Cervical Spine
Arthur Jason De Luigi, DO
Program Director, Sports Medicine Fellowship
Director, Sports Medicine
Director, Interventional Pain
MedStar National Rehabilitation Hospital
MedStar Georgetown University Hospital
Medical Director and Head Team Physician
US Paralympic Alpine Ski Team
Overview
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Cervical Anatomy
Physical Examination
Pathology
Treatment
Cervical Spine
Anatomy
• 3-joint complex
• 50% Flex-Ext
– Atlanto-occipital
• 50% rotation
– C1-C2
• Center of motion
– Flex C 5-6
– Ext C 6-7
• C2 and C7 most
prominent spinous
processes
Anatomy
• Center of motion
– Flex C 5-6
– Ext C 6-7
• Normal lordodic
curve helps absorb
energy of blows to
head and neck
• Lordosis lost @ 30
deg forward flexion
Cervical Nerves
• 8 cervical roots
• C1-C4
– Sensory
• C5-T1
– Brachial Plexus
– Motor Branches
Cervical and Thoracic Nerve ROots
Cervical Nerve Roots
– Exit above the vertebral
body for which they are
named
Thoracic Nerve Roots
– Exit under the vertebral
body and rib
C-Spine Exam Overview
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Inspection
Palpation
Range of Motion
Strength
Neurovascular testing
Special tests
Inspection
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Overall posture
Position of comfort
ROM when walking, talking
Deformity, ecchymosis, swelling
(All marketed devices to improve posture)
Palpation
• Spinous processes
– Bony TTP is a red-flag
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Paraspinal muscles
Anterior & lateral neck
Upper back & scapula
Arms if symptoms there
Range of Motion
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Forward Flexion
Extension
Side bending
Rotation
60 degrees
70 degrees
45 degrees*
80 degrees*
Note mild/moderate/severe restriction
*compare to opposite side
Blocker
Motor Exam
• C5-Deltoid
Beggar
• Elbow Flexion
• C6- Wrist Extension
• Elbow Flexion
Kisser
• C7-Wrist flexion
• Elbow Extension
• Finger Extension
Grabber
• C8- Finger flexors
• T1-Hand intrinsics
Spock
Exam- Sensory
• C5-anterior brachium
• C6- thumb
– Lateral arm
• C7- middle finger
– Posterior arm
• C8-ulnar side hand
– Posterior arm
• T1-inner brachium
– Axilla
Deep Tendon Reflexes
C5: Biceps
C6: Brachioradialis
C7: Triceps
Weakness
DTR’s
decr
Nerve
Root
Disc
Level
Pain/Sensory Loss
C1,2
O-C2
Occiput
C3
C2-3
Post-Sup neck
Ears and mastoid
C4
C3-4
Post-Inf neck/shoulder
C5
C4-5
Lat. neck and shoulder
Ant. Arm
Deltoid
C6
C5-6
Post-Lat arm to
Thumb, +/- index finger
Biceps
Biceps
& Br-rad
C7
C6-7
Post-Mid arm to mid fngr
Triceps
Triceps
C8
C7-8
Post arm to ring/small fingr
T1
T1-2
Proximal inner arm/axilla
Grip
Intrinsics
Special Tests
• Spurling Test
• Lhermitte’s Sign
• Hoffman’s Sign
Spurling Test
• Cervical etiology
– pinched nerve rt.
• Head is extended
and rotated
– Slight axial load
Practical Tip: Extend the pts head and then
tell them to ”look in their back pocket.”
If no symptoms then apply axial load.
Spurling Test
• Also known as
– foraminal compression test
– neck compression test
– quadrant test
Spurling Test
• World War II
• Walter Reed General Hospital
– Roy Greenwood Spurling
• Hospital's first Chief of Neurosurgery
• Organizer of neurosurgery for the entire Army
– First noted this finding in patients of ruptured cervical discs.
