CHAPTER 4:
CERVICAL SPINE TRAUMA
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Cervical spine injuries can be classified as
(1) mild (eg, contusions, strains);
(2) moderate (eg, subluxations, sprains, occult fractures, nerve contusions, neurapraxias);
(3) severe (eg, axonotmesis, dislocation, stable fracture without neurologic deficit); and
(4) dangerous (eg, unstable fracture-dislocation, spinal cord or nerve root injury).
Spasm of the sternocleidomastoideus and trapezius can be due to strain or irritation of the sensory fibers of the spinal accessory nerve as they exit with the C2—C4 spinal nerves. The C1 and C2 nerves are especially vulnerable because they do not have the protection of an IVF. Radicular symptoms are rarely evident unless an IVD protrusion or herniation is present.
PREVALENCE
Because of its great mobility and relatively small structures, the cervical spine is the most frequent site of severe spinal nerve injury and subluxations. A large variety of cervical contusions, Grade 1—3 strains and sprains, subluxations, disc syndromes, dislocations, and fractures will be seen as the result of trauma.
The most vulnerable segments to injury are the axis and C5—C6 according to accident statistics. Surprisingly, the atlas is the least involved of all cervical vertebrae. In terms of segmental structure, the vertebral arch (50%), vertebral body (30%), and IVD (30%) are most commonly involved in severe cervical trauma. While the anterior ligaments are only involved in 2% of injuries, the posterior ligaments are involved in 16% of injuries.
EMERGENCY CARE
In the emergency-care situation, the patient with spinal cord injury must be treated as if the spinal column were fractured, even when there is no external evidence. Immediate and obvious symptom of spinal cord injury parallel those of fractures of the spinal column. The establishment of an adequate airway takes priority over all other concerns except for spurting hemorrhage.
In general, trauma anteriorly to the neck implies soft-tissue damage and possible airway obstruction; trauma posteriorly suggests cervical spine and cord damage; and lateral trauma indicates possible vascular and musculature damage. Due to relative head weight to neck strength and other anatomic differences, neck injury is more critical in the very young.
INITIAL ASSESSMENT
If there are no severe complaints or recognizable signs of major disability, ask the patient to conduct mild active movements if able to do so without discomfort. If slight straight axial compression on top of the head produces unilateral or bilateral radiating root pain, deep injury must be suspected and precautions taken immediately. After the neck has been evaluated, check possible injury to other parts of the body.
Knee and ankle reflexes can be tested, but the neck should not be moved. Stabilize the neck before assessment of severity. A collapsed patient should never be asked to sit or stand until major disability has been ruled out. The first point in analysis is knowing the mechanism of injury. Without moving the patient, check vital signs and palpate for swelling, deep tenderness, deformity, and throat cartilage stability. When logical, another person should apply gentle bilateral traction on the cervical area via the skull during palpation.
Are there bleeding, spasm, pain, motion restrictions, sensory changes, signs of shock? Limb weakness or dysesthesia indicates nerve root compression. Injuries of the upper airway or alimentary canal feature ventilation abnormalities, stridor, bubbling wound, subcutaneous emphysema, hoarseness and dysphagia, bloody sputum, nosebleed, bloody vomitus, or unexplained wound tenderness. Injuries to the cervical nerves are suggested by deviation of the tongue, drooping mouth corner, sensory deficits, and Horner’s syndrome. Cervical fractures are commonly associated with severe pain, spasm, and joint stiffness. Vascular injuries feature vigorous bleeding, absent superficial artery pulsations, an enlarging or pulsatile hematoma, and stroke signs. If there is any suggestion of injury to the carotid artery, palpation should be avoided. Such an injury should be suspected if there is a diagonal erythematous contusion on the side of the neck. Palpation may encourage complete carotid occlusion.
POSTTRAUMATIC ROENTGENOGRAPHIC CLUES
On standard lateral and A-P views, the anterior and posterior soft tissues deserve careful inspection. Signs of widened retrotracheal space, widened retropharyngeal space, displacement of the prevertebral fat stripe, laryngeal dislocation, or tracheal displacement should be sought. Abnormal vertebral alignment may be shown by a loss of the normal lordotic curve or even an acute kyphotic hyperangulation, vertebral body displacement, abnormal dens position, widened interspinous space, or rotation of the vertebral bodies. Abnormal joints may portray unusual IVD-space symmetry or widening of an apophyseal joint space. It is easy to miss lower cervical fractures because they are often obscured on lateral views by the subject’s shoulders if proper precautions are not taken.
INJURY OF THE CERVICAL NERVE ROOTS
Neural dysfunction associated with either acute or chronic subluxation syndromes basically manifest as abnormalities in sensory interpretations and/or motor activities. These disturbances may be through one of two primary mechanisms: direct nerve or nerve root disorders or of a reflex nature.
Contributing and Complicating Factors
The common subluxation picture is rarely pure. It is often superimposed on subclinical processes in the mature patient such as weak or scarred tissue, vertebral instability, osteochondrophytic ridges at the uncovertebral joints, apophyseal thickening and exostosis. Canal encroachment can occur by a buckling ligamentum flavum, spinal stenosis, posterior vertebral body spurs, disc protrusions, dura and dentate thickening, arachnoid cysts, dura and arachnoid adhesions, and ossification of the posterior longitudinal ligament. Loss of disc space, especially in the lower cervical area, may contribute as a source of chronic irritation to an already inflamed root by altering the angulation of the IVF tunnel. The sequence of inflammation, granulation, fibrosis, adhesion formation, and nerve root stricture may follow, along with a loss in root mobility and elasticity. Fortunately for the young, these degenerative changes are not as pronounced during youth.
Motor Aberrations
Nerve root insults from subluxations may manifest as disturbances in motor reflexes and/or muscular strength. Examples include the deep tendon reflexes such as seen in the reduced biceps reflex when involvement occurs between C5 and C6; or the reduced triceps reflex when involvement occurs between C6 and C7. These reflexes must be compared bilaterally to judge whether hyporeflexia is unilateral. Unilateral hyperreflexia is pathognomonic of an upper motor neuron lesion. Prolonged and/or severe nerve root irritation may also produce trophic changes in the tissues supplied.
Interpreting Sensory Irregularities
When direct nerve root involvement occurs on the posterior root of a specific neuromere, it manifests as an increase or a decrease in sensitivity over the dermatome. A typical example is foraminal occlusion or irritating factors exhibited clinically as hyperesthesia, particularly on the dorsal and lateral aspects of the thumb and radial side of the hand, when involvement occurs between C5 and C6. Another example is on the dorsum of the hand, the index and middle fingers, and the ventroradial side of the forearm, thumb, index and middle fingers, when involvement occurs between C6 and C7. In other instances, nerve root involvement may cause hypertonicity and the sensation of deep pain in the muscles supplied by the neuromere. For example, in C6 involvement, there is deep pain in the biceps. In C7 lesions, there is deep pain in the triceps and supinators of the forearm. Direct pressure near the nerve root or along its distribution may be particularly painful.
