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Upper Cervical Ligament Testing
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Upper Cervical Ligament Testing - June 21, 2005 8:57:00 AM
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JLS_PT_OCS
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Many people that I know and whose posts I have read say they regularly test the structural integrity of the upper cervical ligaments before engaging in manual therapy or exercise treatment of the neck.
I can't for the life of me figure out why this testing is a good idea, and have not done this myself for some years now. Can someone enlighten me as to their reasoning behind this practice?
Here's my thoughts:
1. If it is a trauma case, they need films, if films neg, then I won't be doing much if any HVLA stuff for some time, epecially not in the upper cx spine. Especially given current guidelines for WAD.
2. If it is atraumatic, I would never think to check for this instability nor can I think of any reason they would be unstable.
3. If they ARE unstable, the last thing I would want to do is go sliding their vertebrae around up there, producing just the sort of problem I supposedly am trying to avoid by testing in the first place. Reminds me of VBI testing that way.
4. I do not know of any reliability/validity data on these tests (I haven't bothered to look) and can only assume that these probably shake out the same as motion palpation for facet asymmetry - very poor in intra/interrater reliability and probably poor validity as well, with multiple false positive/negative results.
5. I rarely use HVLA in the Cx spine, and then only for the lower Cx spine C3-C7 area.
Now, go ahead, let me have it. Somebody knock me off my horse here, show me where I have gone wrong...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Upper Cervical Ligament Testing - June 21, 2005 10:01:00 AM
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steve
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Jason,
I think you bring up many valid points. I would argue that upper cervical ligament laxity has been associated with rheumatoid arthritis (The only group that research has been done in the upper c-spine for testing), Grisels syndrome and upper respiratory infections in children. Certainly the few research studies performed with those individuals with VBI has shown testing does not pick up those individuals with the condition. My guess is that most testing is performed as a way to potentially decrease liability and make the clinician feel safe with treatment that they may be giving.
Anecdotally, I have been in the clinic when two patients have tested positive for alar ligament instability and then were confirmed with imaging. One was post MVA and the other was a 13 year old who awoke from surgery for another part of the body (Cant remember what) with neck pain and headaches.
Steve
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Re: Upper Cervical Ligament Testing - June 21, 2005 10:17:00 AM
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jbeneciuk
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Jason:
My thaughts are that these tests are not just tests for stability, however also tests for provocation...and although these tests may not be very specific... (other structures may be at risk), the result of a positive test... (be it pain or excessive translation with a "sharp purser" test) would probably lead me to refer to physician for some imaging, however even in the event of trauma with imaging performed...an image is only as good as the reader and we know of the results of false negatives...what about the pt who does not report any trauma, yet while sleeping she had a sneezing attack and the possibilities that could have occured....she presents with neck pain, however doesn't report any trauma...if not for her reporting her sneezing incident, I wouldn't think we would normally order films for this pt, however she may have some damage to these upper cervical ligaments or even a fx in this area....
**i'm going to try to look for some case studies tonight RE: this similar situation..I know I heard of this before, yet cannot remeber where.
Good topic!!
JBeneciuk
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Re: Upper Cervical Ligament Testing - June 21, 2005 11:18:00 AM
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steve
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JBeneciuk,
Unfortunately if the test lacks sensitivity and specificity, that false positive result will lead you to order needless testing (Not a huge consequence) and give you a false sense of security with those patients who test negative (Potentially fatal consequence). The question that should be asked is do these tests provide me with anymore information than the clinical hypothesis I have come up with after taking a history and will it change my clinical course of action based on the results. If we are looking for a fracture as per your example, the Canadian Cervical Spine rules provide 1.0 sensitivity, allowing us to rule a fracture out (SnNout rule) with a negative test. This provides us excellent information upon which to guide our clinical course of action. Upper cervical ligament stress testing has not studied sufficiently to even know the qualities of information provided. I'm not advocating that we completely remove these tests from our assessments but rather be aware of their potential flaws and take the results from the test performed with this in mind.
Steve
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Re: Upper Cervical Ligament Testing - June 21, 2005 2:29:00 PM
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jbeneciuk
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Steve:
point well taken...
I am aware of the potential flaws of these tests, as the obvious potential flaws with the vertebral artery test, however in a society that tends to involve the courts with almost every possible issue, wouldn't it be wise for these tests to be performed and the results documented.
**Lets put a twist on the possibility of an alar ligament strain...which would result in a painful response with an "alar odontoid integrity test"...would this re-direct your course of treatment...as a positive valgus stress test at the knee (which may suggest an MCL sprain) would also assist in selecting your plan of treatment?
