Cervical Spine Orthopedics DX 611 James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic James J. Lehman, DC, MBA, DABCO

Cervical Spine Anatomy James J. Lehman, DC, MBA, DABCO

Orthopedic Examination of the Cervical Spine Involves the taking of a history, performance of physical examination procedures and laboratory evaluation, which may include imaging studies. James J. Lehman, DC, MBA, DABCO

Chief Complaint Interview The O, P, Q, R, S, T process is suggested for all patients presenting with neuromusculoskeletal conditions. James J. Lehman, DC, MBA, DABCO

History Taking Process The history should precede all physical exam procedures but include observation. James J. Lehman, DC, MBA, DABCO

History Taking Process Establishing rapport Listening and questioning Observation Integration James J. Lehman, DC, MBA, DABCO

Obstacles to History Taking Fear Antagonism Mental cloudiness Incoherence Language barriers Rambling and talkativeness James J. Lehman, DC, MBA, DABCO

History Taking Process Chief complaint History of present illness (OPQRST) Past, family, social, and occupational history Systems review (SHEENT)CR, GI, GU, MS, NS, VD, and OB James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Mental Status Appearance Alert Cooperative Oriented x3 / Memory http://library.med.utah.edu/neurologicexam/html/mentalstatus_normal.html James J. Lehman, DC, MBA, DABCO

History Taking and Observation Rust’s sign Dejerine’s sign Lhermitte’s sign Barre-Lieou sign James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Vital Signs Height Weight Blood pressure Pulse rate Respiration rate Temperature James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Patient Preparation Why should the patient be gowned prior to evaluation? James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Prepare Patient Environment Gowned Explain procedures James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Inspection General inspection is a series of accurate and meaningful observations James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Inspection Involves Five Special Senses Allegory of Five Senses Theodore Rombouts Sight Hearing Touch Taste Smell James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Inspection Posture Body movements Gait Speech Surface scars and wounds James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Inspection Nutrition Stature Body temperature Breath odors James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Palpation Static palpation Flat palpation Superficial Deep James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Motion Palpation Technique evaluation includes motion palpation James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Palpation Superficial tissues Deep tissues Joint play James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Palpation Objectives Detect abnormal tissue textures Evaluate symmetry Detect and assess movements Detect and evaluate changes in findings James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Percussion Stroking with the reflex instrument Spinous processes Interspinous ligaments Paravertebral muscles James J. Lehman, DC, MBA, DABCO

Instrumentation Dynamometer Elbow flexion to 90 degrees Record 3 readings with each hand Record dominant hand James J. Lehman, DC, MBA, DABCO

Instrumentation Inclinometer Most accurate mensuration of spinal or joint motion Record 3 readings Impairment ratings and independent medical exams James J. Lehman, DC, MBA, DABCO

Instrumentation Goniometer Easiest to utilize for most joint range of motion examinations James J. Lehman, DC, MBA, DABCO

Instrumentation Reflex Hammer Babinski James J. Lehman, DC, MBA, DABCO

Instrumentation Buck Reflex Hammer James J. Lehman, DC, MBA, DABCO

Instrumentation Taylor Reflex Hammer Patient position Doctor position Relaxed patient and doctor Stroke tendon for rebound James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO DTR Testing Identify the grade of reflex being tested James J. Lehman, DC, MBA, DABCO

Diagnostic Instruments Tuning Forks C128 and C 256 are utilized with orthopedic examinations James J. Lehman, DC, MBA, DABCO

Diagnostic Instruments Tuning Forks Test for osseous fracture pain and perception of vibration James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Safety Pin Sterile Large enough Test for sharp and dull James J. Lehman, DC, MBA, DABCO

Instrumentation Cotton Balls Test for light touch Superficial reflexes James J. Lehman, DC, MBA, DABCO

Instrumentation Paper Clips Test for two-point discrimination but not for pain James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Half Time Who is going to win? James J. Lehman, DC, MBA, DABCO

Cervical Range of Motion Testing James J. Lehman, DC, MBA, DABCO

Range of Motion Evaluation Symmetrical motion Free of restriction or aberrant Pain free or provocative Passive, active, and restricted isometric movements James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Orthopedic Maneuvers Anatomical structure tests Dural tension Foraminal canal patency Spinal canal patency Ligamentous Muscle Tendon James J. Lehman, DC, MBA, DABCO

