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The Cervical Spine The Cervical Spine 방방방방방방방 방방방방방방방 M.D., O.M.D. M.D., O.M.D. 방방방 방방방

The Cervical Spine

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The Cervical Spine. 방배경희한의원 M.D., O.M.D. 신정봉. The Cervical Spine - History -. In general, a good history-taking provides information about: The patient ’ s age Symptoms Pain Paraesthesia vertigo Drugs. The Cervical Spine - History -. 1. Age Acute torticollis - PowerPoint PPT Presentation

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Page 1: The Cervical Spine

The Cervical SpineThe Cervical Spine

방배경희한의원방배경희한의원M.D., O.M.D. M.D., O.M.D.

신정봉신정봉

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In general, a good history-taking provides information aIn general, a good history-taking provides information about:bout:

1.1. The patient’s ageThe patient’s age2.2. SymptomsSymptoms

PainPain ParaesthesiaParaesthesia vertigovertigo

3.3. DrugsDrugs

The Cervical SpineThe Cervical Spine- History -- History -

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1. Age1. Age Acute torticollisAcute torticollis

Acute torticollis due to a disc protrusion – adolesceAcute torticollis due to a disc protrusion – adolescents and young adultsnts and young adults

Children – a afebrile otitis mediaChildren – a afebrile otitis media It is a pure lateral list, whereas in the other disordeIt is a pure lateral list, whereas in the other disorde

rs, mentioned above, the head is side flexed one wrs, mentioned above, the head is side flexed one way and slightly ratated the opposite way by spasm oay and slightly ratated the opposite way by spasm of the sternocleidomastoid musclef the sternocleidomastoid muscle

The Cervical SpineThe Cervical Spine- History -- History -

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1. Age1. Age Root pain Root pain

Over the age of 35Over the age of 35 Neuroma in young patientNeuroma in young patient

Headache Headache The old man’s “matutinal headache”(morning headaThe old man’s “matutinal headache”(morning heada

che) is an upper cervical ligarmentous lesion.che) is an upper cervical ligarmentous lesion.

The Cervical SpineThe Cervical Spine- History -- History -

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2. Symptoms2. Symptoms

◆ ◆ Pain Pain How, When and where did it start?How, When and where did it start?

In the lumbar spine – know what exactily brought thIn the lumbar spine – know what exactily brought the pain on e pain on

In the cervical spine – onset Is spontaneous. pt. cIn the cervical spine – onset Is spontaneous. pt. cannot tell the caused of his symptomsannot tell the caused of his symptoms

The Cervical SpineThe Cervical Spine- History -- History -

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2. Symptoms2. Symptoms

◆ ◆ Pain Pain How did it progress?How did it progress?

A shifting pain(disc) A shifting pain(disc) ↔↔ an expanding pain(tumor) an expanding pain(tumor) Chronology of a posterolateral disc protrusion: starting from the onsChronology of a posterolateral disc protrusion: starting from the ons

et of the arm pain, the spontaneous evolution takes some 3-4monthet of the arm pain, the spontaneous evolution takes some 3-4months. Hence, an arm pain beyond 6 months is probably not caused by a s. Hence, an arm pain beyond 6 months is probably not caused by a disc protrusion.disc protrusion.

Ankylosing spondylitis: a young pt. had lumbar, thoracic and cervical Ankylosing spondylitis: a young pt. had lumbar, thoracic and cervical spinespine

Neuroma: paraesthesia and pain, starting distally in the arm, spreadiNeuroma: paraesthesia and pain, starting distally in the arm, spreading proximally(A neuroma is more probable than PPLP)ng proximally(A neuroma is more probable than PPLP)

The Cervical SpineThe Cervical Spine- History -- History -

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2. Symptoms2. Symptoms

◆ ◆ Pain Pain RecurrencesRecurrences

Duration, frequency, treatmentDuration, frequency, treatment Was it always on the same sideWas it always on the same side How is the patient between the attacksHow is the patient between the attacks