The analogy may be a bit of the beaten track, however they are both ligaments...and in the case of the alar ligament, the consequences of certain treatment options may be more severe when dealing with the sub-cranial region, as opposed to stressing the MCL at the knee.
What do you think ??
What do the chiropractors think of this discussion ??
Thank you
JBeneciuk
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Re: Upper Cervical Ligament Testing - June 21, 2005 3:10:00 PM
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chiroortho
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Honestly I don't think alar lig or VBI tests are reliable. I think they have theoretical utility, but that's as far as it goes.
DCs concocted a test called 'George's Test' for patency of cervical vessels that is totally useless.
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Greg Priest, DC, DABCO
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Re: Upper Cervical Ligament Testing - June 21, 2005 4:49:00 PM
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MPT
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What imaging tests would you want the MD to perform? Flexion/extension films?
I talked with one radiologist who said alar lig damage would not be seen in a MRI or CT unless it was acute. He stated that in an acute case edema around the area may be seen, indicating an injury to the lig.
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Re: Upper Cervical Ligament Testing - June 22, 2005 2:25:00 AM
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Sebastian Asselbergs
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The problem with flexion/extension films is that they do not always "catch" a mid range laxity. Dr. Don Fraser (MD) I think, was involved in researching the precision and accuracy of fluoroscopic imaging of upper spines. Dr. Dvorak has published quite a few studies on the poor specificity of flexion/extension imaging.
Just my 2 cts worth.
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Re: Upper Cervical Ligament Testing - June 22, 2005 5:10:00 AM
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chiroortho
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Sebastian, I too have heard of the 'midrange' ligament failures, but honestly I am not smart enough to understand the logic. To wit, if ligamentous instability is present, it has always been my impression that endrange evaluation with F/E films would accentuate such, not miss it. In other words, if ligs are lax they will demonstrate it more so at end range than they would at midrange.
Greg
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Greg Priest, DC, DABCO
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Re: Upper Cervical Ligament Testing - June 22, 2005 7:07:00 AM
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JLS_PT_OCS
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So what I'm hearing is that we have no way to be really sure if an instability exists, except via history and myelopathic signs/symptoms.
Those people we won't be manipulating or moving aggressively anyway.
So why would I use some testing that doesn't seem to be able to authoritatively state anything in particular?
Just as using Homan's sign for DVT seems unimportant, why would these tests be used? How would using tests with established poor validity/reliability improve my case in a litigation or liability situation?
And if a sneeze can supposedly rupture an upper cervical ligament, why are we not seeing an epidemic of myelopathy and incomplete/complete spinal cord injuries with more aggressive sports or life activities?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Upper Cervical Ligament Testing - June 22, 2005 8:36:00 AM
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steve
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Jason B,
I tend to agree with Jason S on this one. Does using a test with poor validity/reliability improve my standing with respect to litigation? The Ottawa ankle rules are being challenged in court and these rules have excellent sensitivity and have been studied repeatedly. I'm not sure if performing a test simply because its there helps os with respect to litigation if it has little validity.
It sounds like what we really need is for these tests to be studied and determine their sensitivity/specificity and establish if they are actually clinically beneficial. In the meantime it would be prudent to procede with extreme caution irrespective of the results of upper c-spine testing with any suspected cases of instability. I would argue that based on the catastrophic consequences of ligament instability and VBI it would also be prudent to be cautious with any treatment of the cervical spine even if the risk is as high as 6 in 10 million (ONe reported studies incidence of c-spine manipulation and VBI)
Steve
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Re: Upper Cervical Ligament Testing - June 22, 2005 11:25:00 AM
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chiroortho
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I think the fear of causing an incident secondary to VBI can be so overblown that it will keep good clinicians from doing good things for their patients. The science for VBI/instability testing isn't very good, but at the same time the science for a causal relationship between c-spine manipulation and stroke isn't very good either.
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Greg Priest, DC, DABCO
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Re: Upper Cervical Ligament Testing - June 22, 2005 11:39:00 AM
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steve
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Greg,
agreed, and I am in no way advocating that we not treat the cervical spine with manual therapy but rather that we be cautious in this region in general. For me, I would not manipulate the upper cervical spine on the basis that there is no evidence that it is more beneficial than mobilization and appears to have more risk for VBI. I would say that the poor research surrounding VBI and the fact that the embolism may not be thrown off till a significant time period after a manipulation may lead to under estimating the risk of VBI. This, of course, is not proven but is food for thought.
