CERVICAL

SPINE
Lecture by: M.K. Sastry
Program Director,
Post Graduate Studies and PhD Program
 Overview
 Cervical Anatomy
 Physical Examination
 Pathology
 Treatment
 Cervical Spine Anatomy
 3-joint complex

 50% Flex-Ext
 Atlanto-occipital

 50% rotation

 C1-C2
 Cervical Spine Anatomy
 Center of motion

 Flex C 5-6
 Ext C 6-7
 Cervical Spine Anatomy
 C2 and C7 most
prominent spinous
processes
 Anatomy

 Center of motion
 Flex C 5-6

 Ext C 6-7
 Anatomy

 Normal lordodic
curve helps absorb
energy of blows to
head and neck
 Anatomy

 Lordosis lost @ 30
deg forward
flexion
 Cervical Nerves
 8 cervical roots

 C1-C4

 Sensory
 Cervical Nerves
 C5-T1

 Brachial Plexus

 Motor Branches
Cervical And Thoracic Nerve Roots

Cervical Nerve Roots

 Exit above the
vertebral body for
which they are
named
Cervical And Thoracic Nerve Roots

Thoracic Nerve Roots

 Exit under the
vertebral body and
rib.
 C-Spine Exam Overview

 Inspection

 Palpation
 Range of Motion

 Strength
 C-Spine Exam Overview

 Neurovascular testing

 Special tests
 Inspection

 Overall posture
 Position of comfort
 ROM when walking, talking
 Deformity, ecchymosis, swelling
Inspection

(All marketed
devices to
improve
posture)
 Palpation
 Spinous processes

 Bony TTP is a red-flag

 Paraspinal muscles

 Anterior & lateral neck

 Palpation
 Upper back & scapula

 Arms if symptoms there

 Range of Motion
 Forward Flexion - 60 degrees

 Extension - 70 degrees
 Side bending - 45 degrees*
 Rotation - 80 degrees*
 Motor Exam Blocker

 C5-Deltoid
Beggar
 Elbow Flexion

 C6- Wrist Extension Kisser

 Elbow Flexion
Grabber
 Motor Exam Blocker

 C7-Wrist flexion
Beggar
 Elbow Extension

 Finger Extension Kisser

 C8- Finger flexors

Grabber
 T1-Hand intrinsics
 Exam- Sensory
 C5-anterior brachium

 C6- thumb

 Lateral arm

 C7- middle finger

 Posterior arm
 Exam- Sensory
 C8-ulnar side hand

 Posterior arm

 T1-inner brachium

 Axilla
 Deep Tendon Reflexes

C5: Biceps C7: Triceps

C6: Brachioradialis
Nerve Disc Pain/Sensory Loss Weak-ness DTR’s decr
Root Level
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 Deltoid

Ant. Arm
C6 C5-6 Post-Lat arm to Biceps Biceps
Thumb, +/- index finger & Br-rad

C7 C6-7 Post-Mid arm to mid fngr Triceps Triceps

C8 C7-8 Post arm to ring/small fingr Grip

T1 T1-2 Proximal inner arm/axilla 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
 Spurling Test
 Walter Reed General Hospital

 First noted this finding in patients of

ruptured cervical discs.
 Spurling Test
 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
 Spurling Test
 The original description of the test

 Head and neck will be tilted toward the

painful side to reproduce the patient’s
typical radicular symptoms
 Spurling Test
 The original description of the test

 Pressure will then be placed on the top

of the head to further intensify the
symptoms
 Spurling Test
 The original description of the test

 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%
 Spurling Test
 50 surgical patients with findings on
MRI
 Specificity 95%

 Positive predictive value 96.4%

 Negative predictive value 90.9%

 Spurling Test
 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
 Lhermitte’s Sign
 Previously described

 1917
 Marie and Chatelin
 Transient pins and needles
sensations into the limbs on flexion
of the neck
 Lhermitte’s Sign
 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
 Lhermitte’s sign
 Myelopathy

 Multiple Sclerosis
 Lhermitte’s Sign
 Validity and Reliability

 Malanga

 Review

 Insufficient evidence of the inter-

rater reliability, sensitivity, and
specificity
 Lhermitte’s Sign
 Sandmark and nissell