• Spurling and Scoville
– Demonstrated a positive test on 12 patients with presumed ruptured cervical
discs
– confirmed surgically in 1943 and reported their findings in 1944
• The original description of the test
– Head and neck will be tilted toward the painful side to reproduce the patient’s
typical radicular symptoms
– Pressure will then be placed on the top of the head to further intensify the
symptoms
– Whereas tilted the head away from the painful side will alleviate the
symptoms
Spurling Test
• Validity and Reliability
– Shah and Rajshekhar in 2004
• 50 surgical patients with findings on MRI
– Sensitivity 92%
– Specificity 95%
– Positive predictive value 96.4%
– Negative predictive value 90.9%
• Concluding that the Spurling’s test is the gold
standard for evaluating cervical radiculopathy
Lhermitte’s Sign
• Also known as
– Barber Shop Phenomenon
• 1920
– Jean Jacque Lhermitte
• patients with spinal cord concussion and later in other neurologic diagnoses
• Previously described
• 1917
– Marie and Chatelin
• Transient pins and needles sensations into the limbs on flexion of the neck
• 1918
– Babinski and Dubois
• Electric discharges into the limbs with head flexion, sneezing, or coughing in a patient
with Brown-Sequard syndrome
Lhermitte’s sign
• Passive or Active Neck
Flexion
Pain/Electric sensation
shooting down back or
into legs
– Myelopathy
– Multiple Sclerosis
Lhermitte’s Sign
• Validity and Reliability
– Malanga
• Review
– Insufficient evidence of the inter-rater reliability, sensitivity,
and specificity
– Sandmark and Nissell
• Active flexion and extension test
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» resembles the Lhermitte’s sign and was found to
Specificity (90%)
Sensitivity (27%)
Negative predictive value of 75%
Positive predictive value of 55%.
Hoffman’s sign
“Babinski of the Upper Extremity”
• Test for UMN lesion
– Flick middle finger
– Watch for reflexive flexion/adduction of thumb
Cervical Pathologies
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Cervical Strain/spasm
Cervical Sprain
Cervical Instability
Stingers
Spondylosis
Stenosis
HNP
Cervical Cord Neuropraxia
Fractures/subluxation
Cervical Strain & Spasm
• Usually minor
trauma (or none)
– “Slept Wrong”
– Overuse/Posture
– Sudden movement
• Minor muscle fiber
tears, secondary
spasm
Myofascial Pain
• Travell & Simon
• “Trigger Points”
– Discrete hyperirritable spots located within taut
muscle band
– Often with chronic MSK disorder
– Hypersensitive area or firmer than normal tissue,
usually quarter-size area
– Can result in decreased ROM in the affected
muscles
Trigger Points
• Treatments
– Spray and stretch
– Ultrasound
– Massage
– Manipulation
– Trigger point injection
• Injection material
– 3cc lidocaine
– +/- Corticosteroid
– Dry needle (more post injection soreness)
• Disrupts the pain cycle
– Stops hyper-responsive signals
Myofascial Pain
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Muscle Relaxants
Cyclobenzaprine
– Relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions.
– 2RCTs
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Both found no significant differences between the treatment groups.
– Another RCT evaluated the effect of cyclobenzaprine12 in patients with jaw paiin
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No evidence favoring cyclobenzaprine over clonazepam or placebo.
– Cochrane review
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nsufficient evidence to support its use due to a lack of high quality RCTs.9
Tizanidine
– Alpha2 adrenergic agonist
– Two prospective trials (not RCT) evaluated tizanidine for MPS14, 15.
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Manfredini et al., in 2004
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78 patients with MPS, and noted only a slight improvement in pain.
Malanga et al., in 2002
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29 patients who were titrated on tizanidine for 3 weeks.
Significant decrease in VAS, disability and sleep improvement were noted
– Two RCTs
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patients with acute low back pain showed a significant difference in pain reduction favoring tizanidine
to placebo.
– Review article
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Insufficient literature to support the use of tizanidine
Myofascial Pain
• Sedatives/Hypnotics
• Clonazepam
– Benzodiazepinederivative with anticonvulsant, muscle relaxant, and anxiolytic
properties.
– Two RCTs19, 20 evaluated the efficacy of clonazepam for MPS treatment
• Found it to be effective
• However, caution was advised due to side effects such as depression and liver function
– Review article
• Better than placebo for MPS pain relief.
– Analysis of the above literature
• Strongly supports the use of clonazepam, a traditional agent, in the treatment of MPS.