SUBLUXATION-INDUCED REFLEX SYNDROMES
It is generally accepted that certain spinosomatic and spinovisceral syndromes may result from cervical subluxation complexes. For example, if the involvement is in the C1—C4 area, the cervical portion of the sympathetic chain or the 9th—12th cranial nerves (as they exit from the base of the skull and pass into their compartments within deep cervical fascia) may be involved. The syndrome may include
(1) suboccipital or postocular migraine;
(2) greater occipital nerve extension neuralgia;
(3) mandibular, cervical, auricular, pectoral, or precordial neuralgia;
(4) paroxysmal torticollis;
(5) congestion of the upper respiratory mucosa, paranasal sinuses, or eustachian tube with hearing loss;
(6) cardiorespiratory attacks;
(7) ocular muscle malfunction;
(8) pathologic hiccups;
(9) scalenus anticus syndrome; or
(10) painful spasms in the suboccipital area.
Phillips describes that if a subluxation produces a stretching of the paravertebral musculature, there is a continuous barrage of afferent impulses in the Group Ia fibers. “These afferent impulses monosynaptically bombard the alpha motor neurons causing the paravertebral musculature to go into tetany. There is a cessation of this afferent barrage when the stretch is released. The muscle stretching also initiates afferent impulses in the Group II afferents from flower spray endings which may reinforce the spastic muscle condition.” He explains that trauma to facet joints, disturbed articular relationships, spasms of closely related muscles, and overlying trigger points —all the result of a subluxation— inaugurate a barrage of flexor-reflex afferent impulses via the Group II—IV fibers that converge on the internuncial pool in lamina 7 of the spinal cord. “This abundant supply of flexor-reflex afferent impulses excites the alpha motor neurons through multisynaptic connections causing an excess of excitation of paravertebral muscles resulting in spasm.”
Planes of Force and Their Consequences
Compression Forces. Excessive compression forces on the neck commonly lead to facet jamming and fixation, isolated or multiple fractures of the atlantal ring, or vertical, oblique, or bursting fractures of the lower cervical bodies.
1. When the arm is depressed, the clavicle moves inferior and anterior, and this widens the space between the clavicle and 1st rib.
Neural vs Circulatory Symptoms. Compression of nerve tissue results in numbness, pain, paralysis, and loss of function. Compression of vascular structures results in moderate pain and swelling. Obstructed circulation results in clotting within the vessels with possible consequent infarction in the tissues supplied. These unilateral phenomena are somewhat limited to the cervicobrachial distribution.
Passive Cervical Compression Tests. Two tests are involved. First, with the patient sitting, the examiner stands behind the patient. The patient’s head is laterally flexed and rotated slightly toward the side being examined. The examiner places interlocked fingers on the patient’s scalp and gently presses caudally. If an IVF is narrowed, the maneuver will insult the foramen by compressing the disc and further narrowing the foramen, causing pain and reduplication of other related symptoms. In the second test, the patient’s neck is extended by the examiner who then places interlocked hands on the patient’s scalp and gently presses caudally. If an IVF is narrowed, this maneuver mechanically compromises the foraminal diameters bilaterally and causes pain and reduplication of other related symptoms.
Maigne’s Test. The examiner places a sitting patient’s head in extension and rotation. This position is held for about 15—40 seconds on each side. A positive sign is indicated by nystagmus or other symptoms of vertebrobasilar ischemia.
NEUROVASCULAR IMPLICATIONS OF UPPER CERVICAL SUBLUXATIONS
Aside from nerve root dysfunction, subluxation complexes in the cervical spine, especially the upper region, can have serious neurovascular consequences. Function of the vertebral arteries, the vertebral veins and deep cervical veins, cerebrospinal circulation, the medulla oblongata, and the vital vagus nerve may be disturbed.
The artery and vein supplying a spinal nerve are within the foramen between the nerve and the fibrous tissue in the anterior portion of the foramen. Deprived mobility of any one or more segments of the spine correspondingly influences area circulation, and the partial anoxia effected has a harmful influence on nerve function. Because of the vessels’ position, it is unlikely that circulation to the nerve would be disrupted without first irritating or compressing the nerve because the arteries and veins are much smaller, the blood pressure within their lumen makes them somewhat resistant to compression, and nerve tissue is much more responsive to encroachment irritation.
The Vertebral Arteries
Janse explains that any cervical subluxation (particularly atlantal, axial, or occipital) producing muscle spasm may produce unilateral or bilateral constriction of the vertebral arteries resulting in circulatory impairment. A large number of equilibrium, cardiac, respiratory, cranial nerve, extrapyramidal, vagal, visual, and auditory symptoms may follow.
The vertebral nerve (sympathetic) courses along the vertebral artery within the arterial foramen of the cervical transverse processes. Irritation to this nerve can occur from mechanical irritation to the vertebral artery anywhere along its course producing symptoms of a vasomotor nature; eg, headache, vertigo, tinnitus, nasal disturbances, facial pain, facial flushing, and pharyngeal paresthesias. Cailliet points out that although sympathetic fibers have not been found along the cervical roots, surgical decompression of an entrapped nerve root relieves symptoms attributed to the sympathetics. The mechanism for this effect is unclear.
The Vertebral and Deep Cervical Veins
Spasm of suboccipital muscles may cause a decided impediment of venous drainage from the suboccipital area via vertebral and deep cervical veins. The result is passive congestion with consequent pressure on the sensory nerves in the area. This is perceived by the patient as unilateral or bilateral pain and a throbbing discomfort. The site may be palpated as knotty lumps within suboccipital muscles. The condition appears to be of a reflex nature that is more common among people under mental tension or those who work closely with their eyes over long periods.
Cerebrospinal Circulation
Constriction in the connecting area between the cerebral subarachnoid space and the vertebral canal limits the escape of cerebrospinal fluid into the inferior vertebral canal. This results in increased intracranial pressure. An atlanto-occipital subluxation may cause the dura mater of the cisterna cerebellaris to press against the posterior medullary velum and partially occlude the foramina of Luschka and Magendie and thus interfere with flow from the 4th ventricle. The increased intraventricular fluid accumulation can produce a variety of symptoms such as deep-seated stubborn “internal pressure” headaches, nausea, a tendency toward projectile vomiting, bizarre and unusual visual disturbances, and protopathic ataxia.
The Medulla Oblongata
The medulla extends well into the lower reaches of the foramen magnum and the ligament ring connecting it with the atlas, thus any type of occipital or atlantal subluxation may affect this portion of the brain stem. Bilateral posterior shifting of the occiput or atlas can induce pressure in the pyramids or adjacent olivary bodies producing a syndrome of upper-motor-neuron involvement characterized by a degree of spastic paralysis or ataxia. A lateral shift of the occiput may cause pressure on the tubercle of Rolando producing pain in trigeminal nerve distribution, headache, sinus discomforts, ocular neuralgia, and aches in the jaw.