 Active flexion and extension test

 Resembles the lhermitte’s sign and

was found to
 Specificity (90%)
 Lhermitte’s Sign
 Resembles the lhermitte’s sign and
was found to
 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
 Cervical Strain/spasm

 Cervical Sprain

 Cervical Instability

 Stingers

 Spondylosis
 Cervical Pathologies
 Stenosis

 HNP

 Cervical Cord
Neuropraxia
 Fractures/subluxation
 Cervical Strain & Spasm
 Usually minor trauma
(or none)
 “Slept Wrong”

 Overuse/Posture

 Sudden movement
 Cervical Strain & Spasm
 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
 Myofascial Pain
 “Trigger Points”

 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 Points
 Treatments

 Trigger point injection

 Injection material
 3cc lidocaine

 +/- Corticosteroid
 Trigger Points
 Injection material

 Dry needle (more

post injection
soreness)
 Trigger Points
 Disrupts the pain cycle

 Stops hyper-responsive signals

 Myofascial Pain
 Muscle Relaxants

 Cyclobenzaprine

 Relieve skeletal muscle spasms and

associated pain in acute
musculoskeletal conditions.
 Myofascial Pain
 Cyclobenzaprine

 2RCTs

 Both found no significant differences

between the treatment groups.
 Myofascial Pain
 Another RCT evaluated the effect of
cyclobenzaprine12 in patients with jaw
pain
 No evidence favoring cyclobenzaprine
over clonazepam or placebo.
 Myofascial Pain
 Cochrane review

 Sufficient evidence to support its use

due to a lack of high quality RCTs.
 Myofascial Pain
 Tizanidine

 Alpha2 adrenergic agonist

 Two prospective trials (not RCT)

evaluated tizanidine for MPS.
 Manfredini et al., in 2004
 Myofascial Pain
 Manfredini et al., in 2004

 78 patients with MPS, and noted

only a slight improvement in pain.
 Myofascial Pain
 Malanga et al., in 2002

 29 patients who were titrated on

tizanidine for 3 weeks.
 Significant decrease in VAS,
disability and sleep improvement
were noted
 Myofascial Pain
 Two RCTs

 Patients with acute low back pain

showed a significant difference in
pain reduction favoring tizanidine to
placebo.
 Myofascial Pain
 Review article

 Insufficient literature to support the

use of tizanidine
 Myofascial Pain
 Sedatives / Hypnotics

 Clonazepam
 Benzodiazepine derivative with
anticonvulsant, muscle relaxant, and
anxiolytic properties.
 Myofascial Pain
 Clonazepam

 Two RCTs evaluated the efficacy of

clonazepam for MPS treatment
 Found it to be effective
 Myofascial Pain
 Clonazepam

 Two RCTs evaluated the efficacy of

clonazepam for MPS treatment
 However, caution was advised due to
side effects such as depression and
liver function
 Myofascial Pain
 Review article

 Better than placebo for MPS pain

relief.
 Myofascial Pain
 Analysis of the above literature

 Strongly supports the use of

clonazepam, a traditional agent, in
the treatment of MPS.
 Myofascial Pain
 Alprazolam and Diazepam

 Potent benzodiazepines.
 Review article

 Alprazolam or diazepam in
combination with ibuprofen is better
than placebo.
 Myofascial Pain
 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
 Myofascial Pain
 Amitriptyline and Nortriptyline

 Nortriptyline
 Second generation TCA with less
incidence of side effects compared
to amitriptyline.
 Myofascial Pain
 Two RCTs

 Bendsten and Jensen

 Significant reduction in pain and
myofascial tenderness.
 Myofascial Pain
 Two RCTs

 Plesh et al
 Effective for myofascial pain
 Myofascial Pain
 Topical Agents

 Topical Lidocaine Patch

 Case report in 2002

 Did not demonstrate significant

evidence for pain reduction
 Myofascial Pain
 Topical Lidocaine Patch

 Open labeled non randomized trial

 Showed some relief of pain and
improvement in quality of life in 27
patients
 Myofascial Pain
 RCT
 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.
 Myofascial Pain
 Topical Methyl Salicylate and Menthol Patches

