copyright © 2013 wolters kluwer health | lippincott williams & wilkins cervical and thoracic...

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Cervical and Thoracic Spinal Conditions

Cervical and Thoracic Spinal Conditions

Chapter 11


AnatomyAnatomy

• Spinal column– Vertebrae

• Cervical (7)convex anteriorly

• Thoracic (12)concave anteriorly

• Lumbar (5)convex anteriorly

• Sacral (5 fused)concave anteriorly

• Coccyx (4 fused)


Anatomy (cont.)Anatomy (cont.)

– Structure• Rigid enough to support body and protect

spinal cord• Flexible enough to produce a

variety of movements



• Cervical– 7 vertebrae form curve – convex anteriorly– 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 – concave anteriorly – Extra facets for articulation with ribs


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



• Motion segment

– Functional unit

– Any 2 adjacent vertebrae and soft tissues between them



• Intervertebral discs

– Components

• Annulus fibrosus

Thick fibrous ring

• Nucleus pulposus

Gelatinous interior

– Function

• Shock absorption

• Allow spine to bend



• Ligaments

– Anterior longitudinal

– Posterior longitudinal

– Ligamentum flavum

– Interspinous

– Supraspinous



Muscles of the neck: lateral view



Muscles of the neck: posterior view



• Nerve plexus

– Cervical (C1–C4)

– Brachial (C5–T1)



• Blood supply

– Common carotid

– Vertebral


KinematicsKinematics

• Movements involve a number of motion segments– Flexion/extension/ hyperextension– Lateral flexion– Lateral rotation


KineticsKinetics• Effects of loading

– Primary load

• Cervical spine: weight of head

• Thoracic: weight of body above and any load in hands

• Effects of impact forces

– High speed and collision → risk

– Cervical flexion (large bending moment) + axial compression load = danger


Kinetics (cont.)Kinetics (cont.)


Kinetics (cont.)Kinetics (cont.)• Cervical spine compression deformation

– Angular deformation and buckling occurs as load continues and maximum compression deformation is reached

– Continued force results in an anterior compression fracture, subluxation, or dislocation


Anatomic Variations: Injury PotentialAnatomic 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.)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 (cont.)Anatomic Variations: Injury Potential (cont.)


Prevention of Spinal InjuriesPrevention of Spinal Injuries

• Protective equipment

– Neck roll

– Rib protectors

• Physical conditioning

– Strength and flexibility

• Proper technique

– Spearing

– Proper lifting

– Posture


Cervical Spine ConditionsCervical 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 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 Spine Conditions (cont.)

• Cervical spinal stenosis

– Structural

• Torg ratio

– Functional

• Loss of CSF around the cord → cord’s ability to decompress

– Asymptomatic until external force to head



– S&S

• On impact, may develop immediate quadriplegia with sensory changes or motor deficits in both arms, both legs, or all 4 extremities

• Transient with full recovery in 10–15 minutes (or 36–48 hrs)

– Management: activate EMS

– Continued participation



• Spear tackler’s spine

– Mechanism: cervical flexion + axial loading

– S&S

• Immediate pain with sensory changes and motor deficits distal to injury site

– Management: activate EMS

– Criteria to return to play—controversial



• 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



– S&S

• Varying degrees of neck or arm pain, may radiate

• Pain exacerbated by Valsalva maneuvers and neck movement

• + Spurling’s maneuver

• + Babinski’s sign

• Severe cases—potential loss of motor function below injury level

– Management: rest, activity modification, NSAIDs



• 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



• 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



• “Red flags” indicating a possible cervical spine injury: refer to Box 11.1


Brachial Plexus InjuriesBrachial 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.)



Grade Injury Signs Prognosis

I Neurapraxia injury

Temporary loss of sensation or loss of motor function

Recovery within days to a few weeks

II Axonotmesis injury

Significant motor and mild sensory deficits

Deficits last at least 2 weeks

Regrowth is slow, but full or normal function is usually restored

III Neurotmesis injury

Motor and sensory deficits persist for up to 1 year

Poor prognosis

Surgical intervention is often necessary

Classification of Burners



• 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



• Chronic burner syndrome– 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



• Suprascapular nerve injury

– Innervates the supraspinatus, infraspinatus, and glenohumeral joint capsule

– Same mechanism

– S&S

• Muscles weak and atrophied

• Improper functioning of muscles → other problems (e.g., rotator cuff tendinitis, impingement syndrome, bicipital tenosynovitis, or bursitis)

– Management: standard treatment; refer to physician


Thoracic Spine ConditionsThoracic 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


Thoracic Spine Conditions (cont.)Thoracic Spine Conditions (cont.)