The Vital Vagus
As the vagus lies almost in immediate contact with the transverse process of the atlas, rotary subluxation of the atlas may induce pressure that can produce a broad range of symptoms. The syndrome may include nasal and sinus congestion, swallowing and speech difficulties, cardiac arrhythmias, functional coronary artery spasm, gastric and intestinal colic, and other symptoms of vagal disturbance.
CLASSIC EFFECTS OF SEVERE CERVICAL TRAUMA
It was briefly brought out earlier in this chapter that knowing the mechanism of injury is important to accurate diagnosis. This section will confirm this truth.
Hyperextension Forces. The effects of forceful posterior bending may include hyperflexion sprain of the anterior ligaments, wedging of the posterior anulus and vertebral body, posterior subluxation, horizontal fracture of the anterior arch of the atlas, fracture of the anteroinferior margin of a vertebral body, compression of the posterior arch and associated structures, posterior bilateral or unilateral dislocation, spinous process fracture, and/or traumatic spondylolisthesis.
Hyperflexion Forces. Excessive anterior bending may produce hyperflexion sprain of the posterior ligaments, compressive wedging of the anterior anulus and vertebral body, anterior subluxation, anterior bilateral or unilateral dislocation with locked facets, and spinous process avulsion. Abnormal widening of a spinous interspace on a lateral roentgenograph should arouse suspicion of ruptured posterior ligaments.
Lateral Hyperflexion Forces. The effects of excessive lateral bending include transverse process fracture, uncinate process failure, lateral dislocation-fracture of the odontoid process, lateral wedging of the anulus and vertebral body, and brachial plexus injury.
Hyperrotary Forces. Exorbitant segmental rotation about the longitudinal axis produces anterior or posterior ligament torsion overstress, rotary subluxation, spiral loosening of the nucleus pulposus, and unilateral or bilateral atlas-axis dislocation. The traumatic stress involved invariably include shear forces.
Shear Forces. Flagrant shearing forces can disrupt the anterior or posterior ligaments, displace the end-plates, produce anterior or posterior subluxation or dislocation, create anterior or posterior fracture displacement of the dens, and cause anterior compressive fracture of the anterior ring of the atlas or vertebral body.
Fractures and Dislocations of the Atlas
Atlanto-occipital dislocations, often bilateral, are usually quickly incompatible with life. Any severe subluxation in the upper cervical area can lead to quadriplegia or death, often with little warning and few symptoms to differentiate it initially from a mild strain. Thus, it is always better to be extra cautious (and be accused of being too concerned in mild injuries) to insure against a possible disaster. Signs and symptoms vary from subtle to severe pain and gross motor involvement. Tenderness may be acute over the posterior atlas, aggravated by mild rotation and extension.
Fractures and Dislocations of the Axis
Odontoid fractures are often produced by severe forces directed to the head, and the direction of force usually determines the direction of displacement. Suboccipital tenderness may be present. A severe extension force may fracture the odontoid at its base, with possible odontoid posterior displacement. The danger of cord pressure is great. Open-mouth views, flexion-extension x-ray views, or tomography may be necessary for accurate determination.
Severe C3-C7 Injuries
Cervical fractures and dislocations are usually the result of a severe fall, an automobile accident, a football pile-up, or a trampoline or gymnastic mishap. Bruises on the face, occiput, and shoulders may offer clues to the mechanism of injury. Seek signs of vertebral tenderness, limitation in movement, muscle spasm, and neurologic deficits. As in upper-cervical damage, careful emergency management is necessary to avoid paralysis and death. Severe fracture or dislocation of any cervical vertebra requires orthopedic referral. Keep in mind that overdiagnosing instability of C2 on C3 is a common pitfall.
Compression or flexion damage is sometimes seen, but extension injuries (eg, whiplash) are more common. Spinous process fractures usually occur at the C6 or C7 level after acute flexion or a blow to the flexed neck producing ligamentous avulsion. There is immediate “hot” pain in the area of the spinous process that is increased by neck flexion. Any injury to C6 or C7 is difficult to view on film because of overlapping structures.
Spinal Cord Injury
There are direct and indirect classes of cephalad spinal cord injuries. Direct injury to the cord, the nerve roots, or both, may be from impact forces or shattered bone fragments. The cord may be crushed, pierced, or cut. This type of injury is generally an open wound. Indirect injury to the cord can be caused by the disturbance of tissues near the spine by violent forces such as falls, crushes, or blows.
When the cervical cord is injured, there is loss of sensation and flaccid paralysis. The lower limbs exhibit spastic paralysis. If the space in which the spinal fluid flows between the spinal cord and the surrounding vertebral column is either compressed or enlarged, severe headache occurs. Posttrauma penile erection strongly suggests either cervical or thoracic cord injury.
Most cervical cord injuries are caused by extreme flexion where subluxation or fracture/dislocation occurs. Hemorrhage occurs at the site with the same reaction as brain injury (liquefaction, softening, disintegration). Congenital fusions and stenosis may predispose a child to spinal cord trauma during a sporting activity.
VERTEBRAL ARTERY ABNORMALITIES
Vertebral artery abnormalities such as deflection and arteriosclerosis must be determined before any form of cervical manipulation or adjustment is performed. Arteriosclerosis is no longer thought of as an “old person’s disease.” Autopsy studies of young soldiers killed in the Viet Nam War showed well established systemic arteriosclerosis in the majority of the 18—21-year age group.
The vertebral artery is a captive vessel from C6 upward. Extremes of rotation and flexion occur at the upper cervical region, but the four normal curves in the vertebral artery help to compensate for neck movements. Deflection may be caused by any stretching or elongation of the artery during neck trauma. In later years, deflection is commonly associated with bony spurs from covertebral joints or grossly hyperplastic posterior vertebral articulations from arthrosis.
Smith explains that extension of the cervical spine allows the tip of the superior articular process of the posterior joint to glide forward and upward. If sufficiently hyperplastic, the motion may cause encroachment on the vertebral artery and/or the IVF. Deflection of the artery and any resulting symptoms are exaggerated by rotation and/or extension of the neck. As a result of pressure against the artery, there may be temporary lessening in the volume of blood flow. Atheromatous changes may occur within the vascular wall. Symptoms include headache, vertigo, nausea, vomiting, nystagmus, and suboccipital tenderness, which may be provoked by cervical extension. Sometimes symptoms are aggravated by dorsal extension and relieved by forward flexion with cervical traction.