Influence of coughInfluence of cough In disc protrusion, a cough is mostly negativeIn disc protrusion, a cough is mostly negative If not the pain is felt in the scapular areaIf not the pain is felt in the scapular area An arm pain on coughing suggests a neuromaAn arm pain on coughing suggests a neuroma

The Cervical SpineThe Cervical Spine- History -- History -

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Localization Localization HeadacheHeadache

Segmental pain or extrasegmental dural pain. Segmental pain or extrasegmental dural pain. when when

cervicoscapular aching ; cervicoscapular aching ; extrasegmental(dura mater) – the pain from a disc protruextrasegmental(dura mater) – the pain from a disc protru

sion pinching the dura matersion pinching the dura mater segmental(facet joint). – a facet joint lesion is segmental segmental(facet joint). – a facet joint lesion is segmental

The Cervical SpineThe Cervical Spine- History -- History -

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Localization Localization Root pain Root pain

How long? Spontaneous evolution of a posterolateral disc How long? Spontaneous evolution of a posterolateral disc protrusion: irreducible in the second half of the evolutionprotrusion: irreducible in the second half of the evolution

Dermatome: levelDermatome: level With/Without previous cervicoscapular pain: no manipulatWith/Without previous cervicoscapular pain: no manipulat

ion for a PPLPion for a PPLP

The Cervical SpineThe Cervical Spine- History -- History -

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ParaesthesiaParaesthesia (=Paresthesia) (=Paresthesia)

segmental, extrasegmental segmental, extrasegmental segmental : nerve root segmental : nerve root extrasegmental : spinal cord extrasegmental : spinal cord Nerve root or spinal cord? Nerve root or spinal cord?

with/without painwith/without pain Radicular compression : first pain - with pain Radicular compression : first pain - with pain

The Cervical SpineThe Cervical Spine- History -- History -

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VertigoVertigo

Spontanoues or posturalSpontanoues or postural

3. Drugs3. Drugs

Anticoagulants provide an absolute bar to manipulatioAnticoagulants provide an absolute bar to manipulation! n!

The Cervical SpineThe Cervical Spine- History -- History -

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We look for :We look for :

Articular signs Articular signs : partial articular, full articular: partial articular, full articular Root signs Root signs : motor conduction, Sensory conduction, DTR: motor conduction, Sensory conduction, DTR Cord signs Cord signs : pathologic reflex, DTR, Spasticity: pathologic reflex, DTR, Spasticity Alternative causes for the arm painAlternative causes for the arm pain

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Neck Neck movementmovement

Active

Active

Passive

resistive

1. Extension

2. Rotation

3. Side flexions

4. Flexion

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

Neck Neck movementmovement

Active

Active

Passive

resistive

Pain

Range

Willingness

Pain

Range

End feel

Passive

Always (3)Always (3)

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Shoulder ShrugShoulder Shrug

Aactive

Active

Resistive

Pain

Range

Contracture of

costocoracoid fascia

Scapular metastasis

Pulmonary neoplasm

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Shoulder ShrugShoulder Shrug

Active

Pain

Weakness

C2,3,4 roots

Spinal accessory N.

Resistive

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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LimitationLimitation

A. bilat. arm ele.

Neuropathy

Fracture

Muscle/tendon

Painful arc

Ankylosis

Shoulder girdle exam

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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C. Active bilateral arm elevationC. Active bilateral arm elevation<Limitation><Limitation>

MononeuritisMononeuritis long long thoracicthoracic n. n. spinal accessory n.spinal accessory n.

stress fracturestress fracture first ribfirst rib spinous process C7/T1spinous process C7/T1

painful arc :painful arc :

limitation at the shoulder jointlimitation at the shoulder joint<Shoulder Examination><Shoulder Examination>

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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D. Nerve root examinationD. Nerve root examinationBilateral : all resisted tests on the good side first.Bilateral : all resisted tests on the good side first.

