SECTION B: SPINE DISORDERS

CONDITION/DISORDER SYNONYMS

• Bekhterev disease

• Bekhterev syndrome

• Marie-Strümpell disease

• Rheumatoid spondylitis

• Spondylitis

• Spondyloarthropathy

ICD-9-CM CODE¹

• 720.0 Ankylosing spondylitis

ICD-10-CM CODE²

• M45.9 Ankylosing spondylitis of unspecified sites in spine

PREFERRED PRACTICE PATTERNS³

• 4B: Impaired Posture

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders

KEY FEATURES

Description

• Progressive inflammation of the spinal joints that leads to bone formation, natural fusion, and often increased kyphosis of the thoracic spine.

• Ankylosing means fusion; spondylitis means inflammation of the spine.

Essentials of Diagnosis⁴

• Characterized by SI joint pain and dysfunction⁴

• Etiology unknown

• Pain for >3 months

• Relief with NSAIDs

General Considerations

• Begins with intermittent low back pain

• Pain and stiffness at rest or sleep

• Improvement with low levels of activity

• May have rapid and severe onset

• Secondary problems include

  • Pulmonary fibrosis

  • Restrictive lung disease

  • Aortic heart valve (aortic insufficiency)

  • Heart rhythm problems

Demographics

• Disease onset between ages 20 and 40 years

• Male-to-female ratio: 10:1

• Caucasians afflicted more frequently than African Americans

CLINICAL FINDINGS

Functional Implications

• Limited mobility

• Aerobic endurance limitation

Possible Contributing Causes

• Family history of ankylosing spondylitis

• GI infections

Differential Diagnosis

• Spinal stenosis

• Disc herniation

• Crohn disease

• Forestier disease

• Reiter syndrome (reactive arthritis)

• Whipple disease

• Yersinia arthritis

• Facet joint arthritis

• Psoriatic arthritis

• Rheumatoid arthritis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray of the spine and pelvis

• MRI of the spine

Laboratory Tests

• Complete blood count (CBC)

• ESR

• HLA-B27 antigen, genetic marker

• No single blood test

• Negative serologic tests for rheumatoid factor

FINDINGS AND INTERPRETATION

• Late stages affect C1-C2 segment with decreased range of motion⁵

TREATMENT

Medication

• NSAIDs

• TNF-inhibitors

• Corticosteroids

• Cytotoxic drugs

• Biologic medications

IMPAIRMENTS

• Mobility

• Functional rotation and bending

TESTS AND MEASURES

• Straight-leg raise

• Sit and reach test

• Trunk active range of motion (AROM)

INTERVENTION

• Education in gentle range of motion to maintain mobility

• Flexibility and stability strengthening exercises to decrease stress on the joints

  • Core stabilization

• Education on joint protection

• Postural training

• Warm shower or heat to increase mobility

FUNCTIONAL GOALS

• Patient will be able to.

  • Be independent with home exercise program.

  • Have decreased pain and be able to perform household activities, such as cleaning and laundry.

  • Have improved functional level sufficient for grocery shopping.

PROGNOSIS

• Disease progression is not specific; joints may become fused as disease becomes more severe.

• Symptoms may be intermittent.

• Patients function well until severe progression of joint fusion in the spine and hips occurs.

REFERENCES

ADDITIONAL REFERENCE

CONDITION/DISORDER SYNONYMS

• Facet joint syndrome, cervical spine

• Sprain of facet joint

• Arthritic changes in facet joint

ICD-9-CM CODE

• 847.0 Cervical sprain

ICD-10-CM CODE

• S13.8XXA Sprain of joints and ligaments of other parts of neck

PREFERRED PRACTICE PATTERN

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders¹

KEY FEATURES

Description

• Neck pain with primary involvement of cervical facet joint

• Upper limb symptoms might be present in a nondermatomal pattern as a result of referred pain

• No neurological findings

• Unilateral symptoms

Essentials of Diagnosis

• Diagnosis made by clinical examination

• Reproduction of symptoms when joint in closed-packed position (combination of extension, side bending, and rotation toward involved side)

General Considerations

• Presentation can vary based on anatomical structures and psychosocial factors.

• C0 to C3 facet joint dysfunction may be associated with cervicogenic headache or dizziness.

Demographics

• Variable, based on specific condition.

CLINICAL FINDINGS

Functional Implications

• May cause decreased ability to perform ADLs/IADLs.

• May impact ability to participate in sports and other recreational activities.

Possible Contributing Causes

• Congenital anomalies

• Obesity

• Occupational factors

• Physical condition

• Postural changes including forward-head posture

• Psychosocial and behavioral factors

• Smoking

• Socioeconomic factors

Differential Diagnosis

• Malignant spinal tumor or metastasis

• Peripheral nerve impairment

• Radiculopathy

• Referred pain from visceral structures

• Systematic autoimmune diseases (RA, Reiter’s, etc.)