Cervical Spine Assessment Protocol History Observation Physical examination Inspection Palpation Range of motion Orthopedic maneuvers James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Rust’s Sign May grab head upon removal of cervical collar May use hand to lift head when rising from supine position James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Rust’s Sign Suspect upper cervical spine instability History of roll-over MVA or blow to head James J. Lehman, DC, MBA, DABCO

Shoulder Abduction Test Bakody’s sign for nerve root irritation James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Valsalva Maneuver Valsalva maneuver for IVD syndrome or tumor (space occupying lesion) James J. Lehman, DC, MBA, DABCO

Cervical Distraction Test Distraction test for nerve root, facet, or myospasm Positive test relieves pain Negative test increases pain James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Soto-Hall Test Non-specific test for cervical spine injury or lesion Passive flexion of neck with sternum stabilized Contraindicated with severe injury James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Swallowing Test Difficulty swallowing might be related to a space occupying lesion anterior to the cervical spine. James J. Lehman, DC, MBA, DABCO

Cervical Compression Tests Maximal foraminal compression (active) Jackson’s Spurling’s Maximums cervical rotary compression Extension/Flexion James J. Lehman, DC, MBA, DABCO

Common Cervical Provocative Tests All of them test for dural sheath, nerve root, or spinal nerve involvement Positive findings all indicate radicular pain James J. Lehman, DC, MBA, DABCO

Cervical Orthopedic Tests Don’t memorize the tests Practice them with comprehension Discuss the tests and practice Marinate, practice and discuss the relevance of the tests and signs James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Nerve Injuries Neuropraxia Axonotmesis Neurotmesis James J. Lehman, DC, MBA, DABCO

Pathological Neurological Responses Most benign Dysesthesia, paresthesia Brachial plexopathy or neuropraxia Motor or reflex changes Atrophy or denervation James J. Lehman, DC, MBA, DABCO

Severe Pathological Neurological Responses Axonotmesis Cervical cord neuropraxia Cervical stenosis Cervical myelopathy James J. Lehman, DC, MBA, DABCO

Most Severe Pathological Neurological Responses Hemiparesis or neurotmesis Transient quadriparesis James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neuropraxia This is the physiological interruption of an anatomically intact nerve. In this condition there is minimal damage. The axons are intact but conduction is lost because of segmental demyelination. James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neuropraxia This is a transient lesion and recovery is spontaneous after a few days or weeks. James J. Lehman, DC, MBA, DABCO

Neuropraxia "Identify Cause" In neuropraxic insult,  the offending compressive agent, must be eliminated to protect the nerve from further damage.    James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neuropraxia Otherwise, “Wallerian Degeneration” would  likely result.  Therefore, it is imperative that the mechanism of compression  be identified to insure optimal recovery. James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neuropraxia Neuropraxia may be caused by a ligamentous structure, extended pressure, or repetitive motion. James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Axonotmesis Axonotmesis is characterized by axonal and myelin sheath damage that results in loss of continuity with the cell body and its end organ. There is preservation of the endoneurium, perineurium, and epineurium.  James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Axonotmesis A complete absence of sensory modalities can be expected.  The prognosis for recovery is good,.  However, occasionally, the possible loss of some cell bodies inhibits complete recovery. This is due to retrograde neuronal degeneration.  James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Myelopathy Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in older persons. The aging process results in degenerative changes in the cervical spine that, in advanced stages, can cause compression of the spinal cord. Symptoms often develop insidiously and are characterized by neck stiffness, arm pain, numbness in the hands, and weakness of the hands and legs. James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Myelopathy The differential diagnosis includes any condition that can result in myelopathy, such as multiple sclerosis, amyotrophic lateral sclerosis and masses (such as metastatic tumors) that press on the spinal cord. The diagnosis is confirmed by magnetic resonance imaging that shows narrowing of the spinal canal caused by osteophytes, herniated discs and ligamentum flavum hypertrophy. (Am Fam Physician 2000;62:1064-70,1073.) James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neurotmesis Implies complete disruption of all the axon and supporting connective tissue structures.  James J. Lehman, DC, MBA, DABCO

James J. Lehman, DC, MBA, DABCO Neurotmesis Without surgical repair, this injury has a very poor prognosis. James J. Lehman, DC, MBA, DABCO

End of Cervical Orthopedic Tests Thank you for your attention and enjoy the day… James J. Lehman, DC, MBA, DABCO