• Alprazolam and Diazepam
– Potent benzodiazepines.
– Review article
• alprazolam or diazepam in combination with ibuprofen is better than placebo.
– RCT
• significant reduction of pain in both the diazepam and the diazepam with ibuprofen
groups.
Myofascial Pain
• Anti-Depressants
• Amitriptyline and Nortriptyline
– Amitriptyline
• TCA traditionally studied in the treatment of a wide variety of
painful conditions including MPS
– Nortriptyline
• Second generation TCA with less incidence of side effects
compared to amitriptyline.
– Two RCTs
• Bendsten and Jensen
– Significant reduction in pain and myofascial tenderness.
• Plesh et al
– Effective for myofascial pain
Myofascial Pain
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Topical Agents
Topical Lidocaine Patch
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Case report in 2002
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Open labeled non randomized trial
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Methyl Salicylate
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Rubefacient in deep heating liniments For myalgias and muscle spasms
Menthol
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Organic compound with local anesthetic and counterirritant qualities
weak kappa opioid receptor agonist.
A single RCT
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demonstrated a significant global satisfaction and reduction of pain at rest and with movement compared to placebo
Topical Diclofenac Patch and Solution
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single RCT
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Lone RCT studying topical diclofenac solution
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topical lidocaine patch demonstrated a significant reduction of pain episodes, intensity of pain at rest and with activity,
improvement of mood and quality of life as compared to a placebo patch.
Topical Methyl Salicylate and Menthol Patches
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Showed some relief of pain and improvement in quality of life in 27 patients
RCT
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did not demonstrate significant evidence for pain reduction
significant difference in pain, range of motion and disability scores compared to placebo
no significant differences between the groups.
Topical Thiocolchicoside Ointment
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Muscle relaxant with anti-inflammatory and analgesic effects
Competitive GABA-A receptor antagonist and also inhibits glycine receptors
Single blind, RCT
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Significant improvement in pain and range of motion in all treatment groups.
Whiplash
Cervical Sprain
• Usually higher-energy trauma (MVA)
• Often d/t rapid or excessive ROM in one or more
planes
• Ligamentous injury usually coupled with muscle
strain/spasm
• Non-radicular neck/shoulder pain
– worsened by neck motion
• Careful exam to r/o nerve injury
• Consider X-rays to r/o fracture & instability
Imaging
• No imaging required if patient meets all of the
following…
– No midline tenderness
– No focal neuro sx
– Normal LOC
– No drugs/meds
– No distracting injuries
Cervical Spine Trauma Imaging
• AP view
• Lateral view (must include entire C7)
• Odontoid view
• IF NORMAL, consider FLEX/EXT VIEWS
Flexion & Extension Views
Cervical Sprain w/ Instability
• Can present subacutely
– Persistent pain after
appropriate time to
recover
• Flex/Ex view criteria:
– >3.5 mm AP displacement
– >11 deg angulation
• IMMOBILIZE & REFER
ASAP
Cervical Sprain w/o Instability
Treatment:
• Analgesics, +/- muscle relaxer
• +/- Hard/Soft collar
• Relative rest; encourage resumption of
ADL soon
• Early referral to PT
– ROM emphasized (decrease risk disability)
– Modalities
Strain/Spasm Treatment
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NSAID/Tylenol
Muscle relaxer?
Trigger point injections?
Soft collar (rarely)
Relative rest & active
stretching
• Usually improvement
starts after 3-4 days
• If recurrent refer to PT
Cervical Spondylosis
• Degeneration of discs
and facets joints
– Space narrowing
– Osteophytes
– Sclerosis
Cervical spondylosis s/sx
• Paramedian neck tenderness
• Reduced ROM
GRADED
• Mild: HA’s, neck pain (limited to disc, facet jt)
• Moderate: radicular sxs (foramen)
• Severe: myelopathy (canal)
– gait, balance, bladder sx’s
Cervical Stenosis
• Narrowing of the AP
diameter of the cervical
canal
– Developmental
– Acquired: secondary to
degenerative dz, HNP, etc.