CERVICOTHORACIC TUNNEL COMPRESSION SYNDROMES
The cervicothoracic junction is a unique area that receives far less attention than it deserves in all the healing arts. It is a common site of developmental anomalies; it is a major site of arterial, lymphatic, and neurologic traffic; and it presents the juncture of the highly mobile cervical spine with the very limited thoracic spine. This latter point is biomechanically significant.
Several cervicotrhoracic syndromes fall in the class of neurovascular compression syndromes (also termed thoracic outlet or inlet syndromes), each of which may produce the symptom complex of radiating pain over the shoulders and down the arms, atrophic disturbances, paresthesias, and vasomotor disturbances. These features, however, do not necessarily indicate the specific cause of the problem.
Origin
Trauma to the head, neck, or shoulder girdle is a common factor. In some cases, poor posture, anomalies, or muscle spasm or contractures may be involved. Reduced tone in the muscles of the shoulder girdle, by itself, has been shown to allow depression of the clavicle that narrows the thoracic outlet and compresses the neurovascular bundle. Subluxation syndromes (eg, retrolisthesis) may also initiate these and other disturbances of the shoulder girdle. Cervical pathology such as spinal canal or IVF encroachment by a buckling ligamentum flavum, spinal stenosis, or spurs should be a consideration. Degenerating dura and dentates become thickened, dura and arachnoid adhesions become prevalent, and osteochondrophytes may develop from the borders of the canal or foramen —all of which tend to restrict the cord and/or nerve roots during cervical motions.
Osteochondrophytes near the foramen can readily compress the vertebral artery and root together. Differential diagnosis must exclude a cervical rib etiology (rare), infectious neuritis, banding adhesions, arthritis of the shoulder joint, clavicle fracture callus, bifid clavicle, cervical arthritis, subacromial bursitis, 1st rib subluxation and posttraumatic deformities, spinal or shoulder girdle malignancies, Pancoast’s tumor of the lung apex, and heart disease. Aneurysm of the subclavian artery is rare.
Anatomical Considerations. Working above and behind to produce shoulder abduction and retraction (eg, painting a ceiling, repairing a ceiling fixture) produces temporary clavicle encroachment on the brachial plexus and presses the subclavian artery against the scalenus medius. For many years, symptoms were attributed to costoclavicular compression from shoulder depression. However, postmortem stress tests have shown the following:
2. When the shoulder is depressed, the upper and middle trunks of the brachial plexus are stretched tightly over the tendinous edge of the scalenus medius and the lower trunks are pulled into the angle formed by the 1st rib and the scalenus medius tendon. Most symptoms found on shoulder depression will be the result of this traction. There is no compression of the subclavian artery against either scaleni.
3. When the shoulder is retracted, the clavicle does not impinge the subclavian vein but the tendon of the subclavius muscle compresses the vein against the 1st rib. The middle third of the clavicle pushes the neurovascular bundle against the anterior scalenus medius, and this causes compression if a space-occupying lesion is also present (eg, cervical rib, extrafascial band).
Clinical Features
Symptoms usually do not occur until after the ribs have ossified. Two groups of symptoms are seen: those of scalenus anticus syndrome and those due to cervical rib pressure. The symptoms of cervical rib and scalenus syndrome are similar, but the scalenus anticus muscle is the primary factor in the production of neurocirculatory compression whether a cervical rib exists or not.
Symptoms are usually from compression of the lower cord of the brachial plexus and subclavian vessels such as numbness and pain in the ulnar nerve distribution. Pain is worse at night because of pressure from the recumbent position, and its intensity varies throughout the day. Arm fatigue and weakness, finger cramps, numbness, tingling, coldness of the hand, areas of hyperesthesia, muscle degeneration in the hand, a lump at the base of the neck, tremor, and discoloration of the fingers are characteristic. Work and exercise accentuate symptoms, while rest and elevation of the extremity relieve symptoms. Adson’s and other similar compression signs will usually be positive.
Clinical Maneuvers and Tests
Posttrauma radiographs should be taken before performing a neurologic or orthopedic test. It is important to rule out possible conditions that would be aggravated by any testing procedure.
Active Cervical Rotary Compression Test. The sitting patient should be observed while voluntarily laterally flexing his head toward the side being examined. With the neck flexed, the patient is instructed to rotate his chin toward the same side, which narrows the IVF diameter on the side of concavity. Pain or reduplication of other symptoms suggests a narrowing of one or more IVFs.
Shoulder Depression Test. With the patient sitting, the examiner stands behind the subject. The patient’s head is laterally flexed away from the side being examined. The doctor stabilizes the patient’s shoulder with one hand and applies pressure alongside the patient’s head with the palm of the other hand; stretching the dural root sleeves and nerve roots or aggravating radicular pain if the nerve roots adhere to the foramina. Extravasations, edema, encroachments, and conversion of fibrinogen into fibrin can result in interfascicular, foraminal, and articular adhesions and inflammation restricting fascicular glide and the ingress and egress of the foraminal content. Thus, pain and reduplication of other symptoms during the test suggest adhesions between the nerve’s dura sleeve and other structures in and about the IVF.
Cervical Distraction Test. With the patient sitting, the examiner stands to the side of the patient and places one hand under the patient’s chin and the other hand under the base of the occiput. Slowly and gradually the patient’s head is lifted to remove weight from the cervical spine. This maneuver elongates the IVFs, decreases the pressure on the joint capsules around the facet joints, and stretches the paravertebral musculature. If the maneuver decreases pain and relieves other symptoms, it is a probable indication of narrowing of one or more IVFs, cervical facet syndrome, or spastic paravertebral muscles.
Spurling’s Test. This is a variation of the passive cervical compression test. The patient’s head is turned to the maximum toward one side and then laterally flexed to the maximum. A fist is placed on the patient’s scalp, and a moderate blow is delivered to it by the other fist. The patient’s position produces reduced IVF spaces, and the blow causes a herniated disc to sharply bulge further into the IVF space or to aggravate an irritated nerve root, thus increasing the symptoms.
Adson’s Test. With the patient sitting, the examiner palpates the radial pulse and advises the patient to bend his head obliquely backward to the opposite side being examined, to take a deep breath, and to tighten the neck and chest muscles on the side tested. This maneuver decreases the interscalene space and increases any existing compression of the subclavian artery and lower components (C8 and T1) of the brachial plexus against the 1st rib. Marked weakening of the pulse or increased paresthesiae are signs of pressure on the neurovascular bundle, particularly of the subclavian artery as it passes between or through the scaleni musculature, thus indicating a probable cervical rib or scalenus anticus syndrome.
Wright’s Test. With the patient sitting, the radial pulse is palpated from the posterior in the downward position and as the arm is passively moved through an 180° arc. If the pulse diminishes or disappears in this arc or if neurologic symptoms develop, it suggests pressure on the axillary artery and vein under the pectoralis minor tendon and coracoid process or compression in the retroclavicular space between the clavicle and 1st rib, and thus be a hyperabduction syndrome.