1. Motor conduction1. Motor conduction

2. Sensory conduction2. Sensory conduction

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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1. Motor conduction(Shoulder)1. Motor conduction(Shoulder)

Abduction (C5)Abduction (C5) Lateral rotation (C5)Lateral rotation (C5)

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Flexion (C5-C6)Flexion (C5-C6) Extension (C7)Extension (C7)

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

1. Motor conduction(Elbow)1. Motor conduction(Elbow)

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Flexion (C7)Flexion (C7)

- Golf elbow- Golf elbow

Extension (C6)Extension (C6)

- Tennis elbow- Tennis elbow

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

1. Motor conduction(Wrist)1. Motor conduction(Wrist)

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Extension (C8)Extension (C8) Adduction (T1)Adduction (T1)

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

1. Motor conduction(Thumb, Little finger)1. Motor conduction(Thumb, Little finger)

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B. Shoulder shrugging

2. Sensory conduction 2. Sensory conduction

A sensory deficit is sought in the A sensory deficit is sought in the distal part of the dermatomesdistal part of the dermatomes

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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C5: outer part of the forearmC5: outer part of the forearm C6: thumb and index fingerC6: thumb and index finger C7: dorsum of index, middle C7: dorsum of index, middle

and ring fingerand ring finger C8: ring and little finger, ulnar C8: ring and little finger, ulnar

part of the handpart of the hand T1: inner side of the fore armT1: inner side of the fore arm T2: inner side of the armT2: inner side of the arm

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Roots exam.Roots exam. DTR

Motor conduction

Sensory condction

Biceps Jerk C5,C6

Brachiradialis J C5

Triceps J C7

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Cord signCord sign Pathologic Reflex

DTR

Spasticity

Babinski sign

Ankle clonus

Hoffman sign

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Arm testArm test

Tests for neurogenic integrity and alternative causTests for neurogenic integrity and alternative causes of arm paines of arm pain

Active elevationActive elevation

Pain/limitation → Shoulder examination?Pain/limitation → Shoulder examination?

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Arm testArm testResisted movementsResisted movements(tests for motor conduction):(tests for motor conduction):Shoulder:Shoulder:

Abduction - C5Abduction - C5 External rotation - C7External rotation - C7

Elbow:Elbow: Flexion - C5/C6Flexion - C5/C6 Extenstion - C7Extenstion - C7

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Arm testArm test

Wrist:Wrist: Flextion – C7Flextion – C7 Extension-C6Extension-C6

Thumb extension – C8Thumb extension – C8Little finger adduction – T1Little finger adduction – T1

Sensory conductionSensory conduction

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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Arm testArm test

ReflexesReflexes Biceps – C5 / C6Biceps – C5 / C6 Brachioradialis – C5Brachioradialis – C5 Triceps - C7Triceps - C7 Planter - CNSPlanter - CNS

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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A. IntroductionA. IntroductionNot tally with the clinical findings:Not tally with the clinical findings:

The pain can be unilateralThe pain can be unilateral The neck movements can be painful in one directioThe neck movements can be painful in one directio

n and not in another directionn and not in another direction The end-feel is much softer than the hard end-feel The end-feel is much softer than the hard end-feel

of osteophytosisof osteophytosis The patient can have intermittent attacks of pain wiThe patient can have intermittent attacks of pain wi

th painfree episodes between the attacksth painfree episodes between the attacks

The Cervical SpineThe Cervical Spine- - CLINICAL EXAMINATIONCLINICAL EXAMINATION - -

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B. Disc protrusionB. Disc protrusion Dura mater Dura mater

Disc protruding in posterior direction can exert presDisc protruding in posterior direction can exert pressure on Dura mater sure on Dura mater -> pain & tenderness -> pain & tenderness

protrusion near midline-> interfere with articular moprotrusion near midline-> interfere with articular mobility. dural pain &articular signs bility. dural pain &articular signs

posterolateral protrusion-> root pain with or without posterolateral protrusion-> root pain with or without root sign, but better articular sign root sign, but better articular sign

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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Articular signs Articular signs pain maybe limitation, on some, but not all, active pain maybe limitation, on some, but not all, active

movements: movements: more pain on P test no pain on R testmore pain on P test no pain on R test partial articular pattern of internal derangementpartial articular pattern of internal derangement particular end-feel ( "crisp" ) is expectedparticular end-feel ( "crisp" ) is expected