• MRI for diagnosis
• EMG can reveal nerve
damage
Tx of spondylosis/stenosis
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Analgesics +/- muscle relaxer
Soft collar prn
Relative rest from offending activity
Physical Therapy if persistent
Cervical Epidural if refractory
Surgical indications:
– Myelopathy
– Radicular sxs not responding to tx
• Get MRI, talk to surgeon
Herniated Nucleus Pulposus (HNP)
• Acute Radiculopathy
– Rupture of nucleus
pulposus through tear
in the annulus fibrosus
• Chronic Radiculopathy
– Gradual Onset d/t
disc degeneration,
thinning, bulge, and
osteophytes
HNP
• Neck pain with radiation into the shoulder/arm
– Burning pain or weakness
• Sensory changes in a specific nerve root
– Motor if C5-T1 involvement
• Spurling’s maneuver reproduces symptoms
– Improved with distraction maneuvers
• No upper motor neuron deficits
– Neg Hoffman, Babinski
– No rigidity, gait dysfx, hyper-reflexia
HNP Treatment
• Conservative therapy: 40-80% respond by 6-12wk
– Rest, NSAID, ROM ex’s, neck collar, cervical pillow
– Consider oral steroids if severe radicular sx’s
• Physical therapy if poor response 1-2 wks
– Traction, TENS
• Consider referral for invasive tx if:
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Patient is ready
Progressive neurological symptoms
sxs persist despite tx
MRI, EMG/NCV
Epidural Steroid Injections
• Epidural steroid injections (ESI)
commonly used intervention to
treat radicular pain
• In the cervical and thoracic
spine, this pain is most
commonly caused by herniated
disc and/or foraminal stenosis
• Mechanism of pain generation:
mechanical compression and
chemical inflammation
• Corticosteroids thought to
reduce chemical inflammation
and pain
HNP & Radiculopathy
Introduction - ESI
HNP & Radiculopathy
• 2 methods for
delivering medication to
the epidural space in
the cervical and
thoracic spine:
– Interlaminar epidural
steroid injection (ILESI)
– Transforaminal epidural
steroid injection (TFESI)
Cervical TFESI – ISIS Guidelines
• Pre-injection procedures
– IV access
– VS Monitoring: BP,HR,pulse-ox
– Patient Positioning: supine, oblique, lateral
decubitus position
– Sterile Prep: antibacterial solution, sterile draping
Cervical TFESI – ISIS Guidelines
• Target
Identification
– Oblique View
– Identify target
foramen
– Rotate C-arm to
open foramen
– Consider
magnification
Cervical TFESI – ISIS Guidelines
• Within foramen:
– Posterior Wall
– Anterior surface of
SAP
Cervical TFESI – ISIS Guidelines
• Puncture Point
– Skin directly over target
– Mark with sterile marker or small wheel of local anesthetic
– +/- Local anesthetic (shallow)
• Needle Insertion
– 25-guage needle (2.5 inch, SB)
– Needle tip should lie directly over anterior part of SAP, not
foramen (or can be over posterior foramen if checking A/P
early and often)
– Ideally, advance needle down the beam - “hubogram”
– Once SAP is reached, adjust needle to pass into foramen
– Subsequent insertion should not be more than a few mm
in depth, and should never stray into anterior aspect of
foramen
Cervical TFESI – ISIS Guidelines
• Needle
Insertion – AP
view: target is
sagittal midline
of articular
pillar
Cervical TFESI – ISIS Guidelines
• Contrast
injection:
– Under real-time
fluoro, inject
non-ionic
contrast
– Contrast should
disperse in
intervertebral
foramen,
outlining spinal
nerve and DRG
Big Red and his little friends
Big Red
DRG
SAP
Epidural Veins
DISC
SPACE
DRG
SAP
cord
What to watch out for
• DRG/Spinal Nerve
• Vascular flow:
– Arterial
• Vertebral artery – rapid upward flow
• Radicular artery – narrow vessel with transverse flow medially