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Not necessary in most cases; only with persistent symptoms that do not respond to conservative management or presence of red/yellow flags.

• MRI helps visualize compressed or inflamed nerve root/disc pathology in diagnosis²

• X-ray/Plain-film radiograph helps assess alignment, fractures, stability (flexion/extension radiograph)³

• CT scan to show herniation compressing the spinal canal or nerves³

• Electrodiagnostic/Nerve conduction testing can help determine a specific impaired nerve function⁴

• Doppler ultrasound to examine vascular function

Diagnostic Procedures

• Electrodiagnostic/Nerve conduction testing can help determine a specific impaired nerve function⁴

FINDINGS AND INTERPRETATION

• Physical Examination

  • Algorithm for examination of the cervical spine⁴

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

IMPAIRMENTS

• Hypomobile cervical spine

• Weakness of deep neck flexors and upper-extremity stabilizers

• Shortening of upper trapezius, levator scapulae, pectoral muscles

• Postural changes

• Inability to rotate head

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Sub-cranial translation instability testing

• Passive physiological intervertebral mobility testing (PPIVM)⁵

• Upper-extremity screening examination

• Postural examination

• Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles

• Upper limb nerve tension test⁶

• Deep neck-flexor endurance test

• Upper-extremity neurological screen (dermatome, myotome, reflexes)

INTERVENTION

• Joint mobilization/manipulation

• Postural correction

• Initiate stabilization exercises after normalizing ROM (deep neck flexors)

• Stretching exercises and myofascial mobilization for shortened musculature

• Modalities for short-term pain control

FUNCTIONAL GOALS

• Patient will be able to

  • Sit with a cervicothoracic spine posture for more than 30 minutes with 0 out of 10 pain rating.

  • Sit at work station and perform computer work for 45 minutes with 0 out of 10 pain rating.

  • Rotate cervical spine 80 degrees to look over shoulder when driving without pain.

PROGNOSIS

• Fair to very good depending on specific impairments.

• Chronic cervical pain prognosis significantly less.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Herniated intervertebral disk

• Prolapsed intervertebral disk

• Slipped disk

• Ruptured disk

• Herniated nucleus pulposus

ICD-9-CM CODES

• 719.48 Pain in joint involving other specified sites

• 721.1 Cervical spondylosis with myelopathy

• 722.0 Displacement of cervical intervertebral disc without myelopathy

• 722.4 Degeneration of cervical intervertebral disc

• 722.71 Intervertebral disc disorder with myelopathy cervical region

ICD-10-CM CODES

• M47.12 Other spondylosis with myelopathy, cervical region

• M50.00 Cervical disc disorder with myelopathy, unspecified cervical region

• M50.30 Other cervical disc degeneration, unspecified cervical region

PREFERRED PRACTICE PATTERN

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders¹

KEY FEATURES

Description

• Any disorder that affects the spinal nerve roots

• Lateral cervical spine nerve root compression

• Gradual or acute onset secondary to intervertebral disc or osteophyte formation in the intervertebral foramen¹

Essentials of Diagnosis

• Diagnosis made by clinical examination

• Dermatome or myotome pattern

• Reproduction of symptoms

General Considerations

• Herniated disk is one cause

• Avoid positions that increase symptoms

Demographics

• Women at greater risk than men, middle-aged to geriatric

CLINICAL FINDINGS

Functional Implications

• Difficulty sustaining sitting postures secondary to neck and arm pain

• Inability to sleep

• Weakness with upper-extremity lifting

• Loss of movement or feeling in upper extremity

• Difficulty with neck movements, as with driving, secondary to pain

Possible Contributing Causes

• Forward-head or rounded-shoulder posture due to tight pectoralis, weak periscapular, deep neck-flexor muscles

• Prolonged extension or position of cervical side bending toward impaired nerve

• Facet hypertrophy

• Size of spinal canal; can be congenital

Differential Diagnosis

• Carpal tunnel syndrome

• Chiari malformation

• Degenerative disk disease

• Peripheral nerve impairment

• Rhomboid/trapezius spams

• Shoulder pathology with radiating pain pattern

• Spinal tumor

• Thoracic outlet syndrome

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• MRI helps to visualize compressed or inflamed nerve root in diagnosis²

• X-ray/Plain-film radiograph helpful if osteophyte located in intervertebral foramen³