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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Root signRoot sign motor deficit, sensory deficit, sluggish or absent jemotor deficit, sensory deficit, sluggish or absent je

rkrk differance to Lumbar spine-> neurological decifit frodifferance to Lumbar spine-> neurological decifit fro

m Disc protrusion is monoradicularm Disc protrusion is monoradicular

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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Alarm( probably no Alarm( probably no protrusion) protrusion)

a number of particularity, most of them based a number of particularity, most of them based on empirical findingson empirical findings

we should  discard the idea of a disc protrusion we should  discard the idea of a disc protrusion in case of : in case of :

①①Ti-palsy Ti-palsy

②②C1- or C2- palsy C1- or C2- palsy

③③motor deficit C4 (shoulder shrug) motor deficit C4 (shoulder shrug)

④④sensory deficit C5 sensory deficit C5

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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Clinical patterns Clinical patterns 1. Acute torticollis1. Acute torticollis

Young patients( 15~30y) Young patients( 15~30y) Attack with spontaneous recovery in 7-10 day. Attack with spontaneous recovery in 7-10 day. extreme partial articular pattern: head is tilted sideextreme partial articular pattern: head is tilted side

ways, one rotation & one side flexion are completelways, one rotation & one side flexion are completely blocked: the other movement are less limited but y blocked: the other movement are less limited but all painful all painful

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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2. Unilateral cervicoscapular aching2. Unilateral cervicoscapular aching usually over 25 usually over 25 ache is intermittent ( a few weeks) with painfree epiache is intermittent ( a few weeks) with painfree epi

sodes between the attack: maybe not always the ssodes between the attack: maybe not always the same side is affected ame side is affected

partial articular pattern ( but less marked than in prpartial articular pattern ( but less marked than in previous case) evious case)

over 50, the pain may become constant. over 50, the pain may become constant.

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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3. Unilateral root pain3. Unilateral root pain certainly over 35 certainly over 35 attack began with pressure on dura metar first, theattack began with pressure on dura metar first, the

n protrusion reched the nerve root; n protrusion reched the nerve root; severe root pain, possibly paraesthesia(severe root pain, possibly paraesthesia( 이상감각이상감각 ))

& neurological deficit. & neurological deficit. strict chronology with spontaneous recovery in 3-4 strict chronology with spontaneous recovery in 3-4

months months

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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4. Acroparaesthesia4. Acroparaesthesia paraesthesia in both hand and both feet in patient paraesthesia in both hand and both feet in patient

over 60. over 60. The cause is small bilateral protrusion, which is moThe cause is small bilateral protrusion, which is mo

stly irreducible stly irreducible

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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5.Bilateral scapular aching5.Bilateral scapular aching Over the age of 60 Over the age of 60 Central protrusion(need special manipulative)Central protrusion(need special manipulative)

6.Extrasegmental paraesthesia 6.Extrasegmental paraesthesia Pressure on the spinal cord from a central protrusion Pressure on the spinal cord from a central protrusion When no contraindication exists, a disc protrusion should be rWhen no contraindication exists, a disc protrusion should be r

educed at onceeduced at once

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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C. other disorders / C. other disorders / differntial diagnosisdifferntial diagnosis

1.Differential diagnostic interpretation 1.Differential diagnostic interpretation

“ “ All discs are alike, but all other disorders are different.”All discs are alike, but all other disorders are different.”