Steve
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Re: Upper Cervical Ligament Testing - June 22, 2005 1:19:00 PM
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jbeneciuk
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How do you all feel about this comment, which I recalled from my one of my manuals...
"Comment on Ligament Testing"
*a positive alar or transverse ligament test is an indication to proceed with caution. As at the knee joint, a painful or weak ligament will need time to heal and strengthen. If after 6 weeks following the injury the sx remain, then the ligament can be presumed lax and the patient would need to be so advised.....Treatment of the acute injury and the chronic involves support..."
I guess what I take from this is... "proceed with caution"...possibly even more caution than we normally would.
Thaughts??
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Re: Upper Cervical Ligament Testing - June 22, 2005 2:22:00 PM
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jbeneciuk
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Jason:
Good points in your last post, and to come up with a reply for them is tough...
*I just feel that if these tests are positive, it our responsibility to report this finding to the physician, just as if a DVT is suspected...it is our responsibility to report to the physician.
Maybe your right in saying that these poorly researched tests won't hold up in the courts, I don't know ??
Maybe Greg is right in feeling that the "fear" of causing an incident is why I feel the way I do about this topic.
Really gets you thinking though, especially in regards to the rationale behind these tests; while I was introduced to them in school (not too long ago)...
*I might lose some sleep over this one too !!
Thanks Jason
JBeneciuk
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Re: Upper Cervical Ligament Testing - June 22, 2005 4:22:00 PM
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MPT
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*I just feel that if these tests are positive, it our responsibility to report this finding to the physician, just as if a DVT is suspected...it is our responsibility to report to the physician.
What do we expect the MD to do? Is there a test that can reliably identify a tear? If not are we just passing the liability on to the MD if we inform them.
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Re: Upper Cervical Ligament Testing - June 22, 2005 6:42:00 PM
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jbeneciuk
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MPT:
I do not "expect" the physician to do anything, however in a situation like this it would be wise to communicate with them regarding my suspected findings....whether the testing procedures are valid or not...sounds crazy, yet this is my current way of thinking...am I wrong to think this way ?
*my question to you:
1) Do you perform these tests ?
2) If so, with a positive test (excessive motion or pain provocation)...would you proceed with treatment as you would if you found what you would consider a negative test ?
3) would you educate your patient any differently ?
4) scenario: your pt is a high-school baseball catcher with c/o neck pain, no recent trauma, negative radiographs....yet while performing your exam you question your findings regarding your upper-cervical ligament testing...what would you advise / or treat this pt any differently ??
**How would you handle this scenario ?
Dr. Wagner...any feedback on this ?
JBeneciuk
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Re: Upper Cervical Ligament Testing - June 23, 2005 2:05:00 AM
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Sebastian Asselbergs
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Greg, my mistake - I should not have called it a "midrange laxity" but "midrange motion failure". Some cases were described where in the motion from extension to flexion, the dens moved in a diagonal deviation in the middle of the movement, but ended up in the "normal" position. I can not, fot the life of me remember who (Dvorak maybe) descibed this - and since I have moved far away from upper cervical manips, this info tends to sink in the swamps of my memory....
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Re: Upper Cervical Ligament Testing - June 23, 2005 3:25:00 AM
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JLS_PT_OCS
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Are their case studies out there about atraumatic upper cervical instability?
In the absence of trauma, even if we do perform these tests on trauma cases, is there any reason to perform them in an atraumatic scenario?
Given the likely poor reliability/validity data of these tests, would a 'positive' test indicate anything OTHER than the fact we misinterpreted the results?
And MPT's right, what do you expect their physician to do? Go, "OK, thanks..."???
Put yourself in the MDs shoes for a sec. You refer some patient for neck pain without trauma, and this therapist calls and says the patients spine is unstable. MD says to himself "Mental note - stop referring to this joker."
In the direct access setting, we have now officially made some patient officially freaked out. That can't be good for marketing...
In traumatic settings such as MVC, the situation is different, and more difficult to be sure about.
But in the absence of trauma, why is this used?
I study brazilian jui-jitsu, and we are choking each other and cranking on each other's necks all day. So do wrestlers. Now if a sneeze can rupture one of these ligaments, where are all these cases of upper cervical instability?
The VBI thing is another issue entirely, as it kind of crosses the traumatic/atraumatic line.
For VBI, discussions of manips vs mobs and when/why /who are very different.
I am not aware of any diagnostic criteria for upper cervical instability. Anyone else?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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