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Cervical Spine Pathologies and Special Tests Orthopedic Assessment III Head, Spine, and Trunk with Lab PET 5609C Slide 2 Pathologies Brachial Plexus Pathology: Brachial Plexus Pathology: Brachial Plexus Neuropraxia: Brachial Plexus Neuropraxia: Common name: Burner or Stinger Common name: Burner or Stinger Definition: Definition: Transient brachial plexopathy involving the upper trunk Transient brachial plexopathy involving the upper trunk Temporary episode of unilateral upper extremity burning dysethesia with or without motor weakness Temporary episode of unilateral upper extremity burning dysethesia with or without motor weakness Stinger tingling that occurs in upper extremity after injury Stinger tingling that occurs in upper extremity after injury Slide 3 Pathologies Brachial Plexus Pathology: Brachial Plexus Pathology: Epidemiology: (specific studies) Epidemiology: (specific studies) 50% of a Division I FB team had 1 or more burners/season (Robertson et al.) 50% of a Division I FB team had 1 or more burners/season (Robertson et al.) 65% of DIII FB players (201) during careers / 57% > 1 burner (Sallis et al.) 65% of DIII FB players (201) during careers / 57% > 1 burner (Sallis et al.) 70% reported additional burners that they did NOT report 70% reported additional burners that they did NOT report occurrence with defensive players (DBs) Slide 4 Pathologies Brachial Plexus: C5 T1 Brachial Plexus: C5 T1 7 cervical vertebrae 7 cervical vertebrae 8 cervical nerves: 8 cervical nerves: 1 st 7: exit above the corresponding vertebrae 1 st 7: exit above the corresponding vertebrae C8: exits below the 7 th cervical vertebrae C8: exits below the 7 th cervical vertebrae Slide 5 Pathologies Brachial Plexus Pathology: Brachial Plexus Pathology: Mechanism of Injury: Mechanism of Injury: Stretch of the brachial plexus: Stretch of the brachial plexus: Head forced laterally while opposite shoulder is depressed (common MOI tackling) Head forced laterally while opposite shoulder is depressed (common MOI tackling) C5 and C6 (most commonly affected) C5 and C6 (most commonly affected) Nerve root compression: Nerve root compression: Combination of neck hyperextension and ipsilateral lateral flexion Combination of neck hyperextension and ipsilateral lateral flexion Nerve roots impinged between vertebrae Nerve roots impinged between vertebrae Spinal stenosis - risk Spinal stenosis - risk Compression of brachial plexus: Compression of brachial plexus: Direct blow to Erbs point (shoulder pads compress plexus) Direct blow to Erbs point (shoulder pads compress plexus) Slide 6 Pathologies Slide 7 (A) Traction to the brachial plexus (ipsilateral shoulder depression and contralateral lateral neck flexion) (B) Direct blow to the supraclavicular fossa (Erb's point) (C) Compression of the cervical roots or brachial plexus (ipsilateral lateral flexion and hyperextension) Slide 8 Pathologies Slide 9 Pathologies Brachial Plexus Pathology: Brachial Plexus Pathology: Signs and symptoms: Signs and symptoms: Numbness and burning of the entire arm, hands, fingers Numbness and burning of the entire arm, hands, fingers Sensation loss over dermatomes Sensation loss over dermatomes Complete transient paralysis of affected nerves Complete transient paralysis of affected nerves Tenderness over the brachial plexus Tenderness over the brachial plexus Grading: Grading: Grade 1 (Neuropraxia): transient signs/sx. last from a few minutes 2 weeks Grade 1 (Neuropraxia): transient signs/sx. last from a few minutes 2 weeks Grade 2 (Axonotmesis): significant sensory/motor deficits > 2 weeks and less than 2 weeks and less than < 6 months Grade 3 (Neurotmesis): symptoms 6 months 1 year Grade 3 (Neurotmesis): symptoms 6 months 1 year Slide 10 Pathologies Brachial Plexus Pathology: Evaluation Brachial Plexus Pathology: Evaluation Inspection: Inspection: Athlete shakes arm/hand in attempt to regain feeling Athlete shakes arm/hand in attempt to regain feeling Inspect cervical spine for abnormality (fracture/dislocation) Inspect cervical spine for abnormality (fracture/dislocation) Palpation: Palpation: Cervical spine Cervical spine Clavicle, humerus, scapula, sternum, ribs Clavicle, humerus, scapula, sternum, ribs SC, AC, GH joints SC, AC, GH joints Shoulder musculature Shoulder musculature Slide 11 Pathologies Brachial Plexus Pathology: Evaluation Brachial Plexus Pathology: Evaluation Functional Testing: Functional Testing: Active and passive ROM (all neck and shoulder movements) Active and passive ROM (all neck and shoulder movements) RROM can be performed in conjunction with myotome check RROM can be performed in conjunction with myotome check Key muscles tested: deltoid, external rotators, biceps brachii Key muscles tested: deltoid, external rotators, biceps brachii Neurological Screening: Neurological Screening: Upper quarter sensory/motor testing Upper quarter sensory/motor testing Special Tests: Special Tests: Brachial plexus stretch test Brachial plexus stretch test Cervical compression and distraction Cervical compression and distraction Spurling test Spurling test Slide 12 Slide 13 Clinical Evaluation C1-C2 Neck flexion C3 Neck lateral flexion C4 Shoulder shrug C5 Shoulder abduction, ER C6 Elbow flexion, wrist extension C7 Elbow extension, wrist flexion C8 Thumb extension T1 Finger abduction and adduction Slide 14 Pathologies Brachial Plexus Pathology: Brachial Plexus Pathology: Return to Play Criteria: Return to Play Criteria: Full, pain-free active and passive ROM in the cervical spine Full, pain-free active and passive ROM in the cervical spine Full, pain-free neck strength against resistance Full, pain-free neck strength against resistance Full strength of all shoulder and arm movements Full strength of all shoulder and arm movements Normal sensation in all dermatomes Normal sensation in all dermatomes Check shoulder pads/helmet to ensure proper fit Check shoulder pads/helmet to ensure proper fit Recheck in 3-5 minutes Recheck in 3-5 minutes Slide 15 Protective Equipment: A: Neck Roll B: Lifter C: Cowboy Collar Slide 16 Pathologies Research Article #1: Research Article #1: Effects of Football Collars on Cervical Hyperextension and Lateral Flexion Effects of Football Collars on Cervical Hyperextension and Lateral Flexion Objective: Evaluate the effectiveness of 3 football collars in cervical ROM Objective: Evaluate the effectiveness of 3 football collars in cervical ROM Why: Why: MOI for stingers MOI for stingers Do the collars movement? Do the collars movement? PREVENTION PREVENTION Slide 17 Pathologies Effects of FB Collars on Cervical Hyperextension and Lateral Flexion: Effects of FB Collars on Cervical Hyperextension and Lateral Flexion: Methods: Methods: Subjects: 15 D1 football players Subjects: 15 D1 football players Force applied (hand-held dynamometer) Force applied (hand-held dynamometer) Motion: 2-dimensional video analysis Motion: 2-dimensional video analysis Movement: Movement: AROM and PROM AROM and PROM Hyperextension Hyperextension Lateral flexion Lateral flexion Slide 18 Slide 19 Hyperextension Findings: Can be limited by all 3 collars: (rankings) 1. Cowboy collar 2. A-Force 3. Neck roll Note: Passive overloading still resulted in additional 19 0 of hyperextension Lateral Flexion Findings: No collar passive lateral flexion better than the shoulder pads alone Standard neck roll active ROM Slide 20 Pathologies Research Article #2: Research Article #2: Biomechanical Analysis of Football Neck Collars: Biomechanical Analysis of Football Neck Collars: Objective: Perform a biomechanical analysis of neck collars through dynamic testing Objective: Perform a biomechanical analysis of neck collars through dynamic testing Why: Why: MOI for head and neck injuries MOI for head and neck injuries Do the collars force transmission (upon impact)? Do the collars force transmission (upon impact)? Slide 21 Pathologies Biomechanical Analysis of FB Neck Collars: Biomechanical Analysis of FB Neck Collars: Methods: Methods: Collars (3) evaluated: Collars (3) evaluated: Cowboy collar (McDavid) Cowboy