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Orthopedics: Cervical Spine Exams

1) Observe pt, posture (standing)
2) Palpate c-spine (sitting)
3) Test ROM: (sitting) active (AROM), resisted (RROM)
4) MRS: muscle testing
5) MRS: reflex: DTR: deep tendon reflexes
6) MRS: sensory: sharp/dull and light touch to dermatomes
7) Spinal Percussion (still sitting)
8) Valsalva maneuver (to confirm suspicion of herniated disc or SOL in spinal cord or IVF)
9) Special orthopedic tests (cervical compression test & variations, cervical distraction test, shoulder depression test)
10) Passive ROM (PROM) (supine)
11) Soto Hall Test
12) Vertebral basilar artery insufficiency tests

PALPATION (tenderness scale 1-4/4, 1 no physical response, 2 flinch, 3 withdrawal, 4 avoidance)
--skin
--subcu soft tissue
--BV's
--thyroid
--parotid and submandibular glands
--cervical nodes
--muscular structures
----anterior triangle: contains carotid pulse, borders = SCM, mandible, midline of anterior neck
----posterior triangle: borders = SCM, trapezius, clavicle
--bony structures

ROM TESTS
--active, resisted, and passive
--flexion, extension, lateral flexion, rotation
--evaluation: normal, hypomobile, hypermobile, all of these with/without pain

MRS (motor, reflex, sensory)
--0-5/5, 0 = flaccid, no contraction, 5 = muscle completes ROM vs full resistance 4 = some resistance, 3 = completes ROM vs gravity but without resistance (grandma can't lift the milk jug anymore), 2 = can complete ROM with gravity eliminated, 1 = some contractility but no joint motion.

MUSCLES OF MRS
--middle deltoid, C5 (C6), axillary nerve
--biceps, C6, (C5), musculocutaneous nerve
--triceps, C7 (C6, C8), radial nerve
--wrist extensors, C7 (C6), radial nerve
--wrist flexors, C7 (C6), median/ulnar nerve
--finger flexors, C8 (C7, T1), ulnar/median nerve
--finger abductors/adductors, T1 (C7-8), ulnar nerve

REFLEXES
DTR
--graded as 0-4/4, 4 = hyperreflexia (poss clonus), 3 = hyper or jumpier normal, 2 = normal or lower half of normal, 1 = hyporeflexia (trace response or with reinforcement), 0 = no muscle contraction with reinforcement.
--biceps, C5 (C6) (opposite MRS)
--brachioradialis C6, (C5)
--triceps C7 (C8) (different from MRS)
--patellar, L4, (L2-3), contraction of quadriceps
--hamstrings L5, (S1) (semitendinosus tendon)
--achilles, S1, (S2), contraction of gastocsoleus and plantar flexion of foot

PATHOLOGICAL REFLEXES
--Babinski response (plantar response), normal in babies, abnormal in adults
--Hoffman's sign (elicit by holding pts milddle finger loosely and flick fingernail downward, causing finger to slightly rebound into extension, if thumb flexes/adducts it's positive)

SENSORY TESTING
Bilateral Sharp/Dull and Light Touch
C3 - lateral neck
C4 - over deltoid
C5 - lateral upper arm
C6 - lateral forearm and radial aspect of hand (thumb)
C7 - middle finger
C8 - ulnar aspect of hand (pinkie)
T1 - medial forearm
T2 - medial upper arm

SPECIAL ORTHOPEDIC TESTS
--Cervical compression test: seated pt, axial compression at top of head
--Spurling's test: next in extension and lateral flexion to same side, compress
--Maximum foraminal compression: rotation to symptomatic side with extension and lateral flexion
--Jackson's compression test: axial compression wtih rotation to symptomaic side but wihtout ext & lat flex
--Cervical distraction test: pt seated, head neutral, thumbs under occiput and lift at mastoid process (5-30lbs)
--Shoulder depression test: seated or supine, lateral neck bend away from tested side, press shoulder on open side downward
--Soto Hall test: supine, hand on sternum, hand under occiput, flex head toward chest maintain sternal pressure, watch for Brudzinski sign (legs lift reflexively)

VERTEBROBASILAR ARTERY INSUFFICIENCY AND CAD
--tests have no diagnostic value for those at risk
--no tests can rule out dissection in progress
--tests are provocative and may aggravate a dissection in progress
--great majority of pts with VAD in progress present with musculoskeletal complaints ("my arm hurts")
--evaluate pts for risk factors, significant hx, evaluate constellation of symptoms, uniqueness, degree/severity
--risk factors incl: CT Dz (autosomal dominant polycystic kidney dz, Ehlers-danlos type IV, Marfan syndrome, mibromusculrar dystrophy), migraine headaches, recent infx esp respiratory, tobacco smoking, homocystienve over 12micromol/L, age UNDER 45.
--significant Hx incl: trauma, stroke, mitral prolapse, aortic dilation, fever, easy bruising, prolonged bleeding/wound healing, loose thin skin (Ehlers-Danlos type IV
--S/Sx: new or sudden onset of head/upper neck/face pain, totally unfamiliar, worst ever
--S/Sx: 5D's And 3N's: diplopia, dizziness, drop attacks, dysarthria, dysphagia, ataxia of gait, nausea, numbness, nystagmus
--PRE-MANIPULATIVE SETUP POSITION: flex head toward side, rotate away from head, sometime extend slightly:: monitor for nausea, vomiting, syncope, if positive monitor symptoms for 20-30 minutes and if they resolve patient may be released, if symptoms persist further evaluation is required
--ADVERSE POST-MANIPULATIVE RESPONSE ASSESSMENT: can pt smile, raise both arms, steand stead on both feet with eyes closed (Romberg test), speak a simple sentence with a series of different vowel sound that run together "simple Simon says", stick out his/her tongue? If NO, call 911, give suspected dx, age, onset, hx, location.
--if it is a resolving TIA, refer (same day) to PCP, urgent care or ER, pt should not drive
--if pt has temporary adverse manpulative response, stable after 20-30 minutes, unlikely stroke or TIA, pt can be released and drive
--VERTEBROBASILAR ARTERY INSUFFICIENCY TEST: pt supine, extend and laterally flex neck, rotate head to same side and hold for 30 sec, tests open side, (+) if blurred vision, dizziness, nystagmus, slurred speech, altered LOC, severe headache, sensory changes in face/body, unsteady walking, dysphagia (swallowing), weakness in extremities, N/V, etc: indicates partial or copmlete blockage of vertebral artery

alphabet soup and vocab
SOL = space occupying lesion
IVF = intervertebral foramen
PROM = passive range of motion
VBI = vertebrobasilar artery insufficiency
VAD = vertegral artery dissection
CAD = carotic artery dissection
DTR = deep tendon reflex
UMNL = something suggested by sustained clonus of more than 2 beats (hyperreflexia)

clonus = a series of altnerating contractions and relaxations of a muscle in rapid succession

Rust's sign = pt uses one or both hands to stabilize neck, trauma? odontoid fx? transverse ligaemnt sprain/rupture?, atlantoaxial instability->rheumatoid arthritis/pn, neuro dysfx, vertebral artery insufficiency

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