toward cord
• ISIS recommends procedure aborted in this case
– Venous (radicular and epidural veins): slow clearance of
contrast – can reposition needle
• Subarachnoid flow
– Rapid dilution of contrast
– Can be from medial position, or lateral dilatation of dural
root sleeve in foramen
– Procedure should be aborted
Use Digital Subtraction Angiography in
Cervical and Thoracic Spine
Digital Subtraction Angiography – Same
patient
Cervical TFESI – ISIS Guidelines
• Medication Injection: once injection of contrast has
identified acceptable needle position in 2 views,
therapeutic solutions can be delivered
– Corticosteroid:
• Dexamethasone (7.5-15mg)
• Betamethasone (3mg – 12mg)
– Short-acting local anesthetic
• 1% Lidocaine (0.5-1.5 ml)
• 0.5% Lidocaine (1.5-3.0 ml)
– Normal Saline
Cervical Interlaminar ESI (ILESI)
• Cervical epidural space much more narrow
(1.5-2mm at C7 to less than 1mm at higher
levels) compared to lumbar spine
• If less than 1 mm on MRI, avoid interlaminar
• Interlaminar approach: usually 2 cc
celestone/dexamethasone, 2-3 cc of 1-1.5%
lidocaine and 0-2 cc of saline for 4-7 cc total;
usually at C6-7-T1
C5-6
C7-T1
Cervical ILESI
• Position patient
prone with pillow
under chest
• Sterile prep with
betadine and
drape
• Identify target
interlaminar
space (C6-7,7-1)
Cervical ILESI
• Target: superior border
of inferior lamina at
midline
• Mark and anesthetize
(1% lidocaine)
• 18- or 20- gauge Touhy
needle advanced using:
– Frequent lateral imaging
– Loss of resistance
technique with normal
saline
Cervical ILESI
• Once epidural space entered
(based on LOR), inject non-ionic
contrast (1cc) under live fluoro.
• Should see even spread of
contrast, and lateral imaging
should show posterior flow.
• If no vascular flow, no
subarachnoid flow…inject
medication (1-2 cc celestone /
dexamethasone, 2-3 cc of 11.5% lidocaine and 0-2 cc of
saline for a total of 4-7cc)
Cervical ESI - Complications
• Botwin 5/2003: 157 patients receiving a total of 345 cervical ILESI
for cervical radicular pain caused by cervical spondylosis or HNP
– All complications: 16.8%. All resolved without morbidity, and no patient required
hospitalization: Transient increased neck pain (6.7%), transient headaches (4.6%),
insomnia the night of injection (1.7%), Vasovagal reaction (1.7%), facial flushing
(1.5%), Transient Fever 1(0.3%), Dural puncture: 1 (0.3%)
• Ma 8/2005: 844 patients, 1036 Extraforaminal Nerve Root Blocks
(TFESI):
– All complications: 1.66%. No death, paralysis, stroke, vertebral artery injury or
infection recorded: Transient neuro deficit (pain or weakness): 6 pts, HA/Dizziness: 5
patients, Hypersensitivity rxn: 1 pt, Vasovagal rxn: 1 pt, Transient global amnesia,
dizziness, nausea:1 pt (admitted to hospital overnight, neuro w/u negative, resolution
of dizziness by 2 weeks), Injection at incorrect level: 2 pts, Inadvertent facet injection:
1 pt
• Case reports – cervical TFESI (Scanlon 2007): death, vertebrobasilar
infarcts/TIA/RIND, cervical spinal cord infarcts, combined brain and SCI infarcts,
high spinal anesthesia, Seizures, severe HA, brainstem edema with herniation,
cortical blindness from air embolus, cervical epidural hematoma, paraspinal
hematoma
– Mechanism unclear, but thought to be related to particulate steroid causing vascular
embolism – SCI, stroke, death
– Safety measures: Small/no particulate steroid (dexamethasone) and DSA
Cervical ESI - Evidence
• Transforaminal ESI: No RCT’s, just descriptive studies, generally
with positive short-term (<6 weeks) and long-term (>6 weeks)
results for radiculopathy. Limited evidence for axial neck pain.