Eden’s Test. With the patient sitting, the examiner palpates the patient’s radial pulse and instructs the patient to pull the shoulders backward firmly, throw the chest out in a “military posture,” and hold a deep inspiration as the pulse is examined. The test is positive if weakening or loss of the pulse occurs, suggesting pressure on the neurovascular bundle as it passes between the clavicle and the 1st rib, and thus a costoclavicular syndrome.
VERTEBROBASILAR SYSTEM PATENCY TESTS
Although cerebrovascular accidents are extremely rare following cervical manipulation, a few cases have been reported that justify special evaluation before cervical manipulation. Four clinical tests are described below to evaluate the patency of the vertebrobasilar system.
DeKleyn’s Test.
The patient is placed supine on an adjusting table, and the head rest is lowered. The examiner extends and rotates the patient’s head, and this position is held for about 15—40 seconds on each side. A positive sign suggests the same as that in Maigne’s test.
Hautant’s Test. The examiner places a sitting patient’s upper limbs so that they are abducted forward with the palms turned upward (supinated). The patient is instructed to close his eyes, and the examiner extends and rotates the patient’s head. This position is held loosely for about 15—40 seconds on each side. A positive sign is for one or both arms to drop into a pronated position.
ARTHROKINEMATICS
Many injuries of the cervical spine can be attributed to the small, curved vertebral bodies, the wide range of movement in many planes, and the more laterally placed intervertebral articulations that require nerve roots to leave the spinal canal in an anterolateral direction. There is greater space within the cervical canal than below, but this space is occupied by cord enlargement to accommodate the brachial and cervical plexuses. The segmental function of these plexuses is shown in Table 4.1.
Table 4.1. Segmental Function of Cervical Nerves
Segment Function
CERVICAL PLEXUS (C1—C4)
C1 Motor to head and neck extensors, infrahyoid, rectus capitis
anterior and lateral, and longus capitis.
C2 Sensory to lateral occiput and submandibular area; motor,
same as C1 plus longus colli.
C3 Sensory to lateral occiput and lateral neck, overlapping
C2 area; motor to head and neck extensors, infrahyoid,
longus capitis, longus colli; levator scapulae, scaleni,
and trapezius.
C4 Sensory to lower lateral neck and medial shoulder area;
motor to head and neck extensors, longus coli, levator
scapulae, scaleni, trapezius, and diaphragm.
BRACHIAL PLEXUS (C5—T1)
C5 Sensory to clavicle level and lateral arm (axillary nerve);
motor to deltoid, biceps, biceps tendon reflex. Primary root
in shoulder abduction, exits between C4–C5 discs.
C6 Sensory to lateral forearm, thumb, index and half of 2nd
finger (sensory branches of musculocutaneous nerve); motor
to biceps, wrist extensors, brachioradialis tendon reflex.
Primary root in wrist extension, exits between C5–C6 discs.
C7 Sensory to second finger; motor to wrist flexors, finger
extensors, triceps, triceps tendon reflex. Primary root in
finger extension, exits between C6–C7 discs.
C8 Sensory to medial forearm (medial antebrachial nerve), ring
and little fingers (ulnar nerve); motor to finger flexors,
interossei; no reflex applicable. Primary root in finger
flexion, exits between C7–T1 discs.
T1 Sensory to medial arm (medial brachial cutaneous nerve);
motor to interossei; no reflex applicable. Primary root
in finger abduction, exits between T1–T2 discs.
In the healthy cervical (or lumbar) spine displaying a moderate degree of lordosis, a good share of weight bearing is on the zygapophyses because the line of cumulative loading of compressive forces is posterior to the center of the vertebral bodies. This produces considerable articular jamming that tends to restrict a wide range of rotation. That is, the rotary motion occurring at the zygapophyses does so on firmly compressed facets. Fortunately, there is some structural adaptation for this. For the normal adult spine, the cervical discs average 3 mm in thickness, there is a 2:5 disc/body ratio, a 4:7 nucleus/anulus ratio, and the nucleus sits in a position that is slightly posterior to the center of the disc. In addition, the surface area of the cervical facets is larger in proportion to the surface area of the vertebral body than at any other region of the spine. This design contributes greatly to the overall segmental base of support in the neck. In fact, the weight-bearing surfaces of the facets are more than half (67%) that of the centrum. In addition, the superior facets below the axis face posterosuperior and medial to compensate for the normal anteroinferior tilt of the vertebral bodies.
The Atlas. The atlas can be considered a sesamoid between the occiput and axis that serves as a biomechanical washer or bearing between the occipital condyles and the axis. The absent body of the atlas is represented by its anterior arch and the dens of the axis, and the inner aspect of the anterior arch contains a facet for the dens. An IVD does not exist between the occiput and the atlas, nor does the atlas exhibit IVFs or a distinct spinous process.
The Articular Facets. The middle and lower cervical articular processes incline medially in the coronal plane and obliquely in the sagittal plane so that they are near a 45° angle to the vertical. Their bilateral articular surface area, which shares a good part of head weight with the vertebral body, is about 67% of that of the vertebral body.
Upper-Cervical Instability. Moderately strong soft-tissue connections exist in the occiput-atlas-axis complex. Bone, muscle, tendon, ligament, and lymph node abnormalities tend to restrict motion, while tissue tears and lax ligaments without associated muscle spasm allow too much motion. Stability is provided the C1—C2 joint by paravertebral ligaments and muscle attachments. When weakening of these supports occurs (eg, trauma, postural stress, rheumatoid arthritis), a dangerous state of instability arises. Each infant presents a considerable degree of cervical instability because of the relatively large head weight superimposed on the small underdeveloped spine.
Active motion. Regional active cervical flexion and extension motions are tested by having the patient raise and lower the chin as far as possible without moving the shoulders. Note smoothness of motion and degree of limitation bilaterally.
Rotation. Approximately half of cervical rotation takes place at the atlantoaxial joints about the odontoid process, with the remaining half distributed fairly evenly among the other cervical joints. During rotation, the odontoid represents a peg encased within a fairly enclosed ring or a stake surrounded by a horseshoe.
Active Rotation. Regional active rotary motion is tested by having the patient move his nose as far as possible to the left and right without moving his shoulders. Note the smoothness of motion and degree of limitation bilaterally.
Lateral Flexion. Cervical lateral bending is essentially performed by the unilateral contraction of the neck flexors and extensors with motion occurring in the coronal plane. Such flexion is accompanied by rotational torsion below C2 and distributed fairly equally in the normal cervical joints. That is, when the cervical spine as a whole bends laterally, it also tends to rotate anteriorly on the side of the concavity so that the vertebral bodies arc further laterally than the spinous processes.