collar (McDavid) Bullock collar Bullock collar Kerr collar Kerr collar Crash-test dummy: Crash-test dummy: Shoulder pads (raised and unraised), helmet, collar Shoulder pads (raised and unraised), helmet, collar Accelerometers / load cells / angular rate sensors Accelerometers / load cells / angular rate sensors Impacts: Impacts: Pneumatic linear impactor Pneumatic linear impactor 5 m/s and 7 m/s 5 m/s and 7 m/s Slide 22 Slide 23 Pathologies Biomechanical Analysis of FB Neck Collars: Biomechanical Analysis of FB Neck Collars: Results: Results: Top of Head Impact: Top of Head Impact: Most protection: Kerr collar (Bullock 2 nd ) Most protection: Kerr collar (Bullock 2 nd ) Why? Kerr collar contacts the base of the helmet during impact redirects some load to shoulders Why? Kerr collar contacts the base of the helmet during impact redirects some load to shoulders Front Impact: Front Impact: Most protection: Kerr collar (all provided protection ) Most protection: Kerr collar (all provided protection ) head and neck movement ** head and neck movement ** Side Impact: Side Impact: Kerr minimal protection Kerr minimal protection Cowboy and Bullock no protection Cowboy and Bullock no protection Slide 24 Peak Values for Front Impact: Normal Shoulder Pad Configuration Slide 25 Pathologies Cervical Nerve Root Impingement: Cervical Nerve Root Impingement: History: History: Onset: Acute of chronic Onset: Acute of chronic Pain: Radiating symptoms into trapezius, scapula, shoulder, arm, wrist, and hand Pain: Radiating symptoms into trapezius, scapula, shoulder, arm, wrist, and hand MOI: Compression or irritation of nerve MOI: Compression or irritation of nerve Predisposing conditions: Predisposing conditions: Disc pathology, narrowing of intervertebral foramina, facet degeneration Disc pathology, narrowing of intervertebral foramina, facet degeneration Slide 26 Pathologies Cervical Nerve Root Impingement: Cervical Nerve Root Impingement: Inspection: Inspection: Posture of head Posture of head Palpation: Palpation: Point tenderness Point tenderness Functional Tests: Functional Tests: Pain with extension, lateral bending toward same side, and rotation Pain with extension, lateral bending toward same side, and rotation AROM, PROM, RROM AROM, PROM, RROM Neurological Tests: Neurological Tests: Upper quarter screen: Upper quarter screen: Muscle weakness, paresthesia, diminished reflexes Muscle weakness, paresthesia, diminished reflexes Special Tests: Special Tests: Cervical compression test ( symptoms) Cervical compression test ( symptoms) Cervical distraction test ( symptoms) Cervical distraction test ( symptoms) Spurling test / Vertebral artery test / Abduction test Spurling test / Vertebral artery test / Abduction test Slide 27 Slide 28 Special Tests Brachial Plexus Traction Test: Brachial Plexus Traction Test: Patient position: Patient position: Seated Seated ATC position: ATC position: Standing behind the patient Standing behind the patient Procedure: Procedure: One hand placed on side of the patients head; other hand over the AC joint (same side) One hand placed on side of the patients head; other hand over the AC joint (same side) Cervical spine is laterally bent and opposite shoulder depressed Cervical spine is laterally bent and opposite shoulder depressed Positive test: Positive test: Radiating pain on the side opposite the lateral bending Radiating pain on the side opposite the lateral bending Stretching of brachial plexus Stretching of brachial plexus Radiating pain on the side toward the lateral bending Radiating pain on the side toward the lateral bending Compression of cervical nerve roots between 2 vertebrae Compression of cervical nerve roots between 2 vertebrae Slide 29 MOI is duplicated in attempt to replicate the athletes symptoms. Radiating pain down left shoulder traction injury / Radiating pain down right shoulder compression injury. Perform bilaterally and do NOT perform with suspected cervical spine fracture and/or dislocation. Slide 30 Special Tests: Cervical Compression Test: Cervical