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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1. Neck movements 1. Neck movements

A muscular pattern A muscular pattern One or more resistance tests hurt more than the active or the One or more resistance tests hurt more than the active or the

passive testspassive tests Some possibilities: a muscle lesion, a fractured first rib, metaSome possibilities: a muscle lesion, a fractured first rib, meta

stases grandular fever, or psychogenic symptomsstases grandular fever, or psychogenic symptoms

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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A particular partial articular pattern A particular partial articular pattern

The pattern, in which side flexion away from the paiThe pattern, in which side flexion away from the painful side is the only painfully limited movement, sunful side is the only painfully limited movement, suggests an extra-articular(visceral) lesion: pulmonary ggests an extra-articular(visceral) lesion: pulmonary neoplasm(pancoast)neoplasm(pancoast)

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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A full articular pattern A full articular pattern

Elderly patient probably indicates osteoarthrosisElderly patient probably indicates osteoarthrosis Ankylosing spondylitis(younger)Ankylosing spondylitis(younger) MetastasesMetastases Injury(fracture)Injury(fracture)

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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2. Shoulder shrugging 2. Shoulder shrugging limitaion = alarm-bell limitaion = alarm-bell

Contracture of the costocoracoid fasiciaContracture of the costocoracoid fasicia Metastases in the scapulaMetastases in the scapula

Pain without limitationPain without limitation Thoracic disc protrusion Thoracic disc protrusion Subclavius muscle or a sternoclavicular arthritisSubclavius muscle or a sternoclavicular arthritis

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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3. Arm tests 3. Arm tests Active bliateral arm elevationActive bliateral arm elevation

Shoulder girdle test: Shoulder girdle test: Long thoracic or spinal accessory neuritis, Long thoracic or spinal accessory neuritis, clay shoveller's fractureclay shoveller's fracture Painful arcPainful arc supraspinatus, inpraspinatus, subscapularis tendinitis, chronic supraspinatus, inpraspinatus, subscapularis tendinitis, chronic

subdeltoid bursitissubdeltoid bursitis nerve root tests nerve root tests

Excessive, bilateral or pluriradicular palsyExcessive, bilateral or pluriradicular palsy T1-palsy also is extremely unlikely to be caused by a disc protrusionT1-palsy also is extremely unlikely to be caused by a disc protrusion

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4. Neuralgic amyotrophy 4. Neuralgic amyotrophy An uncommon disorder with a spontaneous cure in less than a yeAn uncommon disorder with a spontaneous cure in less than a ye

ar: sudden severe neck pain without limitation: after a few days bar: sudden severe neck pain without limitation: after a few days bilateral, then unilateral, arm pain; rather severe pain for about twilateral, then unilateral, arm pain; rather severe pain for about two months, gradually easing in the next two months. Extreme muso months, gradually easing in the next two months. Extreme muscle weakness, the muscles do not belong to the same rootcle weakness, the muscles do not belong to the same root

Osteophyte => gradual evoutionOsteophyte => gradual evoution no sever painno sever pain usually Cs weaknessusually Cs weakness

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5. pressure on a nerve root 5. pressure on a nerve root cause: cause:

①①disc protrusiondisc protrusion②②osteophyteosteophyte③③neuroma neuroma

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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2. post-concussion headache2. post-concussion headache

①①Our first problem is to find out whether the headache is organic oOur first problem is to find out whether the headache is organic or alleged. r alleged.

②②The immobility, imposed by the concussion, can also lead to uppThe immobility, imposed by the concussion, can also lead to upper cervical ligamentous adhesions, which should be ruptured by er cervical ligamentous adhesions, which should be ruptured by manipulation. manipulation.

③③A muscular lesion, at its occipital insertion, is treated by deep fricA muscular lesion, at its occipital insertion, is treated by deep friction. tion.

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3. The facet joints 3. The facet joints The dura mater is the only structure in the locomotor system, which The dura mater is the only structure in the locomotor system, which

causes extrasegmental reference of pain. Hense, we expect a diffuscauses extrasegmental reference of pain. Hense, we expect a diffuse cervicoscapular ache when a disc protrusion compresses the dura e cervicoscapular ache when a disc protrusion compresses the dura mater, whereas the ache from a facet joint lesion would felt in one dmater, whereas the ache from a facet joint lesion would felt in one dermatome only. ermatome only.

