Case Performa

CVJ and High Cervical Lesions

Usual Chief Complaints:

1) Neck Pain
2) Limb weakness
3) Gait Instability
4) Sensory Abnormali es
5) Drop A acks
6) Neck Tilts
1) Nuchal Pain / Neck
• Site, Onset , Dura on,

• Progression

• Rapidly - system infec on, trauma, metasis leading to collapse

• Gradual - degenera ve

• Nature

Aching type - mechanical

Shoo ng type / sharp burning along the dermatome - radicular

Funicular pain - funicular pain is con nuous, not exacerbated by root

stretching, di use/vague and poorly localized, non-dermatomal distribu on,
deep, contralateral to spinal cord compression, and not correlated with
physical ndings.

• Intensity

• Severe - fractures, infec ons

• Radia on
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 • C5 dermatome - to the shoulder and lateral part of the arm + Aching
pain in the medial scapular border is con rma on that it is c5 (but also
seen in c6 and c7 root irrita on). It does not go below the elbow

• C6 dermatome - deep pain in the biceps, lateral forearm, thumb and

index ngers over both dorsal and palmar aspects

• C7 - deep pain In triceps, central forearm, middle, ring and index

ngers . May complain pain the en re arm ( supplies periosteum of
bone)

• C8 - uncommon .Below olecranon to li le and en re ring nger.

Di cult to dis nguish with ulnar neuropathy below elbow

• T1 - Deep aching sensa on in the shoulder joint and a I’ll. Meadial

upper arm to olecranon

• Aggrava ng / Relieving factors : Rela on to speci c neck movements/ Cough /

li ing weights , relieving by rest / medica ons / cervical collar (mechanical pain
responds to cervical collar)

• H/o neck trauma

• Missed trauma may present as increasing neck pain at the nape of the
neck a er 2 to 3 weeks

• History of sudden electric shock like sensa on

Lhermi e’s sign or barber chair syndrome - chronic demyelina on causing

hyper excitablility of dorsal tracts on irrita on by mechanical compression of
in amma on causes genera on electrical shock radia ng down the spine and
limbs.

Reverse lhermi es - neck extension

Inverse lhermi es - shock in reverse order. NO toxicity

• Diurnal varia ons /Increase pain at night

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 • Worsening in early morning - in ammatory spondyloarthropathies

• Degenera ve - worse at night

• Any change a er interven ons ( eg a er massage)

• Spasm of neck muscles

• Degenera ve diseases of cervical spine

• History of restric on of neck movements

• Lateral exion is most restricted in degenera ve spine

• H/o fever, sore throat , neck swelling

• In infec on, severe rapidly progressive excrucia ng pain because of

periosteal irrita on, aggrava ng on neck movements. So pa ents tend keep the
head s ll or hold the head with hands.

• H/o Neck lts - non-correctable lt with restric on of neck movements at birth -

bony anaomolies

Correctable with no restric on neck movements - muscular weakness

secondary to syringomyelia or dystonia

Look for diplopia

Tor collis - congenital ,

Spasmodic - painful

ocular - involvement of oblique EOM - painless

• Neck clicks

• Worse in the morning with s ness, poly arthroparthy, with neck clicks -
in ammatory arthropathies

• Oc1 pain on exion and extension

• C1c2 - pain on rota on

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 • drop a acks

• Sudden loss of tone with no LOC ( b/L loss of tone because of

ischaemia to CST) - VB insu ency, FoMag lesions, upper cervical compression,
3rd ventricular lesion with HCP

2) Weakness of Limbs
• Onset, dura on , progression

• Ascending / Descending

• Symmetrical/ Asymmetrical

• Proximal/ Distal

• Men on individual ac vi es ac vi es that have been impaired (bu oning

/ unbu oning , cooking etc)

• Trunk or neck muscle weakness

• Weakness of respiratory muscles

• U shaped weakness/ Crossed hemiplegia

• Any LMN signs – was ng / fascicula ons.

• Bring out history so myelopathy can be classi ed according to the

mJOA/ Nurick score

Ini ally in what task f/by what task

Neck muscles

- Any drooping of neck

- neuromuscular disorders
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 • Polymyositis/Scleromyositis. In ammatory myopathies can cause DHS. ...
• Isolated neck extensor myopathy. INEM was rst described in four patients
• Facioscapulohumeral muscular dystrophy. ...
• Anti-glutamic acid decarboxylaseassociated in ammatory myopathy. ...
• Adult-onset nemaline myopathy. ...
• Amyloidosis

- di culty in turning the head

- Di culty in shrugging shoulders

- Di culty in li ing head from supine posi on

- Any di culty in ROM, then neck pain, clicks

Arm

Any di culty in reaching objects above head, combing hair, wearing shirt, di culty in
raising head above head while bathing, occupa on related,

Any di culty in bringing food, glass of water to mouth , any di culty in ge ng

cellphone to ear,li ing an object of desk or bed.

Weakness of the arm to assist while ge ng up from si ng posi on or from chair.