• CT scan to show herniation compressing the spinal canal/nerves³

Diagnostic Procedures

• Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function⁴

FINDINGS AND INTERPRETATION

• Physical examination cluster to rule in cervical radiculopathy³

  • Spurling test²

  • Rotation limited to ipsilateral side

  • Upper limb nerve tension test²

  • Diminished brachioradialis reflex

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

IMPAIRMENTS

• Restricted mobility of the upper- or mid-thoracic spine and subcranial spine

• Hypermobile mid-cervical spine

• Tight pectoralis major and minor

• Weakness of longus colli and longus capitis

• Weakness of periscapular muscles

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Sub-cranial translation instability testing

• Passive physiological intervertebral mobility testing (PPIVM)

• Upper-extremity screening examination

• Postural examination

• Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles

• Upper limb nerve tension test

• Neck Disability Index (NDI)

• Deep neck-flexor endurance test

• Upper-extremity neurological screen (dermatome, myotome, reflexes)

INTERVENTION

• Rest

• Joint manipulation to the thoracic and upper-cervical spine

• Cervical distraction and traction to relieve nerve compression

• Cranio-cervical flexion exercises

• Periscapular strengthening

• Address pain

  • Electrical stimulation

  • Heat/Ice to increase mobility

• Address hypertonicity

  • Soft tissue massage

  • Heat

• Address muscle weakness

  • Deep neck-flexor training

  • Strengthening of lower/middle trapezius, rhomboids, rotator cuff

  • Serratus anterior, latissimus dorsi

FUNCTIONAL GOALS

• Patient will be able to

  • Sit with a neutral cervical and thoracic spine posture for >30 minutes with 0/10 pain rating.

  • Patient will be able to sit at work station and perform computer work for 45 minutes with 0/10 pain rating.

  • Patient will be able to rotate cervical spine 70 degrees to talk on phone with 0/10 pain rating in the neck or arm.

PROGNOSIS

• Fair to very good depending on severity of nerve root compression and cervico/thoracic impairments.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Cervical spinal stenosis

• Cervical central stenosis

• Central stenosis

• Lateral stenosis

ICD-9-CM CODES

• 723.0 Spinal stenosis in cervical region

• 724.0 Spinal stenosis other than cervical

ICD-10-CM CODES

• M48.00 Spinal stenosis, site unspecified

• M48.02 Spinal stenosis, cervical region

PREFERRED PRACTICE PATTERN

• 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated with Spinal Disorders¹

KEY FEATURES

Description

• Common, degenerative spinal condition

• Associated with narrowing of the spinal canal (central stenosis) or foraminal canals (lateral stenosis)

• Caused by degenerative changes in intervertebral disks and facet joints

• Can result in spinal cord compression or nerve root compression

Essentials of Diagnosis

• Causes neurogenic claudication, with pain, cramping, and paresthesias in the upper extremity and lower extremity aggravated by cervical extension, relieved by cervical flexion

• Diagnosis made by clinical examination

• Differentiation between vascular and neurologic claudication

• Reproduction of symptoms in specific postures and activities

General Considerations

• Cervical spinal stenosis can result in spinal cord compression and resulting upper motor neuron signs

• Cervical central stenosis can give both upper- and lower-extremity symptoms

Demographics

• Prevalence increases with age.

• Primarily occurs after 65 years of age.

CLINICAL FINDINGS

Functional Implications

• Difficulty with walking long distances

• Difficulty with standing activities

• Possible bowel or bladder dysfunction with cervical stenosis

• Difficulty looking up

• Difficulty reaching overhead, painting overhead

Possible Contributing Causes

• Postural changes

• Weakness of core musculature

Differential Diagnosis

• Degenerative disk disease

• Osteoarthritis

• Peripheral nerve impairment

• Peripheral neuropathy

• Spinal tumor

• Thoracic outlet syndrome

• Vascular insufficiency

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• MRI

• X-ray/Plain-film radiograph

• CT

Diagnostic Procedures

• Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function.²

• Doppler ultrasound to examine vascular function.

FINDINGS AND INTERPRETATION

• MRI helps to visualize compressed or inflamed nerve root in diagnosis.³

• X-ray/Plain-film radiograph helpful if osteophyte located in intervertebral foramen.⁴

• CT scan to show herniation compressing the spinal canal/nerves.⁴

IMPAIRMENTS

• Hypomobile cervical spine

• Weakness of core stabilizing muscles

• Inability to stand/walk for prolonged time

• Inability to look for prolonged time (visual fatigue)

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Sub-cranial translation instability testing

• Passive physiological intervertebral mobility testing (PPIVM)

• Neck Disability Index (NDI)

• Postural examination

• Muscle length testing, including upper trapezius, levator scapulae, pectoral muscles

• Deep neck-flexor endurance test

• Upper-extremity neurological screen (dermatome, myotome, reflexes)

• Physical examination

  • Two-stage treadmill test

  • ABI to screen for PAD

  • Quadrant test²

  • Slump test³

  • Upper limb nerve tension test³

  • Deep tendon reflexes

  • Passive physiological intervertebral mobility testing (PPIVM)²

INTERVENTION

• Joint manipulation to the thoracic and lumbar spine when joint hypomobility is present.