• Thoracic spinal fractures and apophysitis

– Wedge fracture

• Fracture of vertebral end plates


Thoracic Spine Conditions (cont’d)Thoracic Spine Conditions (cont’d)

• Mechanism

Large compressive loads or landing on the buttock area

Compressive stress during small, repetitive loads

• S&S: standard fracture; pain and muscle guarding

• Management: physician referral



– Scheuermann’s disease

• Leading cause of fractures among adolescents

• Osteochondrosis of the spine

• Abnormal epiphyseal plate behavior allows herniation of disc into vertebral body

• After physician referral, treatment: activity modification, stretching (shoulder, neck, and back muscles), and strengthening (abdominal and spinal extensor muscles)



– Apophysitis

• Repeated flexion–extension of thoracic spine

• Progressive condition characterized by local pain and tenderness

• After physician referral, treatment: eliminate flexion–extension stress; strengthening of abdominal and other trunk muscles


Assessment of Spinal ConditionsAssessment 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.)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 IndividualSpinal 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.)Spinal Assessment—Conscious Individual (cont.)

• Observation/inspection– Postural assessment– Scan exam– Gait analysis– Inspection of injury site– Gross neuromuscular assessment



• Palpation

– Seated, standing, supine, or prone position

– Relax the neck and spinal muscles—lying position

– Posterior neck structures

• Patient supine

– Thoracic region

• Patient prone

• Pillow under the hip region to tilt the pelvis back and relax the lumbar curvature



• 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)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 SpineAROM – Cervical Spine


AROM – Thoracic SpineAROM – Thoracic Spine


ROM (cont.)ROM (cont.)• Normal ranges

– Cervical flexion—80–90°

– Cervical extension—70°

– Lateral cervical flexion (left and right)—20–45°

– Cervical rotation (left and right)—70–90°

– Forward trunk flexion—40–60°

– Trunk extension—20–35°

– Lateral trunk flexion (left and right)—15–20°

– Trunk rotation—35–50°


ROM (cont.)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.)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 TestsStress and Functional Tests

• Brachial plexus traction

Cervical Spine TestsCervical Spine Tests


Cervical Spine Tests (cont.)Cervical Spine Tests (cont.)• Brachial plexus tension test


Cervical Spine Tests (cont.)Cervical Spine Tests (cont.)

• Cervical compression

• Spurling’s test


Cervical Spine Tests (cont.)Cervical Spine Tests (cont.)• Cervical distraction

• Shoulder abduction


Facet Joint MobilityFacet Joint Mobility

• Spring Test


Nerve Root ImpingementNerve Root Impingement

• Valsalva Test

• First thoracic nerve root stretch


Neurologic TestsNeurologic Tests

• Oppenheim

• Babinski

• Hoffman


Neurologic Tests (cont.)Neurologic Tests (cont.)– Myotomes

Nerve Root Segment Action Tested

C1–C2 neck flexion*

C3 lateral neck flexion*

C4 shoulder elevation

C5 shoulder abduction

C6 elbow flexion and wrist extension

C7 elbow extension and wrist flexion

C8 thumb extension and ulnar deviation

T1 intrinsic muscles of the hand (finger & adduction)

*These myotomes should not be performed in an individual with a suspected cervical fracture or dislocation, as they may cause serious damage or death.


Neurologic Tests (cont.)Neurologic Tests (cont.)

– Reflexes

Reflex Segmental Levels

Biceps C5, C6

Brachioradialis C5, C6

Triceps C7, C8



• Cutaneous patterns



• Referred pain


Activity-Specific Functional TestingActivity-Specific Functional Testing

• Normal parameters

• Pain free and unlimited movement


RehabilitationRehabilitation

• Relief of Pain and Muscle Tension

• Restoration of motion

• Restoration of Proprioception and Balance

• Muscular strength and endurance

• Cardiovascular fitness

copyright © 2013 wolters kluwer health | lippincott williams & wilkins cervical and thoracic...

Documents

head slide

fused slide

angulation slide

lateral view slide

posterior view slide

weight of head thoracic

weight of body

vertebrae form curve