Compression Test: Patient position: Patient position: Sitting Sitting ATC position: ATC position: Standing behind the athlete with hands interlocked over the top of the patients head Standing behind the athlete with hands interlocked over the top of the patients head Procedure: Procedure: Press down on the crown of patients head Press down on the crown of patients head Positive test: Positive test: Pain in upper cervical spine and/or upper extremity Pain in upper cervical spine and/or upper extremity Implication; Implication; Compression of the facet joints and narrowing of the intervertebral foramen Compression of the facet joints and narrowing of the intervertebral foramen Slide 31 Special Tests Cervical Compression Test: Attempts to duplicate patients symptoms by pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out. Slide 32 Special Tests Spurling Test (Foraminal Compression): Spurling Test (Foraminal Compression): Patient position: Patient position: Seated Seated ATC position: ATC position: Standing behind the athlete with hands interlocked over crown of patients head Standing behind the athlete with hands interlocked over crown of patients head Procedure: Procedure: Patient laterally flexes the head while a compressive force is placed along patients cervical spine Patient laterally flexes the head while a compressive force is placed along patients cervical spine Positive test: Positive test: Radiating pain down patients arm Radiating pain down patients arm Implication: Implication: Nerve root impingement Nerve root impingement Slide 33 Special Tests Spurlings Test: Attempts to compress a cervical nerve root. Do NOT perform until a cervical fracture, dislocation, or instability has been ruled out. Slide 34 Special Tests Cervical Distraction Test: Cervical Distraction Test: Patient position: Patient position: Supine (relaxes the muscles acting on the cervical spine) Supine (relaxes the muscles acting on the cervical spine) ATC position: ATC position: At head of patient with one hand under the occiput and the other on top of the forehead (stabilizing head) At head of patient with one hand under the occiput and the other on top of the forehead (stabilizing head) Procedure: Procedure: Apply traction on patients head, causing distraction of cervical spine Apply traction on patients head, causing distraction of cervical spine Positive test: Positive test: Relief or reduction in symptoms Relief or reduction in symptoms Implications: Implications: Compression of the cervical facet joints and/or stenosis of neural foramina Compression of the cervical facet joints and/or stenosis of neural foramina Slide 35 Cervical Distraction Test: Attempts to relieve patients symptoms by pressure on cervical nerve roots. Do NOT perform test until cervical fracture, dislocation, or instability has been ruled out. Slide 36 Special Tests Vertebral Artery Test: Vertebral Artery Test: Patient position: Patient position: Supine Supine ATC position: ATC position: Seated at head of the patient with hands placed under the occiput to stabilize the head Seated at head of the patient with hands placed under the occiput to stabilize the head Procedure: Procedure: Passively extend and laterally flex the cervical spine (1) Passively extend and laterally flex the cervical spine (1) Head is rotated toward the laterally flexed side and held for 30 seconds (2) Head is rotated toward the laterally flexed side and held for 30 seconds (2) Positive test: Positive test: Dizziness, confusion, nystagmus, unilateral pupil changes, nausea Dizziness, confusion, nystagmus, unilateral pupil changes, nausea Implication: Implication: Occlusion of the cervical vertebral arteries Occlusion of the cervical vertebral arteries Slide 37 Vertebral Artery Test: Used to assure the competency of the vertebral artery prior to initiating treatment or rehabilitation techniques that may compromise a partially occluded artery. Do NOT perform until the presence of a cervical fracture, dislocation, or instability has been ruled out. Positive Test: Refer to physician