 Methyl Salicylate
 Rubefacient in deep heating liniments For
myalgias and muscle spasms
 Myofascial Pain
 Menthol

 Organic compound with local

anesthetic and counterirritant
qualities
 Weak kappa opioid receptor agonist.
 Myofascial Pain
 A single rct

 Demonstrated a significant global

satisfaction and reduction of pain at
rest and with movement compared
to placebo
 Myofascial Pain
 Topical diclofenac patch and solution

 Single RCT
 Significant difference in pain, range
of motion and disability scores
compared to placebo
 Myofascial Pain
 Topical diclofenac patch and solution

 Lone RCT studying topical diclofenac

solution
 No significant differences between
the groups.
 Myofascial Pain
 Topical Thiocolchicoside Ointment

 Muscle relaxant with anti-

inflammatory and analgesic effects
 Competitive GABA-A receptor
antagonist and also inhibits glycine
receptors
 Myofascial Pain
 Topical Thiocolchicoside Ointment

 Single blind, RCT

 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
 Cervical Sprain
 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
 Imaging
 No imaging required if patient meets all
of the following…
 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 sub
acutely
 Persistent pain
after appropriate
time to recover
 Cervical Sprain w/ Instability
 Flex/Ex view criteria:

 >3.5 mm AP
displacement
 >11 deg angulation
 Cervical Sprain w/ Instability
 IMMOBILIZE &
REFER ASAP
 Cervical Sprain w/o Instability
Treatment:
 Analgesics, +/- muscle relaxer

 +/- Hard/Soft collar

 Relative rest; encourage resumption
of ADL soon
 Cervical Sprain w/o Instability

Treatment:
 Early referral to PT
 ROM emphasized (decrease risk
disability)
 Modalities
 Strain / Spasm Treatment

 NSAID/Tylenol

 Muscle relaxer?

 Trigger point injections?

 Soft collar (rarely)

 Strain / Spasm Treatment

 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
 Para-median neck tenderness

 Reduced ROM

GRADED
 Mild: HA’s, neck pain (limited to disc,
facet jt)
 Cervical spondylosis s/sx
GRADED
 Moderate: radicular sxs (foramen)

 Severe: myelopathy (canal)

 Gait, balance, bladder sx’s

 Cervical Stenosis

 Narrowing of the AP
diameter of the
cervical canal
 Developmental
 Cervical Stenosis

 Narrowing of the AP
diameter of the
cervical canal
 Acquired: secondary
to degenerative dz,
HNP, etc.
 Cervical Stenosis

 MRI for diagnosis

 EMG can reveal nerve

damage
Tx of spondylosis / stenosis
 Analgesics +/- muscle relaxer

 Soft collar prn

 Relative rest from offending activity

 Physical Therapy if persistent

 Cervical Epidural if refractory

Tx of spondylosis / stenosis
 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
Herniated Nucleus Pulposus (HNP)

 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

 HNP
 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
 HNP Treatment
 Physical therapy if poor response 1-2
wks
 Traction, TENS

 Consider referral for invasive tx if:

 Patient is ready
 HNP Treatment
 Consider referral for invasive tx if:

 Progressive neurological symptoms

 sxs persist despite tx

 MRI, EMG/NCV
 Epidural Steroid Injections
HNP & Radiculopathy
 Epidural steroid
injections (ESI)
commonly used
intervention to treat
radicular pain
 Epidural Steroid Injections

 In the cervical and HNP & Radiculopathy

thoracic spine, this

pain is most commonly
caused by herniated
disc and/or foraminal
stenosis
 Epidural Steroid Injections
HNP & Radiculopathy
 Mechanism of pain
generation: mechanical
compression and
chemical inflammation
 Epidural Steroid Injections
HNP & Radiculopathy
 Corticosteroids thought
to reduce chemical
inflammation and pain
 Introduction - ESI
 2 methods for HNP & Radiculopathy

delivering medication
to the epidural space
in the cervical and
thoracic spine:
 Introduction - ESI
 Interlaminar HNP & Radiculopathy