The dura of the spinal cord is firmly fixed to the margin of the foramen magnum and to the 2nd and 3rd cervical vertebrae. In other spinal areas, it is separated from the vertebral canal by the epidural space. Since both the C1 nerve and the vertebral artery pass through this membrane and both are beneath the superior articulation of the atlas and under the overhanging occiput, atlanto-occipital distortion will produce traction of the dura mater producing irritation of the artery and nerve unilaterally and compressional occlusion contralaterally. De Rusha feels that this helps us understand those cases of suboccipital neuralgia where a patient upon turning his head to one side increases the headache and vertigo that are relieved when the head is turned to the opposite side.
(1) lesser occipital neuralgia, involving the posterior area of the occipitofrontalis muscle, mastoid process, and upper posterior aspect of the auricle;
De Rusha suggests that dysphagia and dysarthria may at times be due to upper cervical involvement rather than a CNS situation. The C1 joins the hypoglossal nerve supplying the intrinsic muscles of the tongue. It then descends to join the descending cervical that is derived from C2 and C3. A loop of nerves, the ansi hypoglossi, which supplies muscles necessary for deglutition and speaking, is derived from C1—C3.
STRUCTURAL CHARACTERISTICS OF THE CERVICAL REGION
The more the cervical curve flattens, the more superimposed weight is shifted to the discs. With the shift of normal compressive force normally at the posterior toward the anterior of the motion unit, the discs are forced to carry more weight and assume a greater responsibility in cervical stability. In time, this unusual compressive force on the nucleus can produce degenerative anular thinning, spurs, eburnation, and Schmorl’s nodes. The posterior joints become relatively lax and predispose retropositioning and posterior subluxations. Add the disruptive forces of trauma, and this noxious situation is greatly increased.
The Upper Cervical Spine
The spinal canal of the upper cervical region is relatively large to accommodate the cervical enlargement of the cord. The pedicles, apophyseal joints, uncinate processes, and transverse processes have characteristics peculiar and specific to the cervical spine.
The Axis. The inferior facets of the atlas fit the superior facets of the axis like epaulets on sloping shoulders. The plane is about 110° to the vertical. To allow maximum rotation of the upper cervical complex without stress to the contents of the vertebral canal, the instantaneous axis of rotation is placed close to the spinal cord (ie, near the atlanto-odontoid articulation).
The C2—C3 Interface. Rotation of C2 on C3 is limited by a mechanical blocking mechanism that protects the vertebral artery from excessive torsion. The anterior tip of the superior articular process of C3 impinges on the lateral margin of the foramen transversarium of C2. This blocking mechanism is also found in the subjacent cervical vertebrae.
The Occipitocervical ligaments
It is well to be able to mentally picture the upper cervical ligament complex for serious sprains in this area do occur. The cross-shaped cruciate ligament completely secures the odontoid process. Its main portion is the triangular bilateral transverse ligament, which passes posteriorly on the dens and connects to the lateral masses of the atlas, transversing in front of the spinal cord. Its main function is to restrict anterior translation of the atlas. There are also two vertical bands. One rides from the dens upward to the basiocciput, and the other extends from the dens posteriorly down to the body of the axis. Because these ligaments are usually tough, the odontoid usually fractures prior to ligament failure. In addition, accessory atlantoaxial ligaments extend superiorly and laterally from the base of the inferior vertical cruciate and join the base of the dens with the inferomedial aspect of the lateral mass of C1. Anterior to the upper arm of the cruciate are the apical and alar ligaments.
The Lower Cervical Area
Nature has made many structural adaptations in the mid- and lower-cervical region. The laminae are slender and overlap, and this shingling increases with age. The osseous elevations on the posterolateral aspect forming the uncovertebral pseudojoints tend to protect the spinal canal from lateral IVD herniation, but hypertrophy of these joints added to IVD degeneration can readily lead to IVF encroachment. The IVDs are broader anteriorly than posteriorly to accommodate the cervical lordosis.
The Capsular Ligaments. The short, thick, dense capsular ligaments bind the articulating processes, enclosing the articular cartilage and synovial tissue. Their fibers are firmly bound to the periosteum of the superior and inferior processes and arranged at a 90° angle to the plane of the facet. This allows maximum laxity when the facets are in a position of rest. They normally allow no more than 2—3 mm of movement from the neutral position per segment, and possibly provide more cervical stability than any other ligament. Capsulitis from overstretch in acute subluxation is common. The posterior joint capsules enjoy an abundance of nociceptors and mechanoreceptors, far more than any other area of the spine. Within the capsule, small tongues of meniscus-like tissue flaps project from the articular surfaces into the synovial space. They are infrequently nipped in severe jarring at an unguarded moment during the end of extension, rotation, or lateral bending, establishing a site of apophyseal bursitis.
The Lower Cervical Perivertebral Ligaments. The five lower, relatively similar, cervical vertebrae have eight intervertebral ligaments, four posterior and four anterior in terms of the motion unit. The anterior ligaments are the anterior longitudinal ligament, the anulus fibrosus, the posterior longitudinal ligament, and the intertransverse ligament. The posterior ligaments are the ligamentum flavum, the capsular ligaments, and the interspinous and supraspinous ligaments.
The Intervertebral Foramen. The boundaries of the cervical IVFs are designed for motion rather than stability as compared with the dorsal and lumbar regions. The greatest degree of functional IVF diameter narrowing occurs ipsilaterally in lateral bending with simultaneous extension.
KINEMATICS
The head may be flexed forward so the chin strikes the sternum or thrown sideward so that the ear strikes the shoulder and the neck can still be within the normal range of motion. It is most rare, however, that the occiput strikes the back and does not exceed normal cervical extension.
The Upper Cervical Area
Movements in the cervical spine are relatively free because of the saddle-like joints. The cervical spine is most flexible in flexion and rotation. The latter occurs quite freely in the upper cervical area and is progressively restricted caudad. The specific range of cervical motion differs among so many authorities that any range offered in this chapter should be considered hypothetical depending on individual planes of articulation, other variances in structural design (eg, congenital, aging degeneration, posttraumatic), and soft-tissue integrity. This variance in opinion is also true for the centers of motion.
Extension and Flexion. Considerable cervical motion is concentrated in specific spinal areas. About half of flexion and extension occurs at the atlanto-occipital joints, with the other half distributed among the remaining cervical joints. Inasmuch as the nucleus of the disc is nearer the anterior of a complete cervical vertebra, A-P motion is more discernible at the spinous process than at the anterior aspect of the vertebral body.
Passive motion. Passive cervical flexion and extension are examined by placing the hands on the sides of the patient’s skull and rolling the skull anteroinferior so that the chin approximates the sternum and posterosuperior so that the nose is perpendicular to the ceiling.
Passive Rotation. Passive rotation is examined by placing the hands on the patient’s skull and turning the head first to one side and then to the other so that the chin is in line with the shoulder.
