Cervical spine fracture: Although cervical spine fracture is rare in physiotherapy practice a high index of suspicion is indicated in patients who have sustained trauma involving

• a dangerous mechanisms of injury (e.g. fall > 3 feet / 5 steps
• high speed motor vehicle collisions
• axial loading to the head (e.g. diving)
• > 65 years of age
• bilateral < 45° cervical rotation
• paraesthesia in the extremities.

Such screening is termed the ‘Canadian C-Spine Rule’ (Stiell et al. 2001). Any suspicion of cervical spine fracture requires urgent referral for medical investigation.

Cervical arterial dysfunction. Although rare, cervical arterial dissection has been associated with manipulation, whiplash injury and sports injuries (Hauser et al. 2010; Willett & Wachholtz 2011). In the initial stages CAD could present as stiffness and pain in the neck. Thus the clinician needs to maintain a high index of suspicion. The clinician needs to ask about symptoms that may be related to pathologies of the arterial vessels, which course through the neck, namely the vertebral arteries and the internal carotid arteries. Pathologies of these vessels can result in neurovascular insult to the brain (stroke). These pathologies are known to produce signs and symptoms similar to musculoskeletal dysfunction of the upper cervical spine (Kerry & Taylor 2006). Care must be taken to differentiate vascular sources of pain from musculoskeletal sources. Urgent medical investigation is indicated if frank vascular pathology is identified.

CAD can present initially with pain in the upper cervical spine and head. This is referred to as the preischaemic stage. If the pathology develops, signs and symptoms of brain ischaemia may develop. Of course, many people present with treatable musculoskeletal causes of symptoms, but also with many of the risk factors for Cervical Arterial Dysfunction such as high BP and smoking. This does not necessarily exclude them from manual therapy treatment, and careful clinical reasoning and monitoring of signs and symptoms are required in the management of these patients (Kerry & Taylor 2009).

References

Hauser, V. et al., 2010. Late sequelae of whiplash injury with dissection of cervical arteries. European Neurology, 64(4), pp.214–218.

Kerry, R. 2006 Vertebral artery testing: how certain are you that your pre-cervical manipulation and mobilisation tests are safe and specific? HES 2nd International Evidence Based Practice Conference London

Kerry, R. Taylor, A.J.  2006 Masterclass: Cervical arterial dysfunction assessment and manual therapy. Man. Ther. 11 (3),  243–253.

Kerry, R. Taylor, A.J.  2008 Arterial pathology and cervicocranial pain – differential diagnosis for manual therapists and medical practitioners. Int. Musculoskelet. Med. 30 (2),  70–77.

Kerry, R. Taylor, A.J.  2009 Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. J. Orthop. Sports Phys. Ther. 39 (5),  378–387.

Kerry, R. Taylor, A.J., Mitchell, J.M. et al. 2008 Cervical arterial dysfunction and manual therapy: a critical literature review to inform professional practice. Man. Ther. 13 (4),  278–288.

Stiell, I.G. et al., 2001. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA : the journal of the American Medical Association, 286(15), pp.1841–1848.

Willett, G.M. & Wachholtz, N.A., 2011. A patient with internal carotid artery dissection. Physical Therapy, 91(8), pp.1266–1274.