• Specific exercises in flexion when pain centralizes with repeated movement/posture into flexion

• Lumbar stabilization exercises to address core stability

• Stretching exercises and myofascial mobilization for shortened musculature

• Unweighted treadmill walking

• Aquatic exercise

• Mechanical traction in flexion position

FUNCTIONAL GOALS

• Patient will be able to

  • Walk for 30 minutes with 0/10 pain rating so as to grocery shop or walk in a mall.

  • Increase standing tolerance to >30 minutes without pain to fulfill recreational or work activity requirements.

PROGNOSIS

• Variable: Multimodal conservative management, including progressive exercise, unweighted walking, manual therapy show positive outcomes

• Severe cases of stenosis may require surgical intervention

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Cervical spondylolisthesis

ICD-9-CM CODES

• 738.4 Acquired spondylolisthesis

• 756.12 Spondylolisthesis congenital

• 805.02 Closed fracture of second cervical vertebra

ICD-10-CM CODES

• M43.10 Spondylolisthesis, site unspecified

• Q76.2 Congenital spondylolisthesis

• S12.100A Unspecified displaced fracture of second cervical vertebra, initial encounter for closed fracture

• S12.101A Unspecified nondisplaced fracture of second cervical vertebra, initial encounter for closed fracture

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation¹

KEY FEATURES

Description

• Anterior (forward) translation of a vertebra

• Fracture of the pedicles on the vertebra below

• Slipping of the vertebra in relationship to the vertebra below

• Neurogenic claudication

• Fracture widens at the pars

• Hangman’s fracture

• C2 vertebra anterior translated on C3 with fracture of C2 pedicles

Essentials of Diagnosis

• Made by X-ray

• May be acquired or congenital

• Clinical examination may find step deformity

• Dermatome/myotome pattern

• Low-grade isthmic spondylolisthesis: less than 50% displacement

• High-grade isthmic spondylolisthesis: greater than 50% displacement

• Four grades²

  • Grade 1: 0% to 25% slippage

  • Grade 2: 25% to 50% slippage

  • Grade 3: 50% to 75% slippage

  • Grade 4: 75% to 100% slippage

• Spondylolysis: Fracture without displacement

General Considerations

• Instability

• Avoid extension positions that increase symptoms

• Wiltse–Newman classification of spondylolisthesis²

Demographics

• May be congenital or acquired.

CLINICAL FINDINGS

Functional Implications

• Difficulty sustaining standing postures secondary to neck and arm pain

• Inability to sleep flat on the back without a pillow

• Weakness with lifting

• Loss of movement or feeling in the upper extremity

• Difficulty with movements secondary to pain, especially reaching overhead

• Limited sports participation

Possible Contributing Causes

• Forceful extension from hit under the chin (sports)

• Congenital

• Car accident, hit from rear

• Hyperextension of the cervical spine

• Suicidal hanging

• Increased cervical lordosis posture

Differential Diagnosis

• Peripheral nerve impairment

• Spinal tumor

• Infection

• Peripheral neuropathy

• Paraspinal spasms

• Degenerative disk disease

• Stenosis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• MRI helpful in diagnosis to visualize compressed or inflamed nerve root³

• X-ray/Plain-film radiograph to see vertebra position (Scottie dog collar)²

• CT scan to show herniation compressing the spinal canal or nerves⁴

• Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function⁵

Diagnostic Procedure

• Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function.⁴

FINDINGS AND INTERPRETATION

• Cervical vertebra anterior translated on the lower cervical vertebrae with fracture of pedicles

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

IMPAIRMENTS

• Restricted mobility of the upper cervical spine

• Hypermobility

• Weakness of neck musculature

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Subcranial translation instability testing

• Passive physiologic intervertebral mobility testing (PPIVM)

• Upper-extremity screening examination

• Postural examination

• Muscle length testing, including the upper trapezius, levator scapulae, and pectoral muscles

• Upper limb nerve tension test

• Deep neck flexor endurance test

• Upper-extremity neurologic screen (dermatome, myotome, reflexes)

• Neck Disability Index (NDI)

INTERVENTION

• Rest

• Bracing

• Address pain

  • Electrical stimulation

  • Heat/Ice⁶

• Address hypertonicity

  • Soft-tissue massage

  • Heat

• Address muscle weakness

  • Stability exercises

FUNCTIONAL GOALS

• Patient will be able to

  • Sit with neutral cervical spine posture for >30 minutes with 0/10 pain rating.