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
Cervical TFESI – ISIS Guidelines
 Pre-injection procedures

 Sterile Prep: antibacterial

solution, sterile draping
Cervical TFESI – ISIS Guidelines

 Target
Identification
 Oblique View

 Identify target
foramen
Cervical TFESI – ISIS Guidelines

 Target Identification

 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)
Cervical TFESI – ISIS Guidelines
 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)
Cervical TFESI – ISIS Guidelines
 Needle Insertion
 Ideally, advance needle down the beam -
“hubogram”
Cervical TFESI – ISIS Guidelines
 Needle Insertion

 Once SAP is reached, adjust needle to

pass into foramen
Cervical TFESI – ISIS Guidelines
 Needle Insertion

 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
 Cervical TFESI – ISIS Guidelines

 Contrast injection:

 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

 What to watch out for
 Vascular flow:

 Arterial
 Radicular artery – narrow vessel with
transverse flow medially toward
cord.
 What to watch out for
 Vascular flow:

 Arterial
 ISIS recommends procedure aborted
in this case.
 What to watch out for
 DRG/Spinal Nerve

 Vascular flow:

 Arterial

 Venous (radicular and epidural veins):

slow clearance of contrast – can
reposition needle
 What to watch out for
 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.
Cervical TFESI – ISIS Guidelines
 Corticosteroid:

 Dexamethasone (7.5-15mg)
 Betamethasone (3mg – 12mg)
Cervical TFESI – ISIS Guidelines
 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 inter-
laminar
 Cervical Interlaminar ESI (ILESI)
 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
 Cervical ILESI
 Identify target
inter-laminar space
(C6-7, 7-1)
 Cervical ILESI
 Target: superior
border of inferior
lamina at midline
 Mark and anesthetize
(1% lidocaine)
 Cervical ILESI
 18- or 20- gauge Touhy
needle advanced
using:
 Frequent lateral
imaging
 Cervical ILESI
 18- or 20- gauge Touhy
needle advanced
using:
 Loss of resistance
technique with
normal saline
 Cervical ILESI
 Once epidural space
entered (based on
LOR), inject non-ionic
contrast (1cc) under
live fluoro.
 Cervical ILESI
 Should see even
spread of contrast,
and lateral imaging
should show
posterior flow.
 Cervical ILESI
 If no vascular flow, no
subarachnoid flow…inject
medication (1-2 cc
celestone / dexamethasone,
2-3 cc of 1-1.5% 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%)
 Cervical ESI - Complications
 Ma 8/2005: 844 patients, 1036 Extra-foraminal 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
 Cervical ESI - Complications
 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
 Cervical ESI - Complications
 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
 Patient Selection for Cervical ESI

 Indications:

 Cervical radicular pain +/- radiculopathy

 Hx, PE and imaging c/w nerve root

impingement /irritation
 Patient Selection for Cervical ESI

 Indications:

 Failed conservative treatment (PT, meds,

activity modification) >6weeks
 Patient Selection for Cervical ESI
 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
 Stingers (Burners)
 Burning in arm

 Weakness in C5 and C6
distribution
 Deltoid, biceps, RC, wrist
extensors, pronator teres
 +/- Positive Spurling’s
Stingers
 Stingers
 Treatment

 Protection

 Rest until asymptomatic

 May Return to Play when:

 Full cervical ROM w/o pain

 Stingers
 May Return to Play when:

 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”
 Cervical Cord Neurapraxia

 Sx last 10 min-48 hrs

 Burning Hands Syndrome

 Transient Quadriparesis
 C-spine Injury
On-Field Management
 Assess LOC and simple neuro exam by
question without moving athlete
 Stabilize C-spine and log-roll if
necessary to move athlete to back
 C-spine Injury
On-Field Management
 “Leave helmet on”

 Helmet & shoulder pads

 Manage airway by removing face
mask
 Immediate Transport for…

 Unconscious athlete

 Neuro symptoms in ≥2
limbs
 Immediate Transport for…

 Spinous process
tenderness with
concerning MOI
 Any distracting injuries
Thank You