Moreover, a disc protrusion is more probable than a facet joint lesion if ;Moreover, a disc protrusion is more probable than a facet joint lesion if ;

①①the pain is felt on the midline the pain is felt on the midline ②②there is a shifting pain there is a shifting pain ③③the attacks of unilateral aching are not always felt on the same side the attacks of unilateral aching are not always felt on the same side ④④if a cough hurts if a cough hurts

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Dr. Troisier describes two clinical patterns in Dr. Troisier describes two clinical patterns in case of a facet joint lesion: case of a facet joint lesion: convergence, i.e. "closing" of the facets convergence, i.e. "closing" of the facets

e.g. left sided pain on extension, rotation and side fle.g. left sided pain on extension, rotation and side flexion to the left exion to the left

divergence, i.e. "opening" of the facetsdivergence, i.e. "opening" of the facetse.g. left sided pain on flexion, rotation and side flexioe.g. left sided pain on flexion, rotation and side flexio

n to the right. n to the right.

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Osteoarthrosis(C2~C3, C3~C4) Osteoarthrosis(C2~C3, C3~C4) three possible treatments : three possible treatments :

①①capsular stretching("slow stretch"), capsular stretching("slow stretch"), ②②DF DF ③③an i.a. injection of triamcinolone. an i.a. injection of triamcinolone.

Rheumatoid arthritis Rheumatoid arthritis The treatment : an i.a. injection of triamcinolonThe treatment : an i.a. injection of triamcinolon

e. e.

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4. Migraine 4. Migraine

At the very beginning, an attack of migraine At the very beginning, an attack of migraine can sometimes be stopped by strong traction. can sometimes be stopped by strong traction. It is performed manually and should last about It is performed manually and should last about

30 seconds.30 seconds.

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5. Headache 5. Headache Headache of cervical origin can either be segmental or extrasegmental. Headache of cervical origin can either be segmental or extrasegmental.

Segmental(C1~C2) Segmental(C1~C2) Post-traumatic capsuloligamentous adhesions. Post-traumatic capsuloligamentous adhesions. Capsular contracture in upper cervical osteoarthrosis ; possibly there is Capsular contracture in upper cervical osteoarthrosis ; possibly there is

only referred headache without local pain. capsular only referred headache without local pain. capsular The old man's matutinal headache. The old man's matutinal headache.

Extrasegmental Extrasegmental Compression of the dura mater by a disc protrusion. Compression of the dura mater by a disc protrusion.

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8. Thoracic pain 8. Thoracic pain Upper thoracic pain : extrasegmental reference from tUpper thoracic pain : extrasegmental reference from t

he cervical dura mater he cervical dura mater

Pectoral pain : dural origin Pectoral pain : dural origin

Interscapular pain : central cervical disc protrusion Interscapular pain : central cervical disc protrusion

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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extrasegmental tenderness from dura mater extrasegmental tenderness from dura mater 의 존재가 의 존재가 진단을 어렵게 할 경우 평가되어야 할 점진단을 어렵게 할 경우 평가되어야 할 점

neck flexion - has a cervical and a thoracic meaning neck flexion - has a cervical and a thoracic meaning other neck movements painful - cervical lesionother neck movements painful - cervical lesion pain on scapular tests or on taking a deep breath - thopain on scapular tests or on taking a deep breath - tho

racic lesion racic lesion

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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9. Misleading tenderness9. Misleading tenderness

During palpaion, a tender spot within the painfDuring palpaion, a tender spot within the painful scapular area can be identified by the paitieul scapular area can be identified by the paitient nt

extrasegmental reference from the cervical durextrasegmental reference from the cervical dura mater a mater

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -

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10.Congenital torticollis 10.Congenital torticollis 11. Acute torticollis children11. Acute torticollis children12. Acute torticollis in adult and adolescents12. Acute torticollis in adult and adolescents13. Spasmodic torticollis13. Spasmodic torticollis14. Spastic torticollis 14. Spastic torticollis 15. Hysterical torticollis15. Hysterical torticollis

16. Inspection of the scapular area16. Inspection of the scapular area ① ① position of the scapulaposition of the scapula② ② isolated wasting of the infraspinatus muscle isolated wasting of the infraspinatus muscle

The Cervical SpineThe Cervical Spine- - DisordersDisorders - -