  • Stand at work station and perform computer work for 45 minutes with 0/10 pain rating.

  • Rotate cervical spine 75 degrees to look over shoulder while driving the car with 0/10 pain rating.

PROGNOSIS

• Fair to good, depending on severity of vertebral translation, amount of nerve root compression, and upper/lower extremity impairments.

• Possible death from asphyxia.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Cervical spondylolysis

ICD-9-CM CODE

• 738.4 Acquired spondylolisthesis

ICD-10-CM CODE

• M43.00 Spondylolysis, site unspecified

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation¹

KEY FEATURES

Description

• Stress fracture of the pedicles on the vertebra below

• Tightness or pain in the neck region

• Often no symptoms

• Weakness in the pars

Essentials of Diagnosis

• Diagnosis made by X-ray

• Can be acquired or congenital

• Neck pain

General Considerations

• Instability

• Avoid extension positions that increase symptoms

• Thin vertebral bone: Pars

Demographics

• Teenagers with high-risk activities are more at risk

• Runs in families

CLINICAL FINDINGS

Functional Implications

• Difficulty sustaining standing postures secondary to neck and arm pain

• Inability to sleep flat on the back without a pillow

• Difficulty with movements (reaching overhead) secondary to pain

• Limit sports participation

Possible Contributing Causes

• Forceful extension from hit under the chin (sports)

• Congenital

• Car accident, hit from rear

• Hyperextension of the cervical spine

• Increased cervical lordosis posture

Differential Diagnosis

• Peripheral nerve impairment

• Spinal tumor

• Peripheral neuropathy

• Paraspinal spasms

• Degenerative disk disease

• Stenosis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• MRI helps to visualize compressed or inflamed nerve root in diagnosis²

• X-ray/Plain-film radiograph to see vertebra position³

• CT scan to show herniation compressing the spinal canal/nerves³

• Electrodiagnostic/nerve conduction testing can help determine a specific impaired nerve function⁴

FINDINGS AND INTERPRETATION

• Stress fracture of the pars

TREATMENT

Medication

• Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Corticosteroids

IMPAIRMENTS

• Restricted mobility of the upper cervical spine

• Hypermobility

• Weakness noted in the neck musculature

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Subcranial translation instability testing

• Passive physiologic intervertebral mobility testing (PPIVM)⁵

• Upper-extremity screening examination

• Neck Disability Index (NDI)

• Postural examination

• Muscle length testing, including the upper trapezius, levator scapulae, pectoral muscles

• Upper limb nerve tension test⁶

• Deep neck flexor endurance test

• Upper-extremity neurologic screen (dermatome, myotome, reflexes)

INTERVENTION

• Rest

• Bracing

• Address Pain

  • Electrical stimulation

  • Heat/Ice⁵

• Address hypertonicity

  • Soft-tissue massage

  • Heat

• Address muscle weakness

  • Stability exercises

FUNCTIONAL GOALS

• Patient will be able to

  • Sit with neutral cervical spine posture for >30 minutes with 0 out of 10 pain rating.

  • Stand at work station and perform computer work for 45 minutes with 0 out of 10 pain rating.

  • Rotate cervical spine 75 degrees so as to look over the shoulder while driving the car with 0 out of 10 pain rating.

PROGNOSIS

• Fair to good, depending on severity of vertebral translation, amount of nerve-root compression, and upper/lower-extremity impairments.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Cervical osteoarthritis

• Spinal osteoarthritis

ICD-9-CM CODES

• 721 Spondylosis and allied disorders

• 721.0 Cervical spondylosis without myelopathy

• 721.1 Cervical spondylosis with myelopathy

• 721.9 Spondylosis of unspecified site

• 721.90 Spondylosis of unspecified site without myelopathy

• 721.91 Spondylosis of unspecified site with myelopathy

ICD-10-CM CODES

• M47.12 Other spondylosis with myelopathy, cervical region

• M47.812 Spondylosis without myelopathy or radiculopathy, cervical region

• M47.819 Spondylosis without myelopathy or radiculopathy, site unspecified

PREFERRED PRACTICE PATTERNS

• 4B: Impaired Posture¹

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Format Range of Motion Associated with Connective Tissue Dysfunction²

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation³

KEY FEATURES

Description

• Osteoarthritis of the cervical spine

• Chronic degeneration

• Progressive arthritis of the cervical spinal joints

• As space between the vertebrae decreases, there may be compression onto the nerve roots

• Arthritis can be central- or lateral-foramen based

  • Central: Usually bilateral symptoms

  • Lateral: Usually unilateral

• Pain, paresthesia, and weakness in the upper extremities, can affect lower extremities if central and severe