Di culty in opening windows - triceps and biceps

Prona on supina on

Di culty in unlocking the door with keys

Di culty in pu ng screws if mechanic

Distal -

Di culty in holding glass, di culty in gripping objects, di culty in holding pen

(dominant), di culty in mixing rice or breaking chapa s , di culty in switching on and
o lights, di culty in bu oning and unbu oning

Di culty in wri ng -

Alzheimer’s pa ents shows altera ons in spa al organiza on accompanied by poor control
of movements.
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 micrographia, slower movements and jerk in PD
Many quadriplegics have limited wrist strength. These individuals will o en use a two-hand
technique to write. To do this, they will rst put the pen or pencil in their hand the best they
can, and then they will use their other hand to press the pencil down to the paper and move
the pencil - large unorganised
Diaphragm
Di culty in breathing, chest pain, persistant hiccups.
Trunk
Any di culty in rolling on a bed
Any di culty in si ng on bed from supine posi on

Hip
Any di culty in bearing weight on the limb
Any di culty in standing from si ng or squa ng
Any di culty in squa ng
Any di culty in li ing foot o the ground (any history of trip and fall)
Any di culty in moving forward while walking
Any di culty in stepping sideways
any di culty in drawing circles with leg
Knee
History of buckling of knee
History of di culty in climbing up or down the stairs
Distal
History of dragging of foot
Slipping of footwear with knowledge (without - sensory)
Di culty in wearing the footwear - able to wear with hands or against wall
Di culty in shi ing gears or breaking while riding bike
Di culty in walking on toes.

Bulk
History of thinning of limbs
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 Tone
History of s ness or ghtness of the limbs
Any history of spasms ( exor spasm in spinal cord injury)
Any oppies of the limbs, extension of the limbs beyond limit, if muscles feel so , over hanging or
doughy ( well educated pa ents only you can ask)

History of involuntary movements

3) Gait Instability / Ataxia

• Onset , dura on, progression

• Side of devia on

• Related to posture

Proximal muscle weakness or spas city

• Tightness of limbs/ buckling , inability to walk fast

• Slippage of footwear, squa ng

• Di culty in climbing upstairs / downstairs

Cerebellar

Walking like a drunk

Di culty in manoeuvering the narrow passages and crowded places

Di culty in sharp turns

Di culty in wearing trousers

Di culty in nego a ng foot in slipper **********

Ves bular

Di culty in walking in dim light

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 Gait ataxia only while standing or walking

Sensory

• Di culty uneven surfaces

• Slippage of slippers with out knowledge

• Wash basin phenomenon / Di culty walking in the dark

• Co on wool sensa on

• Band like sensa on

• H/o falls

• Progression of de cit over me and current func onal status

• Need for one/two person suppory / walking s ck

4) Sensory Complaints : onset, dura on progression, , unilateral or bilateral, any history of

loss of sensa on over the perianal region.

▪ Dorsal column :
▪ Awareness of limb posi on at night
• Co on wool sensa on

• Wash basin phenomenon

• Lhermi e’s Phenomenon

▪ Spino Thalamic tract :

• Di erence in temperature while bathing

• Areas of posi ve sensa on / nega ve sensa ons

• Unno ced burns/injuries over extremi es

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 • H/o Dissocia ve sensory loss

• H/o Graded sensory loss

• H/o Band like sensa on

▪ Spinal tract of trigeminal nerve:

• Decreased facial sensa on

• H/o onion peel type sensory loss

• Reddening of eyes or eye pain

• History s/o trigeminal nerve involvement : Jaw devia on, di culty

chewing food on one side , facial pain

5) History s/o Complica ons a/w CVJ / High cervical lesions

• Bowel and bladder involvement

• Storage symptoms - increased Urinary frequency, nocturia, urgency,

urge incon nence, sensa on of full bladder

• Voiding symptoms - pain while micturi on, hesistancy, stream, ow,

terminal dribbling feeling of incomplete voiding

• H/o Autonomic involvement : Potural hypotesion, swea ng, ushing of

skin

• LCN Symptoms - change in voice or nasal twang, hoarseness of voice, any

di culty in swallowing solids or liquids , any nasal regurgita on, any
episodes of choking or cough on food intake, any di culty in making food
bolus in mouth, history of breathing di culty.
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 • Hcp

Cranial Nerve involvement

• II : In raised ICP

• VI : In raised ICP

• VIII : CVJ anomalies a/w hearing loss

• H/o Head lt/ Restric on of neck movements

` History s/o Fever, weight loss, cough, chest pain.

No history sugges ve of horners syndrome
No history of sexual dysfunc on
History of hypo/hyperpigmented patches or other skin lesions.
H/o Syndromic CVJ: Kippel Feil , Downs , Marfans
7) Current Func onal Status and Disability
• Upper limbs : Feeding , bu oning etc

• Lower limbs : Walking , squa ng , si ng crossed leg

• Bowel and bladder func ons

• How it has a ected professional, personal and ac vi es of daily living

• Past History : TB

• Personal History : Mentrual history

• Family History : Syndromic associa on, Pedigree chart

• Treatment History
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 EXAMINATION

General Examina on :
• CVJ Markers

• Postural Hypotension

• NF features

• Single breath Count and Breath holding me

• Rule out syndromic CVJ : Kippel feil , Marfans

• Suboccipital muscle was ng / supraclavicular was ng

• Cle lip

Respiratory System : Percussion to check shi ing liver dullness , chest expansion , SBT , BHT

Cranial Nerves : Jaw jerk , Facial sensa ons

Motor : A tude of neck in detail

Re exes : Ho man’s

Sensory : Sacral sensa on

Neck movement : only ac ve, axial rota on , exion , extension , lateral bending

Gait examina on : Spas c gait

Spine Examina on : Curvature, deformity , gibbus , tenderness

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