Note: If a complete fixation occurs between C1 and C2, the remaining
cervical segments commonly become hypermobile in compensation. Thus,
gross inspection of neck rotation (or other motions) should never be
used to evaluate the function of individual segments.
The Lower Cervical Area
The lower cervical IVDs contain an exceptional amount of elastin, which allows the IVDs to conform to the many possible planes of movement. Excessive flexion is limited by ligament and muscle restraints on the separating posterior arches. Overextension is limited by bony apposition. Other factors include the resistance of the anular fibers to translation, the stiffness property of the anulus relative to its vertical height, and the physical barrier produced by the uncinate processes that are fully developed in late adolescence. Major joint movements and their innervation are shown in Table 4.2.
Table 4.2. Major Joint Movements and Their Innervation
Segments Joints Movement/Roots
C2–T1 Scapulae Elevation and retraction (C2–5)
Depression and protraction (C5–T1)
C5–T1 Shoulder Abduction (C5–6)
Abduction and flexion (C5–T1)
Extension (C5–8)
C5–T1 Elbows Extension (C6–T1)
Flexion (C5–6)
C6–T1 Wrists Flexion (C7–T1)
Supination, pronation, extension (C6–7)
C6–T1 Fingers Extension (C6–8)
Flexion (C7–T1)
Lower-Cervical Instability. Subtle instability is rarely obvious in the ambulatory patient. The most important stabilizing agents in the mid- and lower-cervical spine are the anulus fibrosus, the anterior and posterior ligaments, and the muscles, especially, which serve as important contributing stabilizers. On dynamic palpation, any segmental motion exceeding 3 mm should arouse suspicions of lack of ligament restraint.
Neurologic Insults. There is a rough correlation between the degree of structural damage present and the extent of neurologic deficit. This is more true in the lower cervical area than in the upper region where severe damage may appear without overt neurologic signs. In either case, it’s doubtful that a deficit would exhibit without an unstable situation existing. It is not unusual for a patient to exhibit a neurologic deficit without static displacement; ie, the vertebral segment has rebounded back into a normal position of rest.
Segmental Angulation. Angulation of one vertebral segment on a lateral roentgenograph more than 11º greater than an adjacent vertebra that is not chronically compressed indicates instability and pathologic displacement. While conservative traction may reduce the associated displacement, it is doubtful in very severe cases that a normal resting position can be guaranteed without surgical fusion. But this should be considered as a final alternative.
Facet Action. In the middle and lower cervical areas, A-P motion is a distinctly gliding translation. During flexion and extension, the superior vertebra’s inferior facets slide anterosuperior and posteroinferior on the inferior vertebra’s superior facets. During full flexion, the facets may be almost if not completely separated. Consequently, an adjustment force is usually contraindicated in the fully flexed position. The center of motion is often described as being in the superior aspect of the body of the subjacent vertebra. Some pivotal tilting of the superior facets, backward in extension and forward in flexion, is also normal near the end of the range of motion. The facets also tend to separate (open) on the contralateral side of rotation and lateral bending. They approximate (jam) during extension and on the ipsilateral side of rotation and lateral bending. Likewise, the foramina normally open on flexion, narrow on extension, and close on the concave side of lateral flexion. Because of the anterosuperior slant of the lower cervical facets, an inferior facet that moves downward must also slide posterior, and vice versa.
Adjustment Precautions. Any corrective adjustment must consider the state of the cervical curve, planes of articulation, facet tilting, and degree of facet opening, as well as any underlying pathologic process involved, and applying just enough force to overcome the resistance of the fixation. Here, again, knowledge of the mechanism of trauma and the ability to mentally picture the state of hidden tissues are underscored.
Coupling Patterns. During lateral bending, the vertebral bodies tend to rotate toward the concavity while the spinous processes swing in a greater arc toward the convexity. Note that this is exactly opposite to the coupling action in the lumbar spine. During cervical bending to the right, for example, the right facet of the superior vertebra slides down the 45º plane toward the right and posterior and the left facet slides up the 45° incline toward the left and anterior. This coupling phenomenon is seen in circumstances in which an unusual ratio of axial rotation and lateral bending produces a subluxation or unilateral facet dislocation. The amount of cervical rotation coupled with lateral flexion varies with the segmental level. At C2, there is 1º of rotation with every 1.5° of lateral flexion. This 2:3 ratio changes caudally so that the degree of coupled rotation decreases. For example, at C7, there is 1° of rotation for every 7.5° of lateral flexion, a 2:15 ratio.
Ranges of Motion. All cervical vertebrae from C2 to C7 partake in flexion, extension, rotation, and lateral flexion, but some segments (eg, C5) are more active than others. In the C3—C7 area, flexion and extension occur as slight gliding translation of the upper on the lower facets, accompanied by disc distortion. The site of greatest flexion is near the C4—C5 level, while extension movement is fairly well diffused. This fact probably accounts for the high incidence of arthritis at the midcervical area. Rotation is greatest near the C5—C6 level, slightly less above and considerably less below. Lateral bending in greatest near the C2—C3 level and is diminished caudally. The arc of lateral motion is determined by the planes of the covertebral joints.
The Transitional Cervicothoracic Area
The lateral gravity line of the body falls anterior to the mid thoracic region. With fatigue, there is a tendency for thoracic kyphosis to increase. Thus, when cervical alignment is poor, equal concern must be given to reduce an exaggerated thoracic kyphosis because the positions of the cervical and thoracic regions are interrelated; ie, a thoracic kyphosis is usually accompanied by a compensatory cervical lordosis, and vice versa.
In the cervicothoracic area, normal movement is somewhat similar to that in the lumbosacral area insofar as the type of stress (not magnitude of load) to which both areas are subjected is similar. L5 is relatively immobile on the sacrum and C7 is relatively immobile on T1. Most movement in the cervicothoracic junction is at C6—C7 and primarily that of rotation.
APPLIED ANATOMY OF THE CERVICAL PLEXUS
There is also a synapse between the upper cervical nerves and the trigeminal nerve, which also supplies the dura mater. This may explain why irritation of C1 results in a neuralgia not only confined to the base of the skull but is also referred to the forehead or eye via the supraorbital branch of the trigeminal. The greater occipital (C2) nerve does not tend to do this. It exits between the posterior arch of the atlas and above the lamina of the axis, referring pain to the atlanto-occipital area and sometimes to the vertex of the head.
The superficial sensory cutaneous set of the cervical plexus (C1—C4) is frequently involved in subluxations of the upper four segments (refer to Table 4.3), particularly when there are predisposing spondylitic degenerative changes. Janse describes four resultant neuralgias:
(2) greater auricular neuralgia, extending in front and behind the auricle, skin over the parotid gland, paralleling the distribution of the auriculotemporal branch of the trigeminus and easily misdiagnosed as chronic trifacial neuralgia;
(3) cervical cutaneous neuralgia, involving the area of the middle third of the platysma to the midline, possibly extending from the chin to the sternum;
(4) supraclavicular neuralgia. Depending on which rami are affected, the neuralgia may involve the suprasternal area, pectoral area, or deltoid area. Thus, sternoclavicular and acromioclavicular neuralgias may originate in the spinal levels of the supraclavicular nerve.