• Pressure on the nerve root can cause radiculopathy

Essentials of Diagnosis

• X-ray

• Acute painful flare-ups, chronic persistent pain

• Relief with nonsteroidal anti-inflammatory drugs (NSAIDs)

• Morning stiffness

General Considerations

• Begins with intermittent pain

• Pain and stiffness at rest/sleep

• Improved with low-level activity

• May have rapid and severe onset

• Vertebrobasilar insufficiency is secondary problem

Demographics

• Common in adults aged 60 years and older

CLINICAL FINDINGS

Functional Implications

• Limited mobility in cervical motion

• Difficulty looking over the shoulder while driving

• May have difficulty washing hair at hair dresser due to cervical spine extension

• Increased symptoms with increased weight-bearing

• Aerobic endurance limitation

Possible Contributing Causes

• Family history of osteoarthritis

• Bone spurs

• Instability

• Weakness

• Poor posture

• Limited flexibility

Differential Diagnosis

• Spinal stenosis

• Disc herniation

• Reiter syndrome (reactive arthritis)

• Whipple disease

• Facet joint arthritis

• Rheumatoid arthritis

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• X-ray of the cervical spine⁵

• MRI of the cervical spine⁶

FINDINGS AND INTERPRETATION

• Decreased space between the cervical vertebrae on X-ray

TREATMENT

Medication

• NSAIDs

• Corticosteroids

IMPAIRMENTS

• Mobility

• Functional rotation and bending

TESTS AND MEASURES

• Cervical spine AROM

• Sharp–Purser: Atlantoaxial instability

• Cervical passive intervertebral motion testing

• Subcranial translation instability testing

• Passive physiologic intervertebral mobility testing (PPIVM)⁵

• Upper-extremity screening examination

• Postural examination

• Neck Disability Index (NDI)

• Muscle length testing, including the upper trapezius, levator scapulae, and pectoral muscles

• Upper limb nerve tension test⁶

• Deep neck flexor endurance test

• Upper-extremity neurological screen (dermatome, myotome, reflexes)

INTERVENTION

• Education in gentle range of motion to maintain mobility

• Exercise: Flexibility and stability strengthening to decrease stress on the joints

• Joint protection education

• Postural training

• Joint manipulation to the thoracic and upper cervical spine

• Cervical distraction and traction to relieve nerve compression

• Craniocervical flexion exercises

• Periscapular strengthening

• Address Pain

  • Electrical stimulation

  • Heat/Ice to increase mobility

• Address hypertonicity

  • Soft-tissue massage

  • Heat

• Address muscle weakness

  • Deep neck flexor training

  • Strengthening of the lower/middle trapezius, rhomboids, rotator cuff

  • Serratus anterior, latissimus dorsi

• Heat or warm shower to increase mobility

FUNCTIONAL GOALS

• Patient will

  • Be independent with home exercise program.

  • Be have decreased pain to perform household activities such as cleaning and laundry.

  • Have improved functional level to look over the shoulder while driving.

PROGNOSIS

• Disease progression is not specific; joints may become limited and have increased compression as disease becomes more severe.

• Symptoms may be intermittent.

• Patients function well until severe progression of joint mobility.

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYM

• Coccydynia

ICD-9-CM CODES

• 724.7 Disorders of coccyx

• 724.70 Unspecified disorder of coccyx

• 724.71 Hypermobility of coccyx

• 724.79 Other disorders of coccyx

• 839.41 Closed dislocation, coccyx

• 839.42 Closed dislocation, sacrum

• 847.3 Sprain of sacrum

• 847.4 Sprain of coccyx

ICD-10-CM CODES

• M53.2X8 Spinal instabilities, sacral and sacrococcygeal region

• M53.3 Sacrococcygeal disorders, not elsewhere classified

• S33.2XXA Dislocation of sacroiliac and sacrococcygeal joint, initial encounter

• S33.8XXA Sprain of other parts of lumbar spine and pelvis, initial encounter

PREFERRED PRACTICE PATTERNS¹

• 4B: Impaired Posture

• 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Connective Tissue Dysfunction

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

• 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated with Fracture

KEY FEATURES

Description

• Tailbone pain

• Pain often increases with sitting, defecation, transitional movements, and palpation of the coccyx

General Considerations

• Consider sacroiliac (SI) joint as potential cause of pain

• Ask patient about the history of falls; distant history can contribute to coccydynia

• Occupations requiring prolonged sitting may contribute to coccydynia

• Pain may be referred from muscles, including the obturator internus, levator ani, and gluteus maximus

