hi everyone and welcome to a discussion on the orthopedic assessment of the cervical spine so the cervical spine obviously is an important segment in the spinal column and um as always I want you to think like the Health Care Professionals that you're becoming and so in in taking a detailed patient history there's some really important things that I think will allow us to start getting a good clinical picture of what pathology this patient might be suffering from and so first we're going to start off with what activities are they actually engaged in and what activities increase their symptoms or or is it prolonged posture that increases their symptoms that that might tell you something about muscle um as the muscles try to stabilize the normal curvature of the cervical spine and then what are the sites and boundaries of the pain the first through fourth cervical spine um vertebrae and the nerve roots that exit out uh are not experienced in the arm so they wouldn't have symptoms in their uh extremities at all from C1 to C4 and so is there paresthesia is there tingling or or anesthesia or abnormal sensation if so is it in both extremities or is it in only one what might that tell you if it's only one that's a nerve root right that's exiting out of the spinal cord versus if it's bilateral that could be the cord itself right or maybe the meninges surrounding the cord true radiculopathy those radiating symptoms are are really rare so one uh study cland at all in 2005 found that it's only three out of every thousand patients and so true radiculopathy is uncommon does your patient have problems sleeping he or she might be um um triggering you to a more serious issue grade two and grade three tissue um damage tends to you know moderate and severe tends to wake the patient up at night or maybe they can't go to sleep in the first place and then the age of the patient is so key right this shouldn't surprise you at all older patients tend to have degeneration so spond losis is present in more in more than half of the patients that you're going to see after age 45 and then after age 65 almost nine out of 10 is going to have some sort of degenerative change happening in their cervical spine it's just the nature of uh the aging process and so keep that in mind mechanism of injury as always is very important is it a chronic Insidious um mechanism well that that is going to be a little bit more of a clinical challenge for you it's going to Warrant a thorough postural evaluation to determine what exactly is going on is it acute well that patient is going to be be able to easily recall their mechanism of injury and that's going to provide clues to the trauma did they have an axial load in their cervical spine as they were wrestling well you're going to want to rule out a fracture or dislocation that is the most common ideology for a fracture and a dislocation and then the the consistency of pain uh this is also key right do they have pain with certain movements well that's mechanical uh pathology in nature do they have pain with repetitive movements so that's telling you that that's probably what is causing their pain repetitive flexion versus repetitive extension or lateral bending chemical pain is quite uh opposite from mechanical pain it's not really going to respond um you know increase or decrease with certain movements it's just going to hurt all the time with a variety of movements and so that's going to indicate something else is going on pathologically and then history of previous cervical injury is is the strongest predictor of future injury so so definitely keep that in mind then where is the pain the location of IT muscle and ligament pain is going to be focal it's going to be localized so is a fracture uh if there's not a displaced fracture facet joints um that is not going to radiate symptoms the way that a nerve root or the spinal cord would radiate symptoms down into the um periphery now the one caveat here dislocation if if if the cord is compromised or a nerve root that definitely is going to radiate symptoms and again like we said an onset of pain acute pain is going to have a specific mechanism of injury chronic and Insidious is may be the result of postural dysfunction going to be a little bit harder to figure out so let's start with you know what the patient does more and more of us are more and more sedentary and so you know maybe it needs to start with an ergonomic assessment of their posture how do they sit at their desk what is what are their head and neck doing do they have spasm of their muscles like torticolis which is a spasm of the sternal clom mastoid do they sit with their shoulders level do they slide their butt into the back of the seat are they giving a nice lumbar support to their spine at their desk after all you guys the the desk is going to be where the majority of your working patients spend 40 to 60 hours a week um as you're given the as you're doing the evaluation note their facial expressions sometimes with a more serious discernation or even a muscle spasm they might winse they might be leaning away from the side of discernation with lateral bending and flexion away from from that uh area of discarnation I've been uh recently I attended a conference um and Chad cook was the was the uh person I need to give credit for this but he was um giving a talk on evidence-based Orthopedic assessment of the c-spine and I'll be referring to his work um quite a bit but one of the things I learned there is that cervical tension headaches are common in patients over 30 and they most commonly result from a sustained neck posture um or repetitive neck movements and so over time uh tension headaches can develop as those muscles um need to exert sustained Dynamic um stability of the of the cervical spine so that's important to know okay some more uh information from that cook um presentation particularly these to right here bullet three and four um we'll get to those in a minute but important differential um diagnosis uh facts to consider does your patient have unyielding pain well that might be a disrupture or it might be something that's not even orthopedic in nature like a cancerous neoplastic tumor okay so in some instances you're going to have to think outside of the Orthopedics box so uh also persistent dizziness or ringing in the ears that's tenus this suggests something other than the cervical spine itself and then some helpful indicators for ligament trauma is the patient fearful of moving their head are they hesitant to move their head do they have muscle spasms and focal pain all three of these definitely the combination of those would point to ligament trauma okay and these muscles are protecting uh ligament injury and then another differential so it's important we know the difference between two causes of referred symptoms one of which is radiculopathy so ridicul apathy uh is it is any radiating symptoms from a compression or from a chemical irritation to nerve roots and so nerve Roots if a nerve root is is injured or damaged or compressed how might that act how might it act differently than if the cord is irritated I hope you're thinking that a nerve root would be unilateral muscle and sensory deficits so myotomes and dermatomes are going to be altered whereas if the cord is d damaged or or inflamed or injured or irritated it's going to be bilateral so myelopathy would indicate that the cord is Disturbed not the roots and and the cord can be disturbed from a compression mechanically or a vascular disturbance resulting from injury okay so that's going to be bilateral muscle and sensory deficits it could even be other um over upper excuse me upper motor neuron signs um like babinsky and other reflex signs that we're going to learn in lab okay so let's talk actual um spine pathologies here and let me get out my pointer I thought I was going to be able to get out my pointer I guess I can't that's all right so the most common cervical spine disorders and we're going to talk about each of these although not in detail for all of them but let's go through spondy losis that degenerative process um to the actual zygapophysial joints or the facet joints and then we're going to talk herniated discs degenerative disorders stenosis and Whiplash okay so spondylosis we said that it happens in as we age um but another uh resource says that it's ubiquitous or all over the place in folks over 40 and so really to get us even more specific and refined it's most common in C5 to 7 it's rare in C2 and three so and it's typically related to a cervical spine instability so as vertebrae vertebrae degenerate over time now all of a sudden they're relying on muscle to stabilize uh each segment and then failure of these Dynamic stabilizers the muscle and the ligamentous static structures during posture then results in a kind of a functional cervical spine instability I'm spending time here because this um clinical scenario contributes to a lot of other types of of syndromes like headaches and it can exacerbate rheumato rheumatoid arthritis and it can lead to osteoarthritis and it even can start to degenerate diss over time and so very important uh concept of this spondy losis this degenerative process that you're going to see in your patients as we age what will these patients um sorry what will these patients um act like and look like well their neck will be stiff they'll have diffuse pain not very specific they will develop tension headaches they may um have results good results from manipulation they probably don't have neurologic signs and symptoms so uh neuro upper neuro quar screen is okay unremarkable they're usually younger and they're usually women and it it this instability might be associated with some trauma but it's probably so more likely that it's long-term uh postural uh posturally related and the natural history of this as we said is a degenerative process that eventually could lead to discernation and this shouldn't surprise you right I've said to you before if you do an MRI of a bunch of 60y olds um the majority of those folks would have at least lumbar spine um discerns but now we're saying they also could have cervical spine dis issues there's going to be a an entirely different um clinical phenomenon we we talk about with the cervical spine and that's stenosis so here you go thickening and stenotic changes may cause radiating symptoms that coincide with disk injury so can you see that spondy and instability may lead to dis injury and stenosis this is a new part of my presentation that typically if you're talking about athletic training and acute trauma we don't really get into the spondy and instability but those of you going into PA school and physical therapy and occupational therapy I think you definitely need this presentation and I would be doing you a disservice if I didn't talk about this okay let's talk about cervical uh disc herniations okay cervical discernation do you see this here at c234 five so it's C4 five see that discreation there so at c67 is the most common area that over time with repetitive flexion a disc might fatigue and the nucleus then pushes through the annulus in the same way we learned about this on the lumbar spine and then it can encroach on the cord you see this gray aspect here is the cord and you've got cerebral spinal fluid in here between this white um on either side of the cord and so repetitive cervical loading um definitely can herniate a disc over time and and as we said earlier the older your patient is the more likely she or he is to having a disc herniation disc corations uh tend to happen in folks who have lost their normal lordotic curve in their cervical spine and if uh the the disc encroaches on a nerve route or the cord itself you are going to have ridiculous UL opathy so radiating pain motor weakness uh throughout the dermatomes and myotomes supplied by that nerve root some things you should know here a soft herniation tends to happen as the nucleus protrudes into the annulus in young patients but something called a calcified herniation remember a disc gets uh less hydrophilic it gets more hydrophobic as we age and just less water supply and so a common degenerative process as age is something called calcified herniation so that's more common in older patients how do we manage this we don't talk about management enough probably in this class because it's more of an orthopedic uh assessment class but definitely rest from the insulting activity um you you might want to use a soft collar to immobilize that neck and then uh traction initially can help to um relieve tension on the nerve Roots themselves so traction has been shown to be um valuable particularly with nerve root impingment uh and surgery is the last resort ladies and gentlemen teach your patients that and surgery is not going to decrease their pain it might reduce their radiculopathy uh but surgery is not a Panacea okay so here we've got uh some good pictures right um you've got a bird's eye view here of the dis and so here we've got dis discernation and so which side would this patient's symptoms be on since it's encroaching on the nerve route this is posterior this is anterior so you should have said left side right to yourself at home stop talking to yourself okay and here's another really uh more updated MRI image we're getting nice pristine images with MRI these days and so you've got two levels of discernation here from a motor vehicle accident a very common cause of discreation okay um sorry about this let me let me change the way we're looking at this I'm having a little bit of technical difficulties um with getting the best view and so let's talk stenosis a little bit as as we said earlier stenosis occurs more in uh the Aging patients right so older patients are more susceptible uh and stenosis as you know is any narrowing in the spinal canal that impinges on the cord itself it can be a congenital condition or it can um um result from changes in in the vertebrae over time so for instance uh bone spurs might result after a discreation as you see there but it also could result after repetitive um Stingers um which will break your plexus neuropraxia and so you have like an ocus a bone buildup which can cause stenosis uh and in into an intervertebral foramina where the nerve Roots exit out of and so um again this term myopathy so myopathy is that compression are the symptoms resulting from that compression or the subsequent vascular disturbance of the cord due to the stenosis so myelopathy is a result of stenosis in this case and again as as we previously said uh because the cord is involved so this is um foraminal stenosis right the core the foramin that how es the cord that's going to result in bilateral symptoms in your patient so let's talk um those were more chronic sort of degenerative conditions let's talk acute injuries in sport like what this wrestler might experience as he's being pile driven to the mat your author uh of your textbook for this class says because of its important role in protecting the spinal cord and nerve Roots injury to the vertebrae the cervical vertebrae can have catastrophic results and you already knew that but what I'd like to tell you is as you're doing your clinical evaluation let's say you're on a football field right or uh or a rugby pitch uh please do not perform any cervical special tests uh on the cervical spine until you rule out fracture dislocation or instability and I'm going to tell you how to do that as we progress uh as we start with these acute injuries um it's really important that you know what the most potentially damaging ideologies are and so as you look at this 1 through six uh some of you have had me in another class and we did this so you probably know the answer but why don't you pick the two or three ideologies that are most likely to cause uh potentially catastrophic injury like a fracture or dislocation so if I were you I would pick two and one and what do you think probably four right so a forced axial load of compression through the cervical spine with flex and rotation is most likely to cause a potentially fra uh catastrophic injury that doesn't mean that three five and six can't cause injury they definitely can it's just a different type of injury that they would cause so if we could design the worst position for the cervical spine it would look something like a loaded somebody driving their head into an immovable uh structure here well could be an opposing football player right it could be uh somebody diving into a swimming pool so what happens is as as the cervical spine goes through an axial load we're going to see this in in an upcoming slide but as it goes through an axial load it loses and particularly if it's flexed it loses its um normal lordotic curve and it becomes kind of a straight um r rigid um vertebrae so for lack of a better word there and so as the momentum of the body keeps coming that normal lordotic curve loses the ability to handle um axial load if the cervical spine is in its normal position it loves um to handle extension but once that uh column is straightened out in a flexed position that's when a fracture like a burst fracture can happen and the spine literally buckles on itself okay so what could be the result of the spine buckles well a fracture and a dislocation so the good news uh folks in the American Journal of sports medicine about 12 years ago um did a longitudinal study and they found out that fracturing dislocation are extremely rare in football high school and college football and that's a good thing but when they happen they most happen from an axial load think about players running into each other on a kickoff or kick kick return you athletic trainers in the room or watching at home uh always pay attention after your team scores or the other team scores uh don't celebrate too long always pay attention to the ensuing kickoff and kick return which is where uh just extreme forces uh are going to occur in the cervical spine as as players throw themselves at each other so all right I digress if this injury happens and a b bony fragment becomes dislodged this can compromise the cord and so dislocations definitely are very serious threat to the spinal cord um how do know that somebody has a fracture dislocation well they're probably going to be have um bilateral sensory and motor deficits in two or all four of their limbs so literally they're not going to be able to feel their hands or their feet or their legs you may be able to palpate a muscle spasm in their cervical spine um I'm going to show you a MRI picture in a minute where you're going to see that uh you may be able to sense Mal alignment if you just gently palpate in the posterior aspect of their head their head and neck might be tilted they're going to have tenderness particularly on the spinus process um if they lose bowel or bladder control this could be cord involvement in this case please don't perform range of motion or manual muscle testing and you definitely do need to do full dermatone myotone um I'm sorry full dermatome and reflexes you you're probably not going to want to do myotomes because that would involve manual muscle testing I learned a really cool um test from an orthopedic surgeon Robert Robert Watkins um his father was actually instrumental in developing a lot of the cervical spine return to play um decision-making in the NFL and I'll show you this in lab but basically um to rule out a fracture you don't have to move the cervical spine at all if the if there's no pain um on the spinus processes and you still think they might have a fracture two fingers on the very crown of their head with just a gentle axial compression that would be positive and indicative of a fracture okay some some a couple more things this is a little redundant if the cord is damaged um Hemorrhage edema and esea or lack of blood flow can result and if this happens uh it it could be irreversible because you know um blood flow brings oxygen right lack of oxygen means cells die and so any pain in the cervical spine must also always be thought of as catastrophic until uh proven otherwise what does that mean uh you should um spine board these patients here we've got uh two pictures of um a fracture dislocation which is compressing the spinal cord here you see the cord being impinged on by a displaced vertebrae I was mentioning earlier you may be able to palpate this is the skin right on the back side of this person's neck with a flat hand sweep maybe below their helmet if this is a football player you're going to be able to sense the Mal alignment of this vertebrae way back here two inches away in their skin and so clearly that's a um medical emergency really quickly um the patient's posture might tell you and indicate that either they have a well they have a central nervous system dysfunction so either the brain or the cord itself is injured so the body does a few things in the uh presence of cervical um injury that that uh compromises the cord and so they may have a decorticate posture where their hands are flexed to their core so decorticate hands flexed to the core think about it that way um this is usually a lesion above the brain stem the brain itself is injured the thalamus of the cortex they might do extension of the extremities that's called desbats so this is a lesion lower in the brain stem itself it could happen with heat stroke itself um also I mean and then the flexion contracture where the arms are Flex across their chest so this is more a c56 cord injury I want to talk to those of you who are who are going to be um covering sort of high impact contact and collision Sports this is a unique phenomenon as you see on the top it's called transient quadriplegia so some patients um after they sustain a hit uh you you literally might think that they have a fracture or dislocation and their cord is involved and you need to treat them like they do um the thing is that with with huge force in hyperextension or hyper flexion this can this can send the the cord itself into trauma and so there's a temporary neuropraxia of the cord uh calcium literally kind of um Rises into the um neural cells and and this is um transient a transient shutdown of the cord which is wild if you ever experience it and so so uh somebody who um has a stenosis that they actually don't have enough room for their cord uh in the fmen so they're more prone to transient quadriplegia this happens in football players there's been research done on it and they actually call it spear tackler spine from from the mechanism of injury of spearing where somebody leads with their helmet and so um what's this going to look like well it's going to look like kind of a cord injury the same way that a fracture dislocation would they're have bilateral sensory and motor deficits but it's transient it clears within 15 minutes to 48 Hours you guys you still treat it the same way you're going to spine board them you're going to refer for x-ray or MRI and you really don't know until after the injury happens but this patient is going to have symptoms resolve uh and that's a very good thing right so let's talk a little bit about spear tacular spine because I just mentioned it and so sorry this is a football injury predominantly and so here you see in a through e um when the spine when the spine loses its normal lordotic curve it acts like a rigid segment right segmented column and so like I was saying earlier you know when a football player hits an immovable object like another football player coming in the opposite direction that um cervical spine loses its ability to handle that axial load and actually can buckle on itself and Fracture all this down here is just the history of um the NFL changing its rules to not allow um spearing which was basically uh causing the spine to do this and so after 1976 when the NCAA um enacted rules barring spearing the incidence of catastrophic sepine injury went way way down 270% reduction how do you like that um if you want to follow up uh in your slides this is a really cool case of of doctors treating on the field Kevin Everett when he had a spinal cord injury um they used extremely cold water which wasn't even FDA approved at the time and they probably saved his life um they definitely saved his cord function and so um for further study um you can read uh there's some really important resources in the medical community the n TAA has a campaign called see what you hit if you're going to work with high school football players and college football players you definitely should watch this video um Google it um you should educate yourself on this because you're going to have to educate those folks on how to uh properly hit okay let's switch up uh to some less stressful pathologies and so as in any other joint you can strain muscle acutely or chronically but we're going to talk acute muscle strain and so sudden flexion extension lateral flexion any sudden motion can strain um the cervical spine musculature the most commonly strained muscles are the traps scalings and the splenius muscles splenius capitus and services uh signs and symptoms as with any other muscle strain it's going to hurt when you actively contract that muscle or when you ask it to stabilize the cervical spine or when you passively stretch it uh the differential uh here is that uh muscle doesn't radiate symptoms right so um this patient might be reluctant to move their neck in any direction so reluctance to move remember we said that could be ligament also but the difference between ligament and muscle what is that what is that difference well ligament doesn't hurt when you actively contract right that's a muscle and so ligament could hurt on on stretching because when you stretch the Sur cical spine like let's say in flexion you're asking those posterior ligaments um to stabilize the neck so muscle hurts on active contraction passive stretch so um in addition to a muscle spasm um something uh that could cause the the neck to violently snap from flexion into extension like a car accident uh some of you probably have been involved in a car accident um might damage muscle but it also might do more than that right and we call that mechanism of injury Whiplash let me show you um a picture here and so imagine you're uh in a car and you're rear ended right by a car and so the very first action of your neck is to snap into extension well what would extension um possibly damage well you see here the musculature on the anti ior side being the brakes right but then deeper in the Facet Joint that could uh compress a facet right that could cause Facet Joint Syndrome it could fracture a spinus process it could sprain a ligaments right and then the subsequent recoil so so you've got the initial reaction and then the subsequent recoil what could um an extreme flexion moment doe to the spine well it could strain the the musculature on the back side right it could herniate a disc and so uh Whiplash can have all of those results and so that patient signs and symptoms you see here they could be tendered to palpation on the transverse of spinus processes if that facette was involved or if a ligament's involved or if they fractured a spinus process they could have muscle spasm for the reasons that we just mentioned and so you've got to rule out a fracture or dislocation or disc or cord injury you're going to do this with ridicul symptoms okay so that was very quick through um through Whiplash but uh I I think you can understand that Whiplash is a sort of a reiteration of a muscle strain a discnation Andor a um facet joint sprain well let's finish up with a few more pathologies but uh I want to spend a few minutes on bracho plexus neuropraxia or stingers I bet some of you in the class have had a stinger if you've played football or wrestling Etc uh we did some research on this this is my Master's thesis where we studied an entire uh division one football team triy to identify predictors of stingers in that in those college football players but first of all what is a stinger well in our anatomy section we learned in detail the bracho plexus right nerve Roots C5 to T1 that plexus excuse me that plexus can be injured three ways it can be mechanically stretched you see here um in figure a it can be compressed if the neck snaps back into extension and rotation and it can have um blunt force trauma uh gosh car accident blunt object um um a karate chop to the neck I'm laughing but uh definitely um the bracho plexus is very superficial right above the clavicle and so blunt trauma at herbs Point that's what this b letter B is it's herbs Point um so the the bracho plexus can be injured uh in all three of those mechanisms and so what is uh bracho plexus ner praxia well PR praxia is the mildest form of nerve injury or trauma there's three levels uh this is a grade one and so it's got a high probability of healing these patients um who stretch their bracho plexus typically have transient symptoms and so in Orthopedics it's typically a dysfunction after a blow to the head or neck think about you're trying to tackle somebody on the sideline and that person um causes your head to go to the left but your shoulder gets depressed to the right and that's really going to stretch the bracho plexus and so we found that it's a very common occurrence two-thirds of people in college football will experience a stinger this is really a kicker right here of the folks who experience a stinger nine out of 10 will have recurrent Stingers so something has to be done so we looked at factors that might predispose a player two Stingers how how are these patients going to exhibit symptoms well as you might imagine on the side that's stretched or compressed they're going to have radiating symptoms numbness tingling from their neck into their trapezius muscle into their deltoid all the way into their elbow uh some sometimes all the way down into their fingers and hands this is the person that comes off the field shaking their hand and arm or they're holding it to the side it's it's really hard to miss when somebody has a stinger they're they're holding their arm or shaking their hands and so you on clinical exam are going to have altered myotomes and dermatomes and so definitely in these folks you want to rule out fracture or dislocation real quickly how do you do that well let me answer that for you you you do it uh three ways do they have radiating symptoms bilaterally well that could be cord involvement right do they have tenderness to palpation on the spinus processes themselves if yes they could have a a fracture and that's more than a bracho plexus neuropraxia right is that two-finger compression test the axio low test I showed you that uh Dr Watkins um showed me if that's positive send them for an x-ray okay um bracho Plex of stretch and and Spurling test test we're going to learn in lab but those would be positive and so if if you have this clinical pres presentation do not allow your patient to return to play until they have full strength no symptoms and full range of motion well I'm showing you pictures of of uh what works um what works it doesn't really work what we use to slow down the neck and going back into extension and so that they they don't have nerve root ression because um another way that the bracho plexus can be injured I have to show you this in lab but if the neck snaps back into extension you decrease the space in the intervertebral foramina out of which these nerve Roots exit and so that could be nerve root impingement so the bracho plexus can get impinged here all right as well as it could as it could get stretched here's Spurling test so basically you take the the patient back into extension lateral flexion and rotation and spurling's test is a test for nerve root impingement so if this test were positive this gentleman would have symptoms down his right shoulder okay the other test the bracho plexus stretch test we're going to learn in class that is where you just have you just take the patient's ear towards his shoulder it's a lateral flexion and he would experience that stretches the opposite side the left side of the bracho plexus it's called a bracho plexus stretch test and that patient simp symptoms would be positive uh on the left side and so what did we find we found the mo most common as we followed these patients through the season and and we recorded um Stingers we had 15 stingers and 83 football players um sorry we had 15 players who had Stingers some of those players had multiple Stingers so we had we had more than 15 overall but the most common mechanism of injury was um nerve root compression that was contrary to what we thought we would point and recurrent Stingers as previous research found usually resulted from the same mechanism and occurred on the same side so let's finish up with um a a couple injuries that uh aren't very common but yet you should be aware of them torticolis if you've heard of it uh it typically happens in two ways um we'll start with the the least frequent and that is in young kids even um during birth if if a baby's neck is sort of wrenched in the birth canal they can have an acute spasm of the sternomastoid that's what torticolis is other folks like athletes you know maybe they have a whiplash type ideology and their um cocom mastoid spasms or they just quote slept wrong right end quote in bed uh and they wake up with an a neck spasm that could be an an acute torticolis Okay typically this is pretty easy to fix if it's that ladder uh torticolis in an athlete um a soft collar a heat um traction to that neck massage typically uh sometimes a muscle relaxant um and the patient should resolve symptoms within two to three days okay this is getting pretty long so I want to cover these next five or six slides in class when we see each other um particularly Orthopedic healthare folks those of you who want to deal with highle athletes um these next few slides are very important for determining return to play and so cervical spine stenosis we're going to talk about the Tor ratio and the pavol ratio in class but I want to end you with this so in our pursuit of evidence-based um clinical practice so when should you get an x-ray I just came across these Canadian sepine clinical prediction rule um to predict when an x-ray is warranted after trauma and so it's applicable to patients who are who are um in an alert state so their Glasco Coma Scale is greater than 15 if you don't know what Glasco Coma Scale is I will demonstrate that to you in lab uh and they're stable following trauma okay it's not applicable in non-trauma cases they don't need an x-ray um Etc there let me let me walk you through this and so um it's a typical clinical prediction rule um if if a patient is greater than age 65 or they had a dangerous mechanism of injury you know what that is now right axial load with flexion or they have paresthesia in their extremities if they answered yes to that well it's pretty clear get an x-ray okay if no so there're younger patient they didn't have a particularly dangerous mechanism paresthesia is ambiguous maybe you didn't elicit paresthesia okay let's ask some of these so low risk these are highrisk factors these are lower risk factors um were they in a simple motor vehicle accident or um are they sitting in the emergency department they're unable to stand um or are the ambulatory were they able to be ambulatory at any time um or do they have uh delayed onset of neck pain uh if no so so these are actually positive right which allows safe assessment of range of motion um sorry I'm not explaining that very well am I so if they answer no to these questions x-ray if they answer yes that would be positive yes right they don't have c-spine tenderness they don't have or they have delayed on set neck pain they don't have acute neck pain they were able to move right they are sitting and they were in a simple rear end motor vehicle collision thank you now I'm explaining it better if yes okay we're still looking good they probably don't need x-ray right are they able to actively rotate their neck if they're able to move their neck without pain no x-ray right if they're not able to move their neck x-ray so these are nice CL prediction rules to determine if somebody needs an X-ray and the same way that we used um the Ottawa ankle rules right and so I hope that helps I just came across that I I didn't know that it exists I think it's only been used for the last four or five years and so I thought i' I'd get that into your hands all right so that's the clinical exam of the c-spine thanks for listening all 43 minutes of this presentation when we get to class we will um now be freed up to do a good lab experience so that we can round out your education in in this sepine