Irritative lesions involving the cervical articulations may in turn irritate the sympathetic nerve plexuses ascending into the head via the vertebral and carotid arteries. Some cases of visual and aural symptoms are related to upper-cervical distortion where the arch of the atlas snugly hugs the occiput, thus possibly irritating the sympathetic plexus near the vertebral artery as well as partially compressing the vessel. To appreciate this, note that the visual cortical area of the occipital lobe requires an ideal blood supply dependent on the sympathetics ascending the great vessels of the neck, and this holds true for the inner ear as well. To test this syndrome, De Rusha suggests having the supine patient read some printed matter while the examiner places gentle traction on the skull, separating the atlanto-occipital articulations. A positive sign occurs when the patient, often to his surprise, experiences momentarily enhanced visual acuity or reduced tinnitus.
Table 4.3. Nerve Function of the Cervical Plexus (C1-C4)
Nerve Function
Lesser occipital Sensory to skin behind ear and mastoid process.
Greater auricular Sensory to skin over parotid, jaw angle, ear
lobe, and front of mastoid process.
Cervical cutaneous Sensory to skin over anterolateral portion of neck.
Supraclaviculars Sensory to skin over medial infraclavicular area,
pectoralis major and deltoid.
Muscular branches Motor to capitus anterior and lateralis, longus
capitus, longus colli, hyoid muscles,
sternocleidomastoideus, trapezius, levator scapulae,
scalenus medius.
Phrenic Sensory to costal and mediastinal pleura and pericardium.
Motor to diaphragm.
THE BRACHIAL PLEXUS
See Table 4.4. Many features of brachial plexus involvement manifest in the upper extremities and will be described in subsequent chapters.
Table 4.4. Nerve Function of the Brachial Plexus (C5-T1)
Nerve Function
Radial Motor for wrist and thumb extension; sensory to dorsal
webspace between thumb and index finger.
Ulnar Motor for little finger abduction; sensory to distal
ulnar aspect of little finger.
Median Motor for thumb opposition and abduction; sensory to
distal radial aspect of index finger.
Axillary Motor to deltoid muscle; sensory to lateral arm and
deltoid patch on upper arm.
Musculo- Motor to biceps muscle; sensory to lateral forearm.
cutaneous
THE CERVICOTHORACIC JUNCTION AREA
The area of cervicothoracic transition is a complex of prevertebral and postvertebral fascia and ligaments subject to shortening. It offers a multitude of attaching and crossing muscles such as the longus colli, trapezius, scaleni, sternocleidomastoid, erector spinae, interspinous and intertransverse, multifidi and rotatores, splenius capitis, splenius cervicis, semispinalis capitis, semispinalis cervicis, longissimus capitis, longissimus cervicis, and the levator costarum and scapula —all subject to spastic shortening and fibrotic changes that tether normal dynamics.
CLINICAL MANAGEMENT ELECTIVES IN CERVICAL STRAIN/SPRAIN/IVD LESION
1. STAGE OF ACUTE INFLAMMATION AND ACTIVE CONGESTION
The major goals are to control pain and reduce swelling by vasoconstriction, compression, and elevation; to prevent further irritation, inflammation, and secondary infection by disinfection, protection, and rest; and to enhance healing mechanisms. Common electives include: Disinfection of open skin (eg, scratches, abrasions, etc)
Cryotherapy
Cold packs
Ice massage
Vapocoolant spray
Pressure bandage
Protection (padding)
Indirect therapy (reflex therapy)
Iontophoresis/phonophoresis
Auriculotherapy
Meridian therapy
Spondylotherapy (upper dorsal)
Mild pulsed ultrasound
Pulsed alternating current
Rest
Bedrest
Foam/padded appliance
Immobilization
Brace
Plaster cast
Rigid appliance
Indicated diet modification and nutritional supplementation.
2. STAGE OF PASSIVE CONGESTION
The major goals are to control residual pain and swelling, provide rest and protection, prevent stasis, disperse coagulates and gels, enhance circulation and drainage, maintain muscle tone, and discourage adhesion formation. Common electives include: Indirect articular therapy (reflex therapy)
Alternating superficial heat and cold
Pressure bandage
Protect lesion (padding)
Light nonpercussion vibrotherapy
Mild passive exercise of adjacent joints
Mild surging alternating current
Mild pulsed ultrasound
Meridian therapy
Phonophoresis
Rest
Bedrest
Foam/padded appliance
Immobilization
Brace
Rigid appliance
Plaster cast
Orthopedic pillow
Indicated diet modification and nutritional supplementation.
3. STAGE OF CONSOLIDATION AND/OR FORMATION OF FIBRINOUS COAGULANT
The major goals are the same as in Stage 2 plus enhancing muscle tone and involved tissue integrity and stimulating healing processes. Common electives include: Mild articular adjustment technics
Moist superficial heat
Thermowraps
Spray-and-stretch
Moderate active range-of-motion exercises
Meridian therapy
Alternating traction
Sinusoidal current
Ultrasound
Phonophoresis
Microwave
Vibromassage
High-volt therapy
Interferential current
Spondylotherapy (upper dorsal)
Mild transverse friction massage
Mild proprioceptive neuromuscular facilitation techniques
Rest and Immobilization
Foam/padded appliance
Semirigid appliance
Orthopedic pillow
Indicated diet modification and nutritional supplementation.
4. STAGE OF FIBROBLASTIC ACTIVITY AND POTENTIAL FIBROSIS
At this stage, causes for pain should be corrected but some local tenderness likely exists. The major goals are to defeat any tendency for the formation of adhesions, taut scar tissue, and area fibrosis and to prevent atrophy. Common electives are: Deep heat
Articular adjustment technics
Spondylotherapy (upper dorsal)
Local vigorous vibromassage
Transverse friction massage
Spray-and-stretch
Active range-of-motion exercises without weight bearing
Motorized alternating traction
Negative galvanism
Ultrasound
Sinusoidal and pulsed muscle stimulation
Microwave
High-volt therapy
Interferential current
Meridian therapy
Proprioceptive neuromuscular facilitation techniques
Flexible foam/padded appliance
Orthopedic pillow
Indicated diet modification and nutritional supplementation.
5. STAGE OF RECONDITIONING
Direct articular therapy for chronic fixations
Progressive remedial exercise
Passive stretching
Isometric static resistance
Isotonics with static resistance
Isotonics with varied resistance
Plyometrics
Aerobics
Orthopedic pillow
Indicated diet modification and nutritional supplementation.