Demographics

• Five times more common in women than in men

• Mean age of onset is 40 years

• Three times more common in obese patients

CLINICAL FINDINGS

Functional Implications

• Difficulty sitting, impacting ability to perform work and daily activities

• Difficulty or pain with defecation

Possible Contributing Causes

• Vaginal delivery

• Postpartum

• Direct trauma from fracture, fall, childbirth

• Poor sitting posture

• Prolonged sitting

• Anorectal infection

• Levator ani spasm

• Trigger points of obturator internus, levator ani, or gluteus maximus

• Overuse of levator ani

• Neoplasm

• Pelvic asymmetry

• Stretch or rupture of sacrococcygeal ligaments

• Soft-tissue damage

Differential Diagnosis

• Sacral chordoma

• Tarlov cyst

• Pilonidal cyst

• SI joint pain

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Dynamic radiograph of coccyx position

• Dynamic radiography (stand vs. sit)

Diagnostic Procedures

• Joint injection at the coccyx–sacral junction

• Physical examination

• Diagnostic joint injection

FINDINGS AND INTERPRETATION

• Joint injection at the coccyx–sacral junction to determine relief

TREATMENT

Medications

• Muscle relaxants

• Oral analgesics

• Oral corticosteroids

MEDICAL PROCEDURES

• Trigger point injections

• Corticosteroid injection

• Local anesthetic injection

• Coccygectomy

IMPAIRMENTS

• Pain

• Overactive pelvic floor muscles

• Poor posture

• Limited joint mobility

• Obstructed defecation

TESTS AND MEASURES

• Palpation and mobility of the coccyx

  • Palpate the coccyx externally with single digit; attempt to move it 20 to 30 degrees.

  • Patients with coccydynia often have pain with movement; otherwise, movement should be pain free.

• Assessment of the pelvic floor muscle

• Palpation of the coccygeus, levator ani, obturator internus, and gluteus maximus for trigger points

• Posture assessment

• Assessment of pelvic girdle with pain provocation test

INTERVENTION

• Seating adaptation: Coccyx cut-out wedge cushion (“donut” cushion)

• Postural instruction

• Education on normal defecation, to avoid constipation

• Education on stress management and relaxation for patients with anxiety

• Coccyx manipulation, sacrococcygeal joint manipulation or mobilization

• Joint mobilizations to address hypomobility of the SI joint, lumbar, hip, or pubic symphysis dysfunction

• Myofascial treatment to the coccygeus, levator ani, obturator internus, gluteus maximus, piriformis

• Transvaginal or transrectal myofascial release

• Vaginal or rectal electrical stimulation

• Coccyx taping

• Pelvic floor muscle exercise and training

  • Contraction

  • Relaxation, “bulging”

  • Motor control

  • Endurance

  • Power

• Surface electromyography (sEMG) biofeedback for down-training of pelvic floor muscles

• Exercises to address biomechanical dysfunction of the SI joint

  • Lumbosacral active ROM in quadruped

    • “Cat and camel”

    • Pelvic sway, “tail wag”

  • Isometric contract–relax exercises of gluteal and iliopsoas muscles and/or hip abductors and adductors

FUNCTIONAL GOALS

• Patients will be able to

  • Demonstrate proper posture to reduce pain and prevent reinjury of the coccyx.

  • Perform sit-to-stand transfers independently without increased pain.

  • Increase sitting tolerance to ____ minutes to be able to drive, ride in car, perform desk work.

  • Demonstrate independence with home exercise program, promoting relaxation and awareness of the pelvic floor muscle for long-term self-management.

PROGNOSIS

• Patients with normal coccyx mobility have 43% success rate with conservative treatment.²

• Patients with immobile coccyx have 16% success rate with conservative treatment.²

• Patients with hypermobility or subluxation of the coccyx have 85% success rate with combined manipulation and steroid/anesthetic injection.²

REFERENCES

ADDITIONAL REFERENCES

CONDITION/DISORDER SYNONYMS

• Acquired torticollis

• Adult torticollis

• Anterocollis

• Dystonia

• Focal dystonia

• Laterocollis

• Retrocollis

• Spasmodic torticollis

• Torticollis

ICD-9-CM CODES

• 333.83 Spasmodic torticollis

• 723.5 Torticollis unspecified

ICD-10-CM CODES

• G24.3 Spasmodic torticollis

• M43.6 Torticollis

PREFERRED PRACTICE PATTERN

• 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation

KEY FEATURES

Description

• Dystonia is a condition characterized by involuntary intermittent or prolonged muscular contractions (e.g., twisting, jerky, or repetitive movements) that may cause abnormal postures and movements.

• Dystonia may be generalized or focal.

• Cervical dystonia (CD) is the most common focal dystonia.

• CD is commonly referred to as spasmodic torticollis, which may be misleading.

  • Spasmodic describes movements that are intermittent or clonic and tremulous, though some patients with CD present with prolonged contractions.