– Morvan 1988: 51 pts with radicular pain - 14% obtained complete and long
lasting relief, 86% derived incomplete relief, transitory relief, or no relief
– Bush 1996: 68 pts with radicular pain- Transforaminal +/- Interlaminar – 76%
complete relief of arm pain (7 mos)
– Slipman 2000: 20 pts with radicular pain – 60% success (pain reduction,
return to FT work, decreased meds, patient satisfaction) at avg. 22 mos f/u
– Vallee 2001: 32 pts with radicular pain - at 6 mos – 53% of patients had
>75% pain relief
– Cyteval 2004: CT guided TFESI – 30 pts with radicular pain – good pain relief
in 60% of patients at 2 wks and 6 mos
– Kolstad 2005: 21 surgical candidates (discectomy): significant decrease in
radicular pain at 6 wks and 4 mos, 5 patients avoided surgery
– Lin 2006: 70 surgical candidates (HNP): 63% had significant relief of
symptoms and decided against surgery
Cervical ESI - Evidence
• Interlaminar ESI
– 2 RCT for radiculopathy
• Castagnera 1994: Group 1 (14 pts: LA + Steroid) vs.. Group 2 (10 pts:
LA + Steroid + Morphine) – no diff between groups, but good overall
pain relief (>50mm decrease on VAS):
– Initial: 96%
– 1 Month: 75%
– 3, 6 and 12 mos: 79%
• Stav 1993: Group 1 (25 pts: ESI) vs. Group 2 ( 17 pts: intramuscular LA
+ steroid). Significant outcomes (good-very good pain reduction,
return to FT work, decreased meds, change in ROM)
– 1 week: 76% group 1, 36% group 2
– 1 year: 68% group 1, 12% group 2
– Axial neck pain: limited evidence
Patient Selection for Cervical ESI
• Indications:
– Cervical radicular pain +/- radiculopathy
– Hx, PE and imaging c/w nerve root impingment/irritation
– Failed conservative treatment (PT, meds, activity
modification) >6weeks
• Contraindications (ABCDEFGHIJK)
Absolute:
Relative:
– Coagulopathy (Bleeding)
-Allergy
– Local Infection (Fever)
-Hx steroid psychosis (Krazy)
– Spinal Malignancy (CA) -CHF (decreased EF)
– Uncontrolled DM
-Pregnancy (Gravid)
– Pt. unable to lie still
-Systemic infection (Fever)
(“Jimmy legs”)
-Heart/Respiratory issues
–
-Immunosupression
Stingers (Burners)
• Transient UE neuropraxia of
root or brachial plexus
– Tractionplexus
– Compressionroot
• Burning in arm
• Weakness in C5 and C6
distribution
– Deltoid, biceps, RC, wrist
extensors, pronator teres
• +/- Positive Spurling’s
Stingers
• Treatment
– Protection
– Rest until
asymptomatic
• May Return to Play
when:
– Full cervical ROM
w/o pain
– Normal sensory,
motor exam
– Negative Spurling
Cervical Cord Neurapraxia
• Sxs or neuro findings in ≥2 limbs
– Axial load with hyperextension or flexion
– Cervical cord “pinch”
• Sx last 10 min-48 hrs
– Burning Hands Syndrome
– Transient Quadraparesis
C-spine Injury
On-Field Management
• Assess LOC and simple
neuro exam by question
without moving athlete
• Stabilize C-spine and logroll if necessary to move
athlete to back
• “Leave helmet on”
– Helmet & shoulder pads
• Manage airway by
removing face mask
Immediate Transport for…
• Unconscious athlete
• Neuro symptoms in ≥2
limbs
• Spinous process
tenderness with
concerning MOI
• Any distracting injuries
References
• Abdi S, et al. Epidural Steroids in the Management of Chronic Spinal Pain:
A systematic review. Pain Physician 2007; 10:185-212
• International Spine Intervention Society: Practice Guidelines – Spinal
Diagnostic and Treatment Procedures. 2004 ISIS
• Manchikanti, et al. Evidence-Based Practice Guidelines for Interventional
Techniques in the Management fo Chronic Spinal Pain. Pain Physician
2003;6:3-81
• Rathmal JP, et al. Cervical Transforaminal Injections of Steroids.
Anesthesiology 2004; 100:1595-1600
• Fenton, DS and Czervionke LF: Image-Guided Spine Intervention. Saunders
2003
• Botwin KP, et al. Adverse Effects of Fluoroscopically Guided Interlaminar
Thoracic Epidural Steroid Injections. AJPMR 1/06
References
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