The Upper Cervical Spine and Cervicogenic Headaches: Difference between revisions
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Introduction | == Introduction == | ||
[[Introduction to Cervicogenic Headaches|Cervicogenic headache]] (CGH) is a chronic secondary headache that originates in the cervical spine.<ref>Fernandez M, Moore C, Tan J, Lian D, Nguyen J, Bacon A et al. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta‐analysis. Eur J Pain. 2020; 24(9): 1687-702.</ref> The headache begins in the neck or occipital region and can refer to the face and head. The specific sources of CGH are any structures innervated by the C1 to C3 nerve roots.<ref>Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2000;100(9 Suppl): S7-14.</ref> | |||
When assessing and treating patients with CGH, it is important to be able to clearly identify the symptomatic area in the upper cervical spine. Areas to assess are the:<ref name=":0">Kaplan A. Cervicogenic Headache - Upper Cervical Course. Physioplus, 2020. </ref> | |||
* Occipito-antlantal (OA) joint | |||
* Atlanto-axial (AA) joint | |||
* C2-3 joint | |||
* Suboccipital muscles | |||
== Headache Assessment == | |||
=== Subjective Assessment === | |||
The subjective assessment of the cervical spine is discussed [[Cervical Examination|here]], but when patient's report headaches, it it important to ask specifically about the:<ref name=":0" /> | |||
* Intensity of headaches | |||
* Frequency of headaches | |||
* Duration of headaches | |||
Any change in these parameters at follow-up assessments will help to indicate if the headache is responding as expected to management. | |||
=== Objective Assessment === | |||
A full description of a cervical assessment can be found [[Cervical Examination|here]]. But when assessing for CGH, the following measures should be included:<ref name=":0" /> | |||
* Range of motion testing | |||
* Deep neck flexor endurance testing | |||
* Palpation and joint mobility testing | |||
Common clinical methods for assessing cervical spine mobility include:<ref>Mohamed AA, Shendy WS, Semary M, Mourad HS, Battecha KH, Soliman ES et al. Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. J Phys Ther Sci. 2019; 31(4): 376-381. </ref> | |||
* [[Cervical Flexion-Rotation Test|Flexion rotation test]] | |||
* Active cervical range of motion | |||
* [[Cervical Examination|Passive accessory inter-vertebral movement and physiological inter-vertebral movement]] (PPIM/PPIVM) | |||
* Active cervical flexion test | |||
* Myofascial [[Trigger Points|trigger points]] assessment | |||
* Ischemic pressure tolerance test | |||
* Cervical [[Sensorimotor Impairment in Neck Pain|proprioception assessment]] | |||
=== Red Flags === | |||
It is essential to screen for serious conditions and red flags in any assessment of the cervical spine. | |||
Serious conditions include: | |||
* [[Cervical Arterial Dysfunction|Cranial artery dysfunction]] ([[Cervical Arterial Dysfunction|https://www.physio-pedia.com/Cervical_Arterial_Dysfunction]]) | |||
** Cervical artery | |||
** Carotid artery | |||
* Intracranial issues | |||
* Upper cervical ligament instability: LINK | |||
** Transverse ligament (Sharp purser test: https://www.youtube.com/watch?v=eqS2tIGauXU | |||
** Alar ligament (Test: [[Alar Ligament Test|https://www.physio-pedia.com/Alar_Ligament_Test]]) | |||
==== Upper Cervical Ligament Instability ==== | |||
Upper cervical ligament instability has a prevalence rate of 0.6 percent,<ref name=":1">Hutting N, Scholten-Peeters GG, Vijverman V, Keesenberg MD, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Phys Ther. 2013; 93(12): 1686-95. </ref> but it is more common in patients with inflammatory arthritis (e.g. rheumatoid arthritis).<ref>Takahashi S, Suzuki A, Koike T, Yamada K, Yasuda H, Tada M, Sugioka Y et al. Current prevalence and characteristics of cervical spine instability in patients with rheumatoid arthritis in the era of biologics. Mod Rheumatol. 2014; 24(6): 904-9. </ref><ref>Al-Daoseri HA, Mohammed Saeed MA, Ahmed RA. Prevalence of cervical spine instability among Rheumatoid Arthritis patients in South Iraq. Journal of Clinical Orthopaedics and Trauma. 2020; 11(5): 876-82. </ref> Despite low prevalence rates in the general population, it is important to screen for these conditions. | |||
===== Transverse Ligament ===== | |||
The transverse ligament enables the atlas to pivot on the axis. It holds the atlas in its correct position in order to prevent spinal cord compression during neck and head flexion.<ref>Cramer GD. The cervical region. In: Cramer GD, Darby SA editors. Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier, 2014. p135-209.</ref> | |||
The Sharp Purser test is commonly used in clinical practice to assess for atlantoaxial instability, particularly in patients with rheumatoid arthritis.<ref name=":2">Mansfield CJ, Domnisch C, Iglar L, Boucher L, Onate J, Briggs M. Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test. J Man Manip Ther. 2020; 28(2): 72-81.</ref> This test is discussed in more detail [[Sharp Purser Test|here]]. | |||
Use of the sharp purser test is, however, considered contentious due to its potential to cause harm (i.e. a positive sharp purser test involves compressing the spinal cord via the dens of C2 and then performing a manoeuvre to decrease pressure on the spinal cord. This could be unsafe in high risk populations).<ref name=":2" /> While there is currently no evidence to suggest that this test is harmful, there is a lack of evidence on its use in high-risk populations. It also demonstrates inconsistent validity and poor inter-rater reliability.<ref name=":2" /> | |||
Other tests include the [[Transverse Ligament Stress Test|transverse ligament stress test]]. This test has high enough specificity to rule in patients with upper cervical spine instability. However, when Hutting and colleagues looked at a range of instability tests, they concluded that it is not currently possible to accurately screen for upper cervical instability.<ref name=":1" /> | |||
[[Category:Course Pages]] | |||
[[Category:Cervical Spine]] | |||
Revision as of 10:30, 6 December 2020
Introduction[edit | edit source]
Cervicogenic headache (CGH) is a chronic secondary headache that originates in the cervical spine.[1] The headache begins in the neck or occipital region and can refer to the face and head. The specific sources of CGH are any structures innervated by the C1 to C3 nerve roots.[2]
When assessing and treating patients with CGH, it is important to be able to clearly identify the symptomatic area in the upper cervical spine. Areas to assess are the:[3]
- Occipito-antlantal (OA) joint
- Atlanto-axial (AA) joint
- C2-3 joint
- Suboccipital muscles
Headache Assessment[edit | edit source]
Subjective Assessment[edit | edit source]
The subjective assessment of the cervical spine is discussed here, but when patient's report headaches, it it important to ask specifically about the:[3]
- Intensity of headaches
- Frequency of headaches
- Duration of headaches
Any change in these parameters at follow-up assessments will help to indicate if the headache is responding as expected to management.
Objective Assessment[edit | edit source]
A full description of a cervical assessment can be found here. But when assessing for CGH, the following measures should be included:[3]
- Range of motion testing
- Deep neck flexor endurance testing
- Palpation and joint mobility testing
Common clinical methods for assessing cervical spine mobility include:[4]
- Flexion rotation test
- Active cervical range of motion
- Passive accessory inter-vertebral movement and physiological inter-vertebral movement (PPIM/PPIVM)
- Active cervical flexion test
- Myofascial trigger points assessment
- Ischemic pressure tolerance test
- Cervical proprioception assessment
Red Flags[edit | edit source]
It is essential to screen for serious conditions and red flags in any assessment of the cervical spine.
Serious conditions include:
- Cranial artery dysfunction (https://www.physio-pedia.com/Cervical_Arterial_Dysfunction)
- Cervical artery
- Carotid artery
- Intracranial issues
- Upper cervical ligament instability: LINK
- Transverse ligament (Sharp purser test: https://www.youtube.com/watch?v=eqS2tIGauXU
- Alar ligament (Test: https://www.physio-pedia.com/Alar_Ligament_Test)
Upper Cervical Ligament Instability[edit | edit source]
Upper cervical ligament instability has a prevalence rate of 0.6 percent,[5] but it is more common in patients with inflammatory arthritis (e.g. rheumatoid arthritis).[6][7] Despite low prevalence rates in the general population, it is important to screen for these conditions.
Transverse Ligament[edit | edit source]
The transverse ligament enables the atlas to pivot on the axis. It holds the atlas in its correct position in order to prevent spinal cord compression during neck and head flexion.[8]
The Sharp Purser test is commonly used in clinical practice to assess for atlantoaxial instability, particularly in patients with rheumatoid arthritis.[9] This test is discussed in more detail here.
Use of the sharp purser test is, however, considered contentious due to its potential to cause harm (i.e. a positive sharp purser test involves compressing the spinal cord via the dens of C2 and then performing a manoeuvre to decrease pressure on the spinal cord. This could be unsafe in high risk populations).[9] While there is currently no evidence to suggest that this test is harmful, there is a lack of evidence on its use in high-risk populations. It also demonstrates inconsistent validity and poor inter-rater reliability.[9]
Other tests include the transverse ligament stress test. This test has high enough specificity to rule in patients with upper cervical spine instability. However, when Hutting and colleagues looked at a range of instability tests, they concluded that it is not currently possible to accurately screen for upper cervical instability.[5]
- ↑ Fernandez M, Moore C, Tan J, Lian D, Nguyen J, Bacon A et al. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta‐analysis. Eur J Pain. 2020; 24(9): 1687-702.
- ↑ Biondi DM. Cervicogenic headache: mechanisms, evaluation, and treatment strategies. J Am Osteopath Assoc. 2000;100(9 Suppl): S7-14.
- ↑ 3.0 3.1 3.2 Kaplan A. Cervicogenic Headache - Upper Cervical Course. Physioplus, 2020.
- ↑ Mohamed AA, Shendy WS, Semary M, Mourad HS, Battecha KH, Soliman ES et al. Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. J Phys Ther Sci. 2019; 31(4): 376-381.
- ↑ 5.0 5.1 Hutting N, Scholten-Peeters GG, Vijverman V, Keesenberg MD, Verhagen AP. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Phys Ther. 2013; 93(12): 1686-95.
- ↑ Takahashi S, Suzuki A, Koike T, Yamada K, Yasuda H, Tada M, Sugioka Y et al. Current prevalence and characteristics of cervical spine instability in patients with rheumatoid arthritis in the era of biologics. Mod Rheumatol. 2014; 24(6): 904-9.
- ↑ Al-Daoseri HA, Mohammed Saeed MA, Ahmed RA. Prevalence of cervical spine instability among Rheumatoid Arthritis patients in South Iraq. Journal of Clinical Orthopaedics and Trauma. 2020; 11(5): 876-82.
- ↑ Cramer GD. The cervical region. In: Cramer GD, Darby SA editors. Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier, 2014. p135-209.
- ↑ 9.0 9.1 9.2 Mansfield CJ, Domnisch C, Iglar L, Boucher L, Onate J, Briggs M. Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test. J Man Manip Ther. 2020; 28(2): 72-81.