  • Torticollis implies rotary impairment, though patients with CD often present with combined postures associated with flexion, extension, and side-bending.

• Further classification may be based on the head position or movement.¹

  • Forward tilt is called anterocollis.

  • Backward tilt is called retrocollis.

  • Left or right tilt is called laterocollis.

  • Moving from side to side is called rotational spasmodic torticollis.

  • Turning and shaking of the head is called mixed torticollis.

Essentials of Diagnosis

• Traditional classification is based on etiology.

  • Primary (idiopathic)

  • Secondary (of known cause)

• Current classification describes each person based on the following characteristics:

  • Age of onset

  • Distribution of symptoms

General Considerations

• Most cases develop in adulthood.

• May begin in the neck and progress to the shoulders, usually stabilizes after a few years.

• A similar musculoskeletal condition during infancy is called congenital muscular torticollis.

• Patients with CD can show signs of self-consciousness and depression.

Demographics

• Incidence of CD is 8.9 per 100,000 people

• Occurrence in men to women ranges from 1 man to 1.4 to 2.2 women (1:1.4–2.2)

• Mean age of onset is 39.2 years for men and 42.9 years for women²

• Approximately 90% of cases are idiopathic and 10% to 20% are from a defined cause.

CLINICAL FINDINGS

Functional Implications

• Postural control abnormalities

• Greater reliance on vision for maintaining postural stability²

• Reduced ability to perform activities of daily living involving head or neck movements

• Difficulty sleeping

• Reduced psychosocial functioning

Possible Contributing Causes

• Primary CD

  • Idiopathic cause

• Secondary CD

  • Drugs

    • Neuroleptics

    • Dopamine agonists

    • Anticonvulsants

    • Antimalarial drugs

  • Environmental toxins

    • Manganese

    • Carbon monoxide

    • Methanol

  • CNS lesions

    • Intramedullary lesions of the cervical cord

    • Focal brain lesions, such as vascular malformation, tumor, or abscess

    • Demyelinating lesions, such as with multiple sclerosis

    • Traumatic brain injury to the contralateral basal ganglia or thalamus

    • Encephalitis

    • After hemiplegia as a delayed reaction to stroke

  • Disease or condition

    • Parkinson disease

    • Huntington disease

    • Wilson’ disease

    • Progressive supranuclear palsy

    • Multiple system atrophy

    • Cerebral palsy

    • Hypoparathyroidism¹

Differential Diagnosis

• Diagnosis is by clinical examination; no standard laboratory tests are employed to diagnose CD

• Determining that there is no evidence for cause of secondary dystonia is essential in diagnosing primary dystonia

• In addition to the possible contributing causes listed, the following pathologies must be ruled out to diagnose primary CD:

  • Cervical disc disease

  • Spinal abnormalities

  • Epilepsy

  • Muscular dystrophy

  • Thyroiditis

  • Endocrine disease⁴

MEANS OF CONFIRMATION OR DIAGNOSIS

Imaging

• Imaging

  • X-ray

  • MRI

  • CT

Diagnostic Procedures

• Diagnosis is made by clinical observation

• Toronto Western Spasmodic Torticollis Rating Scale

• Torticollis Rating Scale of Tsui

• CD Impact Profile

FINDINGS AND INTERPRETATION

• Imaging (X-ray, MRI, CT) to rule out congenital deformities of the cervical spine, ocular anomalies, CNS pathology,⁵ neoplasm, thyroiditis, and endocrine disease⁴

TREATMENT

Medication^6,7

• Botulinum toxin A

  • Most commonly used pharmacotherapy for CD

  • Two preparations, botox and dysport, are available

  • Injected into overactive musculature to weaken dystonic muscles

  • Injections often performed with Electromyography (EMG) to enhance accuracy

  • Average duration of benefit is 12 to 16 weeks

• For symptomatic relief and treatment of underlying causes, the following oral medications may be used

  • Analgesics

  • Benzodiazepines

  • Baclofen

  • Dopaminergic drugs

  • Anticholinergic agents

  • Tetrabenazine with lithium²

MEDICAL PROCEDURES

• Surgery is not to be considered unless all other options have failed and symptoms have remained stable over 12 months.²

  • Selective peripheral denervation.

  • For laterocollis, denervation of ipsilateral posterior cervical paraspinals, splenius capitis, and sternocleidomastoid muscles is performed.

  • For rotary torticollis, similar to laterocollis with the exception of denervation of the contralateral sternocleidomastoid.

  • Deep brain stimulation.

• Microelectrodes placed within the globus pallidus internus or subthalamic nucleus.

• Multiple follow-up visits required to properly program settings for the stimulator.

• Procedure is reversible, and microstimulator settings are adjustable.²