adhesive Capsulitis

ORTHOPEDIC GAMUT 3-35 ADHESION DEGREES BETWEEN DURA MATER AND FIBROUS TISSUE

• Grade 0: when the dura mater is free of the fibrous tissue

• Grade 1: when only thin fibrous band or bands between dura mater and fibrous tissue is observed

• Grade 2: when continuous adherence is observed but less than two thirds of the laminectomy defect

• Grade 3: when fibrous tissue adherence is large, more than two thirds of the laminectomy defect, or extends to the nerve roots

PROCEDURE

• With the patient seated, the examiner depresses the patient’s shoulder on the affected side and laterally flexes the cervical spine away from that shoulder (Fig. 3-31).

• The sign is positive if radicular pain is produced or aggravated.

• A positive sign indicates adhesions of the dural sleeves, spinal nerve roots, or adjacent structures of the joint capsule of the shoulder.

FIG. 3-31

As with cervical distraction testing, this maneuver helps predict the viability of cervical traction in therapy. A sharply positive finding usually means that the patient will not tolerate cervical traction. The traction may aggravate the dural sleeve adhesion instead of relieving it.

SOTO-HALL SIGN

PROCEDURE

• The patient is placed supine.

• The examiner places one hand on the sternum of the patient and exerts slight pressure so that no flexion can take place at either the lumbar or thoracic regions of the spine.

• The examiner places the other hand under the patient’s occiput and flexes the head toward the chest.

• The test is primarily used when fracture of a vertebra is suspected.

• The flexion of the head and neck on the sternum progressively produces a pull on the posterior spinous ligaments.

• When the spinous process of the injured vertebra is reached, the patient experiences a noticeable local pain.

• A positive result indicates subluxation, exostoses, disc lesion, sprain or strain, vertebral fracture, or meningeal irritation (an elevated temperature must be present for corroboration) (Fig. 3-32).

FIG. 3-32

Soto-Hall sign is often misapplied in the assessment of fractures and sprains for the entire spine. The sign is a nonspecific test with limited capacity to localize conditions of the cervical and upper thoracic spine. The use of this sign to draw conclusions below T8 is largely guesswork.

With the Kernig or Brudzinski phenomena in this test, the patient’s temperature must be assessed. A febrile patient with Kernig or Brudzinski sign—a variation of Soto-Hall sign—is a high-risk candidate for meningitis.

SPINAL PERCUSSION TEST

Assessment for Osseous or Soft-Tissue Injury

ORTHOPEDIC GAMUT 3-39 ATLANTOAXIAL INJURIES

The radiographic signs of atlantoaxial injuries are often subtle:

1. The prevertebral soft-tissue shadow on the lateral radiograph should be less than 5 mm wide at C2 and 5 to 10 mm wide in front of the ring of the atlas.

2. The lateral C-spine view will reveal fractures of the posterior ring of the atlas.

3. The open-mouth odontoid view helps in detecting subtle displacement of the lateral masses in relation to the facets of the axis.

ORTHOPEDIC GAMUT 3-40 CERVICAL SPINE FLEXION-EXTENSION RADIOGRAPHS

The following are prerequisites for cervical spine flexion-extension radiographs:

1. A neurologically intact patient

2. Performance of all movements actively by the patient

3. No altered state of consciousness (including intoxication)

4. Direct physician supervision of the radiographic study

Comment

Pain or discomfort that is nonarticular may be myofascial in origin. The patient with myofascial pain typically has multiple sites of trigger points that refer pain to a distant site (Table 3-16).

TABLE 3-16 REFERRAL ZONES ASSOCIATED WITH TRIGGER POINTS IN MYOFASCIAL PAIN SYNDROME

Localized Trigger Points	Referral Zone
Suboccipital muscles	Temporal region Vertex of head Temporalis muscle via greater occipital nerve

Levator scapula Inferior or superior scapula border, occiput Greater or lesser rhomboid muscles Cervical spine, shoulder, or scapula region Infraspinous or teres minor muscles Arm, shoulder, hand Sternocleidomastoid muscles

Supraorbital region

Temporal region

Forehead, ear

Scalene muscles Shoulder, arm or hand, chest, scapula Masseter muscle Ear, suboccipital region, temporal region Trapezius muscle Suboccipital region, shoulder, orbit or temporal area

From Brier SR: Primary care orthopedics, St Louis, 1999, Mosby.

PROCEDURE

• With the patient seated and the head slightly flexed, the examiner percusses the spinous processes and associated musculature of each of the cervical vertebra with a neurologic reflex hammer (Fig. 3-33).

• Evidence of localized pain indicates a possible fractured vertebra.

• Evidence of radicular pain indicates a possible disc lesion.

• Because of the nonspecific nature of this test, other conditions will also elicit a positive pain response.

• A ligamentous sprain will cause pain when the spinous processes are percussed.

• Percussing the paraspinal musculature will elicit a positive sign for muscular strain (Fig. 3-34).

FIG. 3